Every finding on record at Sterling Hills Rehabilitation and Healthcare Cente

Based on interview and record review the facility failed to transmit completed discharge assessment that accurately reflected the residents' status for 1 of 23 sampled residents (Resident #83) whose records were reviewed, in that: Resident #83 discharge MDS was not transmitted within 14 days of the completed date. This failure could place residents at risk by not receiving the appropriate assessments.Based on interview and record review the facility failed to transmit completed discharge assessment that accurately reflected the residents' status for 1 of 23 sampled residents (Resident #83) whose records were reviewed, in that: Resident #83 discharge MDS was not transmitted within 14 days of the completed date. This failure could place residents at risk by not receiving the appropriate assessments. The findings include: Resident #83 Record review of Resident #83 admission Record dated 03/26/2026 revealed a [AGE] year-old male resident admitted to the facility on [DATE] and a discharge date of 12/31/2025 with admitting diagnoses of muscle weakness, nontraumatic subacute subdural hemorrhage (bleeding in the brain), seizures, and major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities). Record review of Resident #83's electronic medical record MDS tab revealed a discharge Return Not Anticipated MDS dated [DATE] with a status of complete. The assessment history revealed the discharge MDS had not been submitted (no batch created). Record review of Resident #8's3 discharge MDS dated [DATE] revealed the following: Section A0310 Type of assessment: .F. Code 10 - Discharge assessment - return not anticipated .Section A2000 discharge date : [DATE] .Section Z0500 RN assessment Coordinator Verifying Assessment Completion:A. Signature: DON B. Date RN assessment Coordinator signed assessment as complete: 01-08-2026 During an interview with MDS Nurse A and MDS Nurse B on LVN D on 03/25/2026 at 03:49 a.m. MDS Nurse A stated Resident #83 was not traditional Medicare, he was managed care and MDS assessments were not transmitted to CMS. MDS Nurse B Stated Resident #83 discharged MDS should have been submitted to CMS. MDS Nurse B stated all discharge MDS' should be transmitted to CMS within 14 days of the completed MDS. MDS Nurse B stated it was missed by mistake. MDS Nurse A stated there was a box they must uncheck or once the MDS was completed it would not be transmitted to CMS. MDS Nurse A stated the box was checked and the discharge MDS for Resident #83 had not been transmitted to CMS. MDS Nurse A stated it had been corrected and would be transmitted today (3/25/2026). MDS Nurse A stated the discharge MDS was completed and the DON reviewed it for accuracy and signed it. MDS Nurse A stated once the DON signed, the MDS it was transmitted. MDS Nurse A stated they had been trained in completing MDS and timeframes. During an interview with the DON on 03/26/2026 at 09:40 a.m. she stated the purpose of the discharge MDS was to notify CMS of the status of the resident. She stated when a resident discharges an assessment was completed the day of discharge. She stated she reviews and signs the discharge MDS and the MDS nurses transmit to CMS. She stated she was not aware Resident #83 discharge MDS was not transmitted. She stated the MDS nurses had been trained on MDS assessments and transmission. She stated the potential negative outcome would be not notifying CMS of a resident's status and the facility could continue to bill and receive payments from Medicare for a resident not in the facility. During an interview with the ADM on 03/26/2026 at 09:49 a.m. she stated the purpose of the discharge MDS was to inform CMS of the resident's status and stop billing. She stated the MDS nurses and DON were responsible for completing and transmitting the MDS to CMS. She stated they had training on MDS completion and time frames. She stated the discharge assessment should be transmitted within 14 days. She stated she was not aware Resident #83 discharge MDS had not been transmitted until today. She stated the potential negative outcome could affect the billing process. Record review of facility policy dated 06/02/2025, titled MDS Coding Policy revealed: affiliated facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident assessment, timely and accurately.The most current RAI manual may be found on the CMS.gov website. Review of the RAI manual dated October 2025 revealed: . 09. Discharge assessment - Return not anticipated (A0310F=10) .Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days) .

Based on interview and record review, the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 23 residents (Resident #43) reviewed for pain management. The facility failed to ensure Resident #43 had effective pain management by failing to have their PRN pain medication available. This failure could place residents at risk for increased pain and decreased quality of life.Findings included: Record review of an undated face sheet revealed Resident #43 was a [AGE] year-old female with an initial admission date of 05/02/2025 and admission date of 02/23/2026 with the diagnoses vascular dementia, unspecified severity, without behavioral disturbance mood disturbance, and anxiety (cognitive decline caused by reduced blood flow to the brain, often following strokes or small vessel disease with a mental health condition), inflammatory polyneuropathy unspecified (autoimmune disorder where the immune system mistakenly attacks the nerves), chronic pain due to trauma (persistent pain lasting beyond 3-6 months that stems from physical injury or emotional/psychological trauma), essential (primary) hypertension (high blood pressure), rheumatoid arthritis, unspecified (a chronic inflammatory disorder that could affect more than just your joints. In some people, the condition could damage a wide variety of body systems, including the skin, eyes, lungs, heart, and blood vessels), unspecified osteoarthritis (lack of cartilage at the ends of the bones which causes joint pain, stiffness, and reduced mobility), pain in right shoulder, low back pain, muscle spasms of back (sudden involuntary painful contractions or tightening of the muscles), fibromyalgia (chronic long-term disorder characterized by widespread musculoskeletal pain), pain unspecified, localization-related focal partial symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus (a severe treatment-resistant form of epilepsy where seizures originate in a specific, localized area of the brain, causing conscious simple focal seizures that have progressed to dangerous, prolonged seizure activity), and fracture of first thoracic vertebra, initial encounter for closed fracture (a break or collapse of the bones in the upper or mid-back). Record review of Resident #43's Comprehensive MDS assessment dated [DATE] revealed she had a BIMS score of 15 which indicated Resident #43 was cognitively intact. In Section J - Health Conditions, the pain assessment revealed Resident #43 reflected pain almost constantly and that pain interfered with day-to-day activities frequently. Record review of Resident #43's undated care plan revealed: focus: The resident has chronic pain related to inflammatory polyneuropathy, right shoulder pain, lower back pain, osteoarthritis, muscle spasms, fracture of thoracic vertebra, fibromyalgia, rheumatoid arthritis. (Fentanyl patch, Lyrica, HCD 10 MG (hydrocodone 10 mg), Lidocaine patch, meloxicam), date initiated 08/27/25, revision on: 01/19/2026. Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain, monitor/record/report to the nurse resident complaints of pain or requests for pain treatment, observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal, or resistance to care. The resident prefers to have pain controlled by Fentanyl patch (a powerful synthetic opioid designed for pain management) every 2 hours - check for placement every shift. Hydrocodone PRN (an opioid and acetaminophen used to manage severe pain). Lidocaine patches (fast acting numbing agent) to the lower back. Lyrica (medication used to treat nerve pain) as instructed by the physician, Methocarbamol (muscle relaxant use to treat painful muscle spasms and stiffness) as instructed by the physician for muscle spasms. Meloxicam (nonsteroidal anti-inflammatory medication used to relieve pain) as instructed by the physician. Record review of Resident #43's physician's orders revealed active orders as of 03/26/26 for Hydrocodone/Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) (an opioid and acetaminophen used to manage severe pain) give 1 tablet by mouth every 6 hours as needed for breakthrough pain. Order date 03/09/2026. Start date 03/09/26. No end date indicated. Record review of Resident #43's MAR, dated 03/01/2026 to 03/31/2026, revealed she was prescribed Hydrocodone/Acetaminophen 10-325 MG (1) tablet by mouth every 6 hours as needed for breakthrough pain with an order date of 03/09/2026. The MAR revealed Resident #43 received doses on 3/23/26 at 5:29 AM and 12:44 PM. Resident #43's MAR revealed the next dose was received on 3/24/26 at 11:36 AM. Record review of Resident #43's narcotic count sheet dated 02/16/2026 revealed the last Hydrocodone/Acetaminophen 10-325 MG (1) tablet was administered at 12:30 PM on 03/23/2026. The count was zero after the 12:30 PM dose was administered on 03/23/2026. Record review of Resident #43's narcotic count sheet was dated 03/25/2026 revealed a new prescription of Hydrocodone/Acetaminophen 10-325 MG was filled with a count of 56 pills. Record review of progress notes for Resident #43's dated 03/25/2026 at 8:28 AM, revealed a notation that a nurse called the physician's office and requested a prescription for Norco (a prescription medication combining hydrocodone (an opioid) and acetaminophen used to manage severe pain) to be sent to the pharmacy provider, and the physician's nurse replied the prescription would be sent to the physician and pharmacy provider today. During an interview on 03/24/2026 at 2:43 PM, Resident #43 stated she requested her prescription hydrocodone pain medication the other day at night because she was in pain and was told by the nurse that they could not get the code needed to access to the emergency medication kit because they could not get ahold of the pharmacy provider. She stated the nurse told her the hydrocodone was ordered previously but had not yet been delivered. She stated the facility told her they ran out of the hydrocodone that was kept in the medication cart which was why they had to get them from the backup emergency medication supply kit. During an interview on 03/26/2026 at 9:23 AM, Resident #43 stated after she reported pain, the nurse told her she called the pharmacy provider every hour, but they were not answering. She stated staff repositioned her with pillows a few times which helped alleviate some of the pain. She stated staff also rubbed her fentanyl patch that she was already wearing. She stated she was aware she could have taken over-the-counter acetaminophen but did not want to take it because then she would not have been able to take the prescription medication had they gotten access to the emergency medication kit. She stated staff also offered to send her to the hospital to get the medication if she wanted, but she declined. She stated staff updated her and checked on her every hour during that shift. She stated she slept off and on throughout the night. She stated she received the pain medication early the next morning. She stated this was the first time this had ever happened and that the facility did well managing her pain on a regular basis. She stated her regular prescription had since been filled and the issue was resolved. During an interview on 03/26/2026 at 11:36 AM, LVN E stated on Monday night (3/23/26) Resident #43 asked for pain medication one time during her shift. She stated she tried calling the pharmacy several times and kept getting a busy tone. She stated she checked on Resident #43 several times throughout the night and she was always asleep. She stated she could not recall the exact time the resident asked for pain medication, but she believed it to have occurred sometime after 10:00 PM. She stated she tried to call the pharmacy throughout the night. She stated she told Resident #43 about the issue of not being able to get ahold of the pharmacy and she replied that she was okay with it. She stated she passed on the issue of Resident #43's pain medication in report to the oncoming nurse before she left the facility. She stated Resident #43 only asked for the pain medication one time during her shift. She stated Resident #43 was not crying in pain or she would have called the physician immediately. She stated she should have called the DON but did not do it because the resident was able to sleep. She stated this had never happened to her before. She stated the reason she needed a code from the pharmacy to access the emergency medication kit was because there were no pain pills on the cart from Resident #43's regular prescription. She stated a potential negative outcome of not having resident's pain medications was that residents would have ongoing excruciating pain, which could cause high blood pressure, respiratory distress, and a high pulse rate. She stated she was the nurse on hall 4 and was responsible for ensuring residents on hall 4 received their medications that night. During an interview on 03/26/2026 at 12:39 PM, the DON stated she wanted pain for residents to be controlled and if not controlled, staff were to notify the physician to get medications to control the pain. She stated she was not aware staff could not get ahold of the pharmacy when Resident #43 requested pain medication. She stated staff were to notify her or the doctor if they could not get ahold of the pharmacy so they could attempt to find other options to help control pain. She stated there would not have been any other medication in the building that was stronger to give the resident than the medication that was available in the emergency medication kit. She stated Resident #43 had chronic pain but she told staff when she had severe pain. She stated she expected staff to notify her or the physician anytime staff could not get medications including PRN medications regardless of pain level of the resident so she could see if she could get the medication for the resident. She stated all staff knew they should call her as they had all been trained to notify her when medications were not available. She stated a potential negative outcome was that residents were without their life saving medications and having uncontrolled pain could have had adverse effects on the residents. She stated the emergency medication kit was the backup plan for when the medication was not available on the medication cart. She stated the prescription had since been filled. During an interview on 03/26/2026 at 12:58 PM, the ADM stated staff were to continue to call the pharmacy to get the code to access medications from the emergency medication kit when the medications were not available on the medication cart. She stated she expected staff to maintain communication with residents as to why the medication was not available. She stated she was not aware staff were not able to get ahold of the pharmacy on the night of 03/23/2026 for pain medications for Resident #43. She stated staff should have called the DON right away to see if there was another way to contact the pharmacy or get access to the medication by another route. She stated superiors could have helped the staff troubleshoot other options. She stated Resident #43 had a continuous fentanyl patch and often slept well. She stated staff should have notified the DON of not being able to get ahold of the pharmacy regardless of the resident's pain level. She stated she expected staff to call her or the DON for help in those situations. She stated the nurse was responsible for calling them and notifying them of the issue so they could have helped expedite the medication. She stated a potential negative outcome was that the resident was in pain and it was their right to not be in pain. The ADM stated another negative outcome was that they were not aware there was an issue with the pharmacy and had not addressed it and fixed the problem so to prevent it from happening again. Record review of facility policy titled, Pain Management Program Policy , reviewed 3/03/2026, revealed in part: The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices, related to pain management. 1. The facility will identify individuals who have pain or who are at risk for having pain. a. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes.b. This includes a review of any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments.c. Caregiver will review when the resident is experiencing pain and identify circumstances when pain can be anticipated.d. Residents pain will evaluate and managed with residents' goals and preferences. Treatment/Management Strategies for the prevention and management of pain may include but are not limited to the following: - Assessing Pain: Recognizing the onset, presence, and duration of pain, and assessing the characteristics of the pain.- Addressing Underlying Causes: Treating the underlying causes of the pain, to the extent possible. Monitoring Pain Assessment/Interventions/Orders and Care Planning 1. Pain evaluation will be completed for each resident upon admission, readmission, quarterly, and with significant changes in condition. 2. If pain is identified, the following steps are initiated:- Create a pain care plan using standardized pain assessment tools.- Obtain orders for pharmaceutical and/or non-pharmaceutical interventions. 3. Nurses will assess residents' pain every shift using the appropriate pain evaluation tool and document the effectiveness of interventions.4. For residents experiencing unmanaged pain, the Interdisciplinary Team will reassess and determine new causes, adjust care plans, and implement new interventions as needed. 5. Pain should be assessed before potentially painful procedures, such as wound care, and medication should be administered in advance to reduce discomfort.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 23 residents (Resident #43) reviewed for pharmacy services. The ADON failed to document pain medication given on 03/18/26 to Resident #43 on the residents' narcotics count sheet and the MAR. This failure could place residents at risk for medication error and drug diversion.Findings included: Record review of an undated face sheet revealed Resident #43 was a [AGE] year-old female with an initial admission date of 05/02/2025 and an admission date of 02/23/2026 with the diagnoses of vascular dementia, unspecified severity, without behavioral disturbance mood disturbance, and anxiety (cognitive decline caused by reduced blood flow to the brain, often following strokes or small vessel disease with a mental health condition), inflammatory polyneuropathy unspecified (autoimmune disorder where the immune system mistakenly attacks the nerves), chronic pain due to trauma (persistent pain lasting beyond 3-6 months that stems from physical injury or emotional/psychological trauma), essential (primary) hypertension (high blood pressure), rheumatoid arthritis, unspecified (a chronic inflammatory disorder that could affect more than just your joints. In some people, the condition could damage a wide variety of body systems, including the skin, eyes, lungs, heart, and blood vessels), unspecified osteoarthritis (lack of cartilage at the ends of the bones which causes joint pain, stiffness, and reduced mobility), pain in right shoulder, low back pain, muscle spasms of back (sudden involuntary painful contractions or tightening of the muscles), fibromyalgia (chronic long-term disordered characterized by widespread musculoskeletal pain), pain unspecified, localization-related focal partial symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus (a severe treatment-resistant form of epilepsy where seizures originate in a specific, localized area of the brain, causing conscious simple focal seizures that have progressed to dangerous, prolonged seizure activity), and fracture of first thoracic vertebra, initial encounter for closed fracture (a break or collapse of the bones in the upper or mid-back). Record review of Resident #43's Comprehensive MDS assessment dated [DATE] revealed she had a BIMS score of 15 which indicated resident #43 was cognitively intact. In Section J - Health Conditions, the pain assessment revealed Resident #43 reported pain almost constantly and that pain interfered with day-to-day activities frequently. Record review of Resident #43's physician's orders revealed active orders as of 03/26/26 for Hydrocodone/Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) (an opioid and acetaminophen used to manage severe pain) give 1 tablet by mouth every 6 hours as needed for breakthrough pain. Order date 03/09/2026. Start date 03/09/26. No end date indicated. Record review of Resident #43's narcotic count sheet dated 02/16/2026 for Hydrocodone/Acetaminophen 10-325 MG (1) tablet revealed a dose administered at 4:07 PM on 03/17/2026 with an amount of remaining pills as 15. The next entry line was blank. Then the next entry line revealed a dose was administered at 11:00 AM on 03/18/2026 with an amount of remaining pills as 13. Record review of Resident #43's MAR dated 03/01/2026 to 03/31/2026, revealed she was prescribed Hydrocodone/Acetaminophen 10-325 MG (1) tablet by mouth every 6 hours as needed for breakthrough pain with an order date of 03/09/2026. The MAR did not reveal Resident #43 received a dose on 3/18/26 at 12:30 AM. Record review of progress notes for Resident #43, date range 01/25/2026 to 03/26/26, did not reveal documentation by the ADON of when she administered Hydrocodone/Acetaminophen 10-325 MG to resident #43 on 03/18/2026 at 12:30 AM. During an interview on 03/26/2026 at 11:49 AM, the ADON stated she worked on 03/17/26 from 6:00 PM to 6:00 AM in hall 1 and was training two nurses. She stated Resident #43 lived on hall 4. She stated Resident #43 asked for pain medication (Hydrocodone/Acetaminophen 10-325 MG) and she gave it to her at 12:30 AM (03/18/2026) when the hall 4 nurse was on a break. She stated she forgot to sign the medication out on the narcotics count sheet and on the resident's MAR. She stated she got sidetracked because there was a feeding that needed to be done and she needed to show the two nurses how to do it. She stated that she was trained in the medication pass process which was that she was to pop the pill, sign it out on the narcotic count sheet, give it to the resident, and then document on the MAR if the resident refused or took the medication. She stated this was the system in place to ensure medications were accounted for. She stated she expected staff to pass medication according to the appropriate process of passing medications. She stated she was not aware she forgot to document the medication prior to surveyor notification today. She stated she was responsible for ensuring all medications were documented on the narcotics count sheets and the MAR. She stated a potential negative outcome of not following the medication pass process and not documenting medications given to residents was that the resident could be double dosed, which would be a medication error, or the resident could overdose on the medication. During an interview on 03/26/2026 at 12:39 PM, the DON stated staff must document all medications as they were given to residents. She stated staff must document in the narcotic count sheet as soon as they pop the medication, then document on the MAR indicating the resident took the medication, locked the computer screen but left the MAR open for possible changes, then attempted to administer the medication to the resident. The DON stated if the resident refused the medication, the staff was to correct the MAR to reflect the medication was refused. She stated she was not aware hydrocodone was given to resident #43 and was not documented on the resident's narcotic count sheet or the MAR. She stated the system they had to ensure all medications were accounted for was for the off-going and oncoming staff to count them on each shift. She stated she expected staff to notify her if medication counts were off. She stated she trained staff to follow and count medications from shift to shift and notify her of any medication discrepancies. She stated all nursing staff and herself were responsible for ensuring medications were being counted and documented correctly. She stated she expected staff to document medications when they were giving them and follow up to ensure they were effective. She stated a potential negative outcome of not following the medication pass process and not documenting medications was that staff could give medications again and residents could have had an adverse effect. During an interview on 03/26/2026 at 12:58 PM, the ADM stated staff were to sign out narcotics medication as soon as they administer it on the narcotic count sheet and on the resident's MAR. She stated she was not aware of the pain medication given to Resident #43 was not documented on the MAR or the narcotic count sheet until after surveyor inquiry today when it was brought to her attention. She stated the system to ensure medications were accounted for was for staff to document on the MAR and narcotic counts. She stated staff had been trained by senior floor staff, the ADON, and the DON on the medication administration process which includes documenting the medications on the narcotic count sheet and the MARs. She stated the nurse passing the medications and the DON were responsible for ensuring all medications given were documented. She stated she expected staff to follow all policies and procedures given to them. She stated a potential negative outcome was resident's care could be reduced, and it could affect resident's rights. She stated also that residents could get an additional dose before it was due, which could be very detrimental to the residents. Record review of facility policy titled, Medication Administration, reviewed and revised 03/05/2026, revealed in part: Documentation RequirementsAfter administration, the nurse documents:- Date and time administered- Dosage- Route- Injection site (if applicable)- Indication (if PRN)- Resident response, when required- Signature and credentials. Record review of facility policy titled, Controlled Substances , reviewed 6/24/2025, revealed in part: Policy Statement The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule 11-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Policy Interpretation and Implementation Handling Controlled Substances1. Only authorized licensed nursing and/or pharmacy personnel have access to Schedule IIcontrolled substances maintained on premises.3. Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record.4. If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record contains:a. name of the resident;b. name and strength of the medication;c. quantity received;d. number on hand;e. name of the prescriber;f. prescription number;g. name of issuing pharmacy;h. date and time receivedi. time of administration;j. method of administration;k. signature of person receiving medication; andl. signature of nurse administering medication. Dispensing and Reconciling Controlled Substances1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/ follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substancesincludes the following:a. Records of personnel access and usage;b. Medication administration records;c. Declining inventory records; andd. Destruction, waste and return to pharmacy records.12. Some controlled substances may be stored in the emergency medication supply. Reconciliation of controlled substances in the emergency supply is conducted at intervals established by the director of nursing services.

Based on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 23 residents (Resident #43) reviewed for accuracy of records. LVN E failed to document an incident when she could not get access to Resident #43's pain medication during the night shift on 03/23/2026 because she could not get ahold of the pharmacy provider in the electronic health record. These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment.Findings included: Record review of an undated face sheet revealed Resident #43 was a [AGE] year-old female with an initial admission date of 05/02/2025 and an admission date of 02/23/2026 with the diagnoses of vascular dementia, unspecified severity, without behavioral disturbance mood disturbance, and anxiety (cognitive decline caused by reduced blood flow to the brain, often following strokes or small vessel disease with a mental health condition), inflammatory polyneuropathy unspecified (autoimmune disorder where the immune system mistakenly attacks the nerves), chronic pain due to trauma (persistent pain lasting beyond 3-6 months that stems from physical injury or emotional/psychological trauma), essential (primary) hypertension (high blood pressure), rheumatoid arthritis, unspecified (a chronic inflammatory disorder that could affect more than just your joints. In some people, the condition could damage a wide variety of body systems, including the skin, eyes, lungs, heart, and blood vessels), unspecified osteoarthritis (lack of cartilage at the ends of the bones which causes joint pain, stiffness, and reduced mobility), pain in right shoulder, low back pain, muscle spasms of back (sudden involuntary painful contractions or tightening of the muscles), fibromyalgia (chronic long-term disordered characterized by widespread musculoskeletal pain), pain unspecified, localization-related focal partial symptomatic epilepsy and epileptic syndromes with simple partial seizures, intractable, with status epilepticus (a severe treatment-resistant form of epilepsy where seizures originate in a specific, localized area of the brain, causing conscious simple focal seizures that have progressed to dangerous, prolonged seizure activity), and fracture of first thoracic vertebra, initial encounter for closed fracture (a break or collapse of the bones in the upper or mid-back). Record review of Resident #43's Comprehensive MDS assessment dated [DATE] revealed she had a BIMS score of 15 which indicated resident #43 was cognitively intact. In Section J - Health Conditions, the pain assessment revealed Resident #43 reported pain almost constantly and that pain interfered with day-to-day activities frequently. Record review of Resident #43's physician's orders revealed active orders as of 03/26/26 for Hydrocodone/Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen) (an opioid and acetaminophen used to manage severe pain) give 1 tablet by mouth every 6 hours as needed for breakthrough pain. Order date 03/09/2026. Start date 03/09/26. No end date indicated. Record review of Resident #43's MAR dated 03/01/2026 to 03/31/2026, revealed she was prescribed Hydrocodone/Acetaminophen 10-325 MG (1) tablet by mouth every 6 hours as needed for breakthrough pain with an order date of 03/09/2026. The MAR did not reveal documentation of when the medication was requested by Resident #43 and was not available after 10:00 PM on 3/23/26. Record review of progress notes for Resident #43, date range 01/25/2026 to 03/26/26, did not reveal documentation by LVN E in the electronic health record of when she could not get access to pain medication requested by Resident #43 because she could not get ahold of the pharmacy provider during the night shift on 03/23/2026. During an interview on 03/24/2026 at 2:43 PM, Resident #43 stated she requested her prescription hydrocodone pain medication the other day sometime at night because she was in pain and was told by the nurse that they could not get the code needed to access to the emergency medication kit because they could not get ahold of the pharmacy provider. She stated the nurse told her the hydrocodone was ordered previously but had not yet been delivered. She stated she did not know the nurse's name. She stated the facility told her they ran out of the hydrocodone that was kept in the medication cart which was why they had to get them from the backup emergency medication supply kit. During an interview on 03/26/2026 at 9:23 AM, Resident #43 stated after she reported pain, the nurse told her she called the pharmacy provider every hour, but they had not answered. She stated staff updated her and checked on her every hour during that shift. She stated she received the pain medication early the next morning. She stated it was the first time this had ever happened and that the facility did well managing her pain on a regular basis. She stated her regular prescription had since been filled and the issue was resolved. During an interview on 03/26/2026 at 11:36 AM, LVN E stated on Monday night (3/23/26) Resident #43 asked for pain medication one time during her shift. She stated she tried calling the pharmacy several times and kept getting a busy tone. She stated she kept trying to call pharmacy throughout the night. She stated she told Resident #43 about the issue of not being able to get ahold of the pharmacy and she replied that she was okay with it. She stated she did not notate this incident anywhere in the electronic health record like she was trained, but she should have. She stated she passed it on in report to the oncoming nurse before she left the facility. She stated she should have called the DON but did not do it because the resident was able to sleep. She stated this had never happened to her before. She stated the reason she needed a code from the pharmacy to access the emergency medication kit was because there were no pain pills on the cart from Resident #43's regular prescription, they had run out, but there was some available in the emergency medication kit. She stated she was the nurse in hall 4 and was responsible for documenting the residents' chart and ensuring residents in hall 4 received their medications that night. During an interview on 03/26/2026 at 12:39 PM, the DON stated she wanted pain for residents to be controlled and if not controlled, staff were to notify the physician to get medications to control the pain. She stated she was not aware staff could not get ahold of the pharmacy when Resident #43 requested pain medication. She stated staff was to notify her or the doctor if they could not get ahold of the pharmacy so they could attempt to find other options to help control pain. The DON stated this incident should have been documented in the resident's electronic health record. She stated a potential negative outcome was that residents were without their life saving medications and having uncontrolled pain could have adverse effects on the residents. During an interview on 03/26/2026 at 12:58 PM, the ADM stated staff were to continue to call the pharmacy to get the code to access medications from the emergency medication kit when the medications were not available on the medication cart. She stated she expected staff to maintain communication with residents as to why the medication was not available. She stated she was not aware staff were not able to get hold of the pharmacy on the night of 03/23/2026 for pain medications for Resident #43. She stated staff should have called the DON right away to see if there was another way to contact the pharmacy or get access to the medication by another route. She stated the nurse was responsible for calling them and notifying them of the issue so they could have helped expedite the medication. She stated the nurse was responsible for documenting the incident. She stated staff had been trained by senior floor staff, the ADON, and the DON on the medication administration process which includes documenting the medications on the narcotic count sheet and the MARs. She stated she expected staff to follow all policies and procedures given to them. The ADM stated a negative outcome was that they were not aware there was an issue with the pharmacy and had not addressed it and fixed the problem so to prevent it from happening again. She stated another potential negative outcome was resident's care could be reduced, and it could affect resident's rights. Record review of facility policy titled, Medication Administration , reviewed and revised 3/05/2026, revealed in part: PurposeTo ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice. General StandardsOnly individuals licensed or legally authorized in this state may prepare, administer, and document medications.The Director of Nursing or designee supervises and oversees all personnel involved in medication administration.4. Medications are administered according to prescriber orders and within ordered timeframes.6. Medication errors are documented, reported, and reviewed by the QAPI (Quality Assurance and Performance Improvement) committee to inform process changes and/or the need for additional staff training. During Medication PassMissed medications are followed up after completion of the medication pass.Refused, withheld, or rescheduled medications are documented appropriately on the MAR. Documentation RequirementsAfter administration, the nurse documents:- Date and time administered- Dosage- Route- Injection site (if applicable)- Indication (if PRN)- Resident response, when required- Signature and credentials. Record review of facility policy titled, Pain Management Program Policy , reviewed 3/03/2026, revealed in part: Monitoring Pain Assessment/Interventions/Orders and Care Planning1. Pain evaluation will be completed for each resident upon admission, readmission, quarterly, and with significant changes in condition. 2. If pain is identified, the following steps are initiated:- Create a pain care plan using standardized pain assessment tools.- Obtain orders for pharmaceutical and/or non-pharmaceutical interventions. 3. Nurses will assess residents' pain every shift using the appropriate pain evaluation tool and document the effectiveness of interventions.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #8 and Resident #52) reviewed for incontinence care.CNA C failed to utilize hand hygiene between glove changes when performing indwelling Foley catheter (a flexible tube inserted into the bladder to drain urine) care for Resident #8.CNA D failed to utilize hand hygiene between glove changes when performing incontinence care for Resident #52.These failures could place residents at risk for cross contamination and infection.The findings include:Resident #8Record review of Resident #8's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Resident #8 had a medical history of cerebral palsy (disorders affecting movement, muscle tone, and posture caused by damage to the developing brain, usually before birth), chronic kidney disease (long-term, irreversible loss of kidney function), and neuromuscular dysfunction of bladder (nerve damage from diseases or injuries disrupts communication between the brain and bladder, leading to incontinence, urgency, or urinary retention).Record review of Resident #8's MDS dated [DATE] Section C- Cognitive patterns, revealed a BIMS score of 14 which indicated she was cognitively intact. Section H- Bowel and Bladder revealed Resident #8 had an indwelling catheter.Record review of Resident #8's physician ordered revealed Foley catheter care [every] shift and PRN with a start date of 10/5/2025.Record review of Resident #8's care plan revealed an intervention dated 3/13/2026 for The resident has (Indwelling) Catheter: DX: NEUROMUSCULAR DYSFUNCTION OF BLADDER.During a Foley catheter care observation on 3/24/2026 at 9:47am, revealed CNA C unfastened Resident #8's brief and cleaned the front genitalia (external sex organs). CNA C removed her dirty gloves and put on new gloves. CNA C did not utilize hand hygiene between glove changes. CNA C cleaned Resident #8's bottom and removed her dirty gloves. CNA C did not use hand hygiene prior to putting on clean gloves. CNA C removed Resident #8's dirty brief, removed her dirty gloves and applied new gloves. CNA C did not use hand hygiene between glove changes.Resident #52Record review of Resident #52's undated face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #52 had a medical history of chronic kidney disease with heart failure, muscle weakness and chronic gout (a painful, chronic form of inflammatory arthritis) due to renal (refers to the kidneys) impairment. Record review of Resident #52's quarterly MDS dated [DATE], Section C revealed a BIMS score of 15 which indicated Resident #52 was cognitively intact. Section H- Bowel and Bladder revealed Resident #52 was always incontinent of bladder.During an incontinence care observation on 3/24/2026 at 10:19am revealed CNA D unfastened Resident #52's brief and cleaned the front. CNA D turned Resident #52 onto her left side and cleaned her bottom. CNA D did not change her gloves or use hand hygiene before cleaning a different area Resident #56's body. CNA D changed her gloves after cleaning Resident #52's bottom and put on new gloves. CNA D did not use hand hygiene between glove changes. CNA D applied skin barrier cream to the resident's bottom with her right gloved hand. CNA D removed the glove to her right hand only and put on a new glove. CNA D did not use hand hygiene between the glove change.On 3/26/2025 attempted phone interview times for CNA C were conducted at 9:29AM, 9:44am and 11:01 AM. CNA C was not available for interview.During an interview on 3/26/26 at 9:31AM with CNA D, she stated she had been trained on infection control and hand hygiene. She stated her last training was approximately three months ago and every year she has skills checkoffs. She stated hand hygiene during incontinence was to be performed before starting the care, during the care, anytime gloves were removed, and after the care was completed. She stated she had been educated to use hand hygiene between glove changes and to have hand sanitizer on her at all times. She stated she usually did use hand sanitizer between glove changes but had not used hand hygiene during glove changes because she was nervous.During an interview on 3/26/26 at 10:33 AM with the DON, she stated she was the infection preventionist. She stated infection control training was done quarterly and the training included hand hygiene and incontinence care. She stated compliance was monitored through infection trends and observations. She stated training on incontinence care included teaching staff to use hand hygiene between glove changes. She stated the potential negative outcome of not using hand hygiene between glove changes could be spreading infection. She stated she was not aware of staff not utilizing hand hygiene between glove changes. During an interview on 3/26/26 at 11:45AM with the ADM, she stated the DON was the infection preventionist. She stated infection control training was conducted quarterly. She stated in-services were also conducted regularly and as needed. She stated she expected nursing staff to follow policies and procedures when performing incontinence care, including utilizing hand hygiene between glove changes. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infections between residents or themselves. She stated she was not aware staff was not utilizing hand hygiene between glove changes.Record review of facility policy titled Handwashing-Hand Hygiene Policy and Procedures last revise 10/2020 revealed: 7. This facility considers hand hygiene the primary means to prevent the spread of infections.use an alcohol base hand rub contain at least 62% alcohol or alternatively soap.and water for the following situations.b. before and after direct contact with residents;.m. after removing gloves.9. The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview and record review the facility failed to notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally or in writing; the right to file grievances anonymously; the contact information of the grievance office with whom a grievance can be filed, that is, his or her name business address and business phone number, a reasonable expected time frame for completing the review of the grievance, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system for 20 of 20 confidential residents reviewed for grievances . The facility failed to ensure 20 of 20 confidential residents were provided information of how to file a grievance, who the facility grievance official was and their right to obtain a written decision related to their grievance . This failure could place residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and record review revealed 20 of 20 confidential residents, stated they did not have access to the Grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form in to, and what happened once a grievance was filed. The residents did not know they had the right to receive a written decision once their grievance was resolved. Observation of prominent postings on 12/12/2024 at 12:30 PM revealed the facility did not include instructions regarding the grievance procedure with any of the prominent postings. Grievance forms were not available to residents and there was no access to submit a grievance anonymously. Interview with the ADM on 12/12/2024 at 11:35 AM, the ADM stated she was the Grievance Officer for the facility. The ADM stated she and Social Services shared the responsibility of reviewing Grievances and assigned them to department heads. The ADM stated the Grievance form was kept in the Social Worker's office. The ADM stated the residents did not have access to the Grievance form. The ADM stated there used to be a box in the hallway with Grievance forms in it, but it had since fallen off the wall, had not been replaced, and residents in wheelchairs were not able to reach the Grievance forms in the box. The ADM stated staff completed Grievance forms for residents, residents did not ask for forms or complete them on their own. The ADM stated there were no procedures for residents to submit grievances anonymously. The ADM stated the facility had 72 hours to resolve grievances once they were submitted. The ADM stated Social Services assigned the grievance to the appropriate department, that department addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant . The resolutions were documented on the grievance form and the completed form was submitted to the ADM for review. The ADM stated completed grievance forms were kept in a notebook for 3 plus years. The ADM stated she monitored the grievance process for success by following up with the staff member assigned to resolve the grievance. The ADM stated she also met with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the grievance process. The ADM stated she was not aware the grievance procedure was not being discussed in Resident Council. Interview with the SW on 12/12/2024 at 12:32 PM, the SW stated she reviewed grievances and assigned grievances to the appropriate department heads. The SW stated the facility had 72 hours to resolve grievances once they were submitted. The SW stated department heads addressed the grievance with the complainant, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the grievance form and the completed form was submitted to the ADM for review. The SW stated completed grievance forms were kept in a notebook. The SW stated the grievance forms were kept in her office. The SW stated the residents did not have access to the grievance form . She stated there used to be a box on a wall in the facility, however, the box fell off the wall many months ago. The SW stated she assisted residents with completing grievance forms and she completed grievances forms once she received the Resident Council minutes. The SW stated there was no procedure for residents to submit Grievances anonymously , however, she understood the need to have a protocol for residents completing the Grievance form anonymously. Record review of the facility's Grievance policy on reflected the Grievance/complaint procedure should be posted on the resident bulletin board. Record review of the facility's Grievance Policy, last revised in 2024, reflected Our facility will assist Residents and their representatives, other interested family members, or advocates in filing grievances or complaints when such requests are made . Policy Interpretation and Implementation: 1. Any resident, family member, or representative may file a grievance or complaint. 2. Grievances and/or complaints may be submitted orally, in writing, or electronically and may be filed anonymously. 3. All grievances, complaints, or recommendations stemming from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing. 4. Upon admission residents are provided with written information on how to file a grievance. A copy of our grievance/complaint procedure is posted in the facility. 5. The contact information for the individual with whom a grievance may be filed is provided to the resident and/or representative upon admission. 6. The ADM has delegated the responsibility of grievance investigation to the grievance officer. 7. The grievance officer will review and investigate the allegations and submit the written report of such findings to the ADM within 72 hours of receiving the grievance. 8. The grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. 9. The ADM and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 10. The ADM will review the findings with grievance officer to determine what corrective actions need to be taken. 11. The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. 12. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. 13. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision .

Based on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 2 of 2 residents (Residents #4 and #63) reviewed for advanced directives. The facility failed to ensure Residents #4 and #63, who were listed as DNR had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that did not have required information on the OOH-DNR. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings include: 1. Record review of Resident #4's, undated, face sheet reflected a [AGE] year-old-female who was admitted to the facility on [DATE], Resident #4 had diagnoses which included Chronic Obstructive Pulmonary Disease (lung disease that blocks airflow), kidney disease (damage to or disease of a kidney) Mental Disorder (a wide range of conditions that affect mood, thinking, and behavior), Major Depressive Disorder (persistently depressed mood), Cognitive Communication Disorder ( difficulty communicating due to a disruption in cognitive processes such as attention, memory, and problem solving), and Psychotic Disorder ( disconnection from reality ). The face sheet reflected under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #4's physician order summary, dated 12/12/24, reflected the following order: DNR-Do Not Resuscitate, dated 11/29/20. Record review of Resident #4's care plan, dated 04/19/21, reflected a care plan for DNR. Record review of Resident #4's OOH-DNR form, dated 05/02/19, reflected there was no printed physician's name associated with the physician's signature. 2. Record review of Resident #63's, undated, face sheet reflected an [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #63 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other mental functions), heart disease (diseased vessels, structural problems, and blood clots), and Cognitive Communication Disorder (difficulty communicating due to a disruption in cognitive processes such as attention, memory, and problem solving) and dysphagia (difficulty swallowing). The face sheet also reflected under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #63's physician order summary, dated 12/11/24, reflected the following order: DNR-Do Not Resuscitate dated 02/20/24. Record review of Resident #63's care plan, dated 02/06/24, reflected a care plan for DNR. Record review of Resident #63's OOH-DNR form, date retrieved on 02/13/2024, reflected there was no indication of the relation of the qualified relative who signed the DNR. The qualified relative did not sign or date the bottom of the DNR. During an interview on 12/12/24 at 12:52PM with the SW, she stated an OOH DNR was not valid if it was not filled out correctly. She stated she was not responsible for auditing OOH-DNRs, the ADM was responsible for auditing OOH-DNRs. She stated there was missed information on OOH-DNRs for Residents #4 and #63. She stated there was no system for monitoring OOH-DNRs for accuracy. She stated the reason the DNR's were not completed correctly was human error. She stated there was no potential negative outcome for residents as the staff would review other forms in the residents' record to determine if a resident was a DNR or Full Code. During an interview on 12/13/24 at 12:20 PM with the ADM, she stated the OOH DNR was not valid if it was not filled out correctly. She stated the SW was responsible for making sure the OOH DNR was completed accurately. She stated they did not have a system in place to monitor OOH DNRs for accuracy. She stated the SW should be reviewing the OOH DNRs for accuracy. She stated there was missing information on the OOH DNR for Residents #4 and #63. She stated the missing information was due to human error. She stated the potential negative outcome was residents may not have their final wishes followed. She stated she was trained on how to complete an OOH DNR and her expectations were for them to be filled out completely and be correct . Record review of the Social Services Policies and Procedures Advanced Directives (Revised August 2023) reflected the following: Policy Statement Advance directives will be respected in accordance with state law and facility policy . Prior to or upon admission, the Social Services Director will inquire of the resident, his or her family members about the existence of any written advanced directives. Information about whether or not the resident has executed an advance directive shall be displayed in the medical record. If the resident indicated he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives . The team will review annually with the resident his or her advance directives to ensure that such directives are still the wishes of the resident. Changes or revocation of a directive must be submitted in writing to the facility. The director of nurses or designee will notify the attending physician of advance directives as well as obtain appropriate orders. The licensed nurse will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive . The Social Services Director will maintain a list of Residents with an Advanced Directive on file. A code status audit will be conducted by the DON or designee on a quarterly basis or designee on a quarterly or as needed basis. Record review of the facility's undated policy titled Advance Directives reflected no information regarding the creation of an OOH DNR.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts (Medication Cart 2 and Medication Cart 4) reviewed for medication storage . 1. The facility failed to keep Medication Cart 2 free of loose and unlabeled pills. 2. The facility failed to keep Medication Cart 4 free of loose and unlabeled pills. These failures could place residents at risk of harm or decline in health due to lack of medication labeling. Findings include: 1. During an observation on [DATE] at 1:25 PM, with LPN A, revealed one oval white loose pill found on the last bottom drawer of medication cart 2. LPN A and the DON verified medication was metoprolol (a blood pressure medication). During an interview with LPN A at 1:25 PM, she stated she has been trained to check the medication carts daily when taking over the cart. She stated she was trained to check for cleanliness, expired medication or items, and loose pills. She stated the potential negative outcome of having loose pills in the cart could be a medication error if someone were to accidently grab it . 2. During an observation on [DATE] at 1:39 PM, with LPN B, revealed one round orange pill was found on the last bottom drawer of medication cart 4. LPN B and the DON verified the loose pill was Bisacodyl (a laxative). During an interview with LPN B on [DATE] at 1:39 PM, she stated the night shift usually checked the carts at night and she would also check the cart when she took over. She stated they were trained to check for expired medication and cleanliness. She stated her last training was approximately one year ago upon hire. She stated the potential negative outcome of having loose pills in the cart could be giving the wrong medication to a resident . During an interview with the DON on [DATE] at 10:08AM, she stated the medication carts should be checked daily. She stated the medication carts should be checked for expiration dates, loose pills and restock items as needed. She stated the DON and ADON would check the carts at least once a week as well as the medication room. She stated they monitored compliance by doing a check after a nurse completed their check of the medication cart. She stated the potential negative outcomes of loose pills in the cart could be a missed resident medication, and a potential for medication error. During an interview with the ADM on [DATE] at 10:59AM, she stated the nurses were trained to check the medication carts daily when they came on shift. She stated compliance was monitored by the nursing administration. The ADM stated the potential negative outcome could be a medication error, or the medication being placed in the incorrect bottle. Record review of the facility's policy titled Storage of Medications:, last revised in [DATE], revealed, Policy Statement The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation . 2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . .10. Resident medications are stored separately from each other to prevent the possibility of mixing.

Based on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 3 food forms (puree) at 2 of 4 meals (12/12/24 noon meal and 12/11/24 dinner meal) reviewed for palatability. The facility failed to provide food that was palatable for 1 of 3 food forms served (regular, mechanical soft and puree) at 2 of 4 meals observed (12/10/24 lunch and 12/11/24 dinner) . These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings include: During an observation on 12/10/24 at 12:20 PM revealed 4 puree plates served to residents with chunky baked chicken and okra/tomatoes with large seeds. During an observation on 12/10/24 at 12:35 PM revealed a test tray with rotisserie chicken that had large chunks of meat that had to be chewed. The okra/tomato had whole okra seeds that had to be chewed. During an observation on 12/11/24 at 03:51 PM revealed [NAME] A prepared puree hamburger meat, cheese, and bread per the menu. A test tray revealed the hamburger meat, cheese and bread puree had chunks that had to be chewed. [NAME] A prepared puree Mexican cream corn, a test tray revealed the Mexican cream corn had corn skin that had to be chewed . During an interview on 12/11/24 at 04:10 PM with [NAME] A, she stated puree should be smooth, like baby food. She stated she was not able to make the corn smooth. She stated puree diet was made for residents who were unable to chew or swallow. She stated she had been trained on how to prepare puree meals. She stated the potential negative outcome could be the resident choking. During an interview on 12/13/24 at 09:43 AM with the DM, she stated she was responsible for training staff. She stated puree foods should be the consistency of apple sauce texture with no chunks. She stated residents were on puree diet because they had trouble swallowing. She stated cooks were trained to add more liquid if needed and spin food around with spoon and then look at food for chunks. She stated the potential negative outcome could be a resident could choke or aspirate on the food chunks. During an interview on 12/13/24 at 10:00 AM with the ADM, she stated the DM trained all staff on how to prepare puree diets. She stated puree should be pudding consistency. She stated residents were on a puree did because they could not chew food. She stated the potential negative outcome could be a resident choking. Record review of the facility policy titled Texture Modifications, dated 2013, revealed the following documentation, Pureed Texture Description - the pureed texture is a mechanical modification of the Regular Diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and a poor ability to protect their airway. This texture allows pureed food (pudding like consistency) that is smooth and easily stays together. Food should be avoided if they require chewing. Coarse and dry texture, raw fruits and vegetables, breads and nuts should also be avoided . Food Group - Vegetable Food Allowed - Vegetables should be soft, well cooked and pureed without lumps, husk or seeds

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Residents #229) reviewed for infection control. CNA C and CNA D failed to utilized enhanced barrier precautions during foley care for Resident #229 on 12/11/2024. This failure could place residents at risk for infection and cross contamination. Findings include: Record review of Resident #229's, undated, face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #229 had a medication history of COPD (a condition caused by damage to the airways or other parts of the lung), fracture of the left femur, atrial fibrillation (abnormal heartbeat), and chronic kidney disease, end stage. Record review of Resident #229 admission MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 13, which indicated Resident #229 was cognitively intact. Record review of Resident #229 physician orders revealed an order for Foley Catheter care every shift and as needed, dated 10/23/2024. Record review of Resident #229's care plan revealed the following intervention Enhanced Barrier precautions, last revised 12/04/2024. During an observation of foley care on 12/11/2024 at 3:00 PM, revealed Resident #229's door had an Enhanced barrier precaution sign that was visible from the hallway and prior to entering the room. CNA C and CNA D entered Resident #229's room to perform foley care. CNA C and CNA D failed to use a gown for foley care. During an interview with CNA C on 12/11/2024 at 3:18 PM, she stated she was trained on infection prevention, but she was an agency CNA and did not remember being trained at this facility. She stated enhanced barrier precautions were utilized for residents who had tubes or wounds. She stated the enhanced barrier precautions were used to prevent contamination and many other things. She stated the potential negative outcomes could be passing infection to another resident. She stated with Resident #229 she was supposed to wear the gown, but she felt they did everything too fast and they did not grab the gown. She stated she realized she forgot the gown but did not want to say anything because she was nervous. She stated the infection preventionist at the facility was the DON. During an interview with CNA D on 12/11/2024 at 3:39 PM, she stated she was trained on infection control and her last training was about three weeks. She stated anytime a resident had a foley catheter or feeding tube, they were to use gloves and gowns. She stated she realized she forgot to wear the gown when she entered the room. She stated the potential negative outcome of not utilizing all the PPE could be spreading infection. She stated she utilized PPE for residents who were on EBP, but she got nervous and forgot to grab the gown. She stated the DON was the infection preventionist. During an interview with the DON on 12/12/2024 at 10:03 AM, she stated she was the infection preventionist. She stated staff were trained monthly on infection control and anytime anything came up. She stated she was doing more EBP training. She stated the potential negative outcome of staff not utilizing proper PPE could be spreading infection. She sated she expected her staff to wear the correct PPE when they provided care, and that was why the signs were on the doors. She stated she monitored compliance by doing rounds and educating staff. She stated she educated agency staff to make sure they knew what was expected and that they were aware of the rules. She stated they made rounds to make sure the correct PPE was being utilized. During an interview with the ADM on 12/12/2024 at 10:58AM, she sated the DON was the infection preventions. She stated staff were trained on EBP at least every three months. She stated compliance was monitored by making rounds. She stated the potential negative outcome of not utilizing proper PPE could be spreading infection. She stated for EBP, the staff was to wear gowns and gloves when they provided care. Record review of the facility's policy titled Enhanced Barrier Precautions last revised on 4/1/2024, revealed, . EBP are indicated for residents with any of the following: . Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO (multi-drug resistant organism) . Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies . The facility will ensure PPE and alcohol-based hand rub are readily accessible to staff prior to entry to their room. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities .changing briefs or assisting with toileting- yes don gloves and gown.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed and pureed under sanitary conditions. 2) The facility failed to ensure foods were stored in a manner to prevent contamination. 3) The facility failed to ensure foods were served at temperature above 135 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made during a kitchen tour on 10/17/23 that began at 9:00 AM and concluded at 10:10 AM: Dessert plates and dessert bowls stored right side up in tub on shelf. Raw chicken stored in tub on shelf in fridge above sack of raw onions. Bowl of fruit with marshmallow covered with plastic wrap stored above box of raw bacon dripping clear liquid onto open box. Cups of milk and juice stored on tray in fridge not covered and no date. The following observations were made on 10/17/23 at 11:00 AM during observation of puree meal preparation: After pureeing fried chicken, Cook A took processor bowl, lid, and blade to 3 compartments sink and cleaned all 3 parts. Cook A took all there parts back to processor base and assembled. Bowl had water in bottom and lid was dripping water. Cook A prepared puree corn then took processor bowl, lid and blade to dishwasher and ran through dishwasher. She then took bowl, lid and blade to processor base and assembled. The bowl, lid and blade had water on all of them. The following observation was made on 10/17/23 at 11:50 AM while observing Cook A take temperatures of puree foods. Puree chicken temp was 124 degrees Fahrenheit. Cook A placed puree fried chicken back in steam oven and closed the door. Cook A prepared resident tray by taking all 3 bowls out of steam oven and placed on plate. Cook A did not re-temp puree fried chicken. Record review temperature log dated October 17, 2023, revealed menu item: puree meat, acceptable temperature (degree F) 140-155-degree F, Tuesday 124-degree F. During an interview on 10/17/23 at 01:46 PM Cook A stated the temp for puree chicken was 124 degrees Fahrenheit. Cook A stated she forgot to recheck the temp of the puree chicken before serving it and stated she did not turn the steam oven back on because she did not want the puree to get to hot. She stated the steam oven will keep the puree food at the correct temperature. She stated she did not know what the temperature was when she served the puree chicken. She stated she cleaned the processor bowl, lid and blade in the 3 compartment sink the first time and the dishwasher the second time. She stated she did not allow the processor bowl, lid, or blade to air dry. She stated she was in a hurry and forgot to allow it to air dry. She stated they only have one processor bowl, lid, and blade. She stated she had been trained and the proper way was to allow it to air dry. She stated the potential negative outcome could be water or chemical on the bowl, lid, or blade. She stated raw chicken should have been stored on the bottom shelf. She stated she stored the chicken above the raw onions. She stated she did not realize the onions were on the bottom shelf. She stated the potential negative outcome could be cross contamination. She stated all food and drinks should be covered and dated. She stated staff who put the food/drinks in the refrigerator were responsible to making sure it was covered and dated. She stated the potential negative outcome of not dating the items or covering them was cross contamination and serving out of date food. During an interview on 10/19/23 08:47 AM DM she stated that chicken should be stored on the bottom shelf of the refrigerator. She stated that bowls and plates should be stored upside down never right side up. She stated that chicken should be served at 165 F. She stated all food items including drinks should be covered and dated. She stated the potential negative outcome could be contaminated food. She stated all staff have been trained and have safe serve certificates. She stated that all staff were responsible for making sure items were dated and covered when they put the items in the refrigerator. She stated that the food processor should be air dried before using again. She stated the potential negative outcome could be standing water with chemicals. During an interview on 10/19/23 09:15 AM the ADM stated that raw chicken should not be stored above raw onions. She stated that all dishes should be stored upside down. She stated all food items in the refrigerator should be covered and dated. She stated all staff were responsible to cover and dated food items placed in the refrigerator but that the DM was responsible for overseeing the dietary staff. She stated the potential negative outcome could be residents end up sick or the food becomes contaminated. She said all staff have their safe serve certificates. Record review of the facility policy, titled Cleaning Food Mixers, revised April 2004, revealed the following: Immediately after use: . 5. Air dry. Record review of the facility policy, titled Food Preparation and Service, dated October 2022, revealed the following: Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation Food Preparation Area . 4. Appropriate measures are used to prevent cross contamination. These include: a. Storing raw meat separately and in drip-proof containers, and in a manner that prevents cross-contamination from other foods in the refrigerator; . Thawing Frozen Food 1. Foods will not be thawed at room temperature. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container; . Food Preparation, Cooking and Holding Time/Temperatures 1. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause food borne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. therefore, PHF must be maintained below 41 F or above 135 F . 11. Mechanically altered hot foods prepared for a modified consistency diet remain above 135 F during preparation or they are reheated to 165 F for at least 15 seconds . Record review of the facility policy, titled Dietary/Food Handling, dated April 2001, revealed the following: Purpose: the purpose of this procedure is to provide guidelines for the safe preparation handling and storage of perishable food and proper environmental cleaning . 2. Temperatures must be maintained at the following (Fahrenheit) settings for the items indicated below: . e. Stuffing, poultry, stuffed meats, wild game - 165 degrees Fahrenheit or above; . 25. d. Open containers must be dated and sealed or covered during storage . Record review of the facility policy, titled Food Receiving and Storage, dated October 2022, revealed the following: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices . 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) . 13. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods .

Based on interviews and record review, the facility failed to ensure all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 3 of 24 residents (Residents #8, #35, and #59) reviewed for PASRR screening, in that: Residents #8, #35, and #59 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 Evaluation and no PASRR Level 2 Evaluation at risk for not receiving care and services to meet their needs. The findings included: Resident #8: Record review of Resident #8's electronic face sheet dated 10/18/2023 revealed a [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Schizoaffective Disorder/Depressive Type. Record review of Resident #8's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Schizoaffective Disorder/Depressive Type. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 indicating the resident was cognitively intact. Record review of Resident #8's most recent care plan, undated, revealed a focus area and diagnosis of Schizoaffective Disorder/Depressive Type, this problem started 01/07/2022. Resident #8 was prescribed Cymbalta 30mg once a day and Risperdal 4mg once a day to assist with this area of need. Record review of Physician progress notes for Resident #8 dated 10/18/2023 revealed under current medications, Resident #8 was prescribed Cymbalta 30mg once a day and Risperdal 4mg once a day to assist with Schizoaffective Disorder/Depressive Type . Record review of Resident #8's Preadmission Screening and Resident Review Level One (PL1) form dated 03/08/2021 revealed under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. Resident #35: Record review of Resident #35's electronic face sheet dated 10/18/2023 revealed a [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of PTSD, Chronic. Record review of Resident #35's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of PTSD. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 14 indicating the resident was moderately cognitively impaired. Record review of Resident #35's most recent care plan, undated, revealed a focus area and diagnosis of PTSD, this problem started 03/24/2021. Resident #35 was prescribed Abilify 10mg twice a day, Paroxetine 20mg once a day, and Topiramate 50mg twice a day to address this diagnosis. Record review of Physician progress notes for Resident #35 dated 09/06/2023 revealed under current medications, Resident #35 was prescribed Abilify 10mg twice a day, Paroxetine 20mg once a day, and Topiramate 50mg twice a day to address her diagnosis of PTSD. Record review of Resident #35's Preadmission Screening and Resident Review Level One (PL1) form undated revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #59 Record review of Resident #59 electronic face dated 10/18/2023 revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, Major Depressive Disorder. Record review of Resident #59's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Major Depressive Disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 0 indicating the resident was severely cognitively impaired. Record review of Resident #59 most recent care plan, undated, revealed a focus area and diagnosis of Major Depressive Disorder, this problem started 01/30/2023. Resident #59 was prescribed Sertraline 100mg once a day to assist with this area of need. Record review of Physician progress notes for Resident #59 dated 10/18/2023 revealed under current medications, Resident #59 was prescribed Sertraline 100mg once a day for Major Depressive Disorder. Record review of Resident #59's Preadmission Screening and Resident Review Level One (PL1) form dated 1/12/2023 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview conducted on 10/19/23 at 11:00am with the ADM, she verified Residents #8, #35, and #59 had a diagnosis of mental illness. The ADM verified Residents #8, #35, and #59 did not have PASRR 2 Evaluations as all their PASRR 1 Evaluations were negative. The ADM stated the purpose of the PASRR 1 Evaluation was to identify if a Resident required additional services. She said if the PASRR 1 Evaluation was positive then it gets put into an online system and they reach out to the necessary people to ensure a PASRR 2 Evaluation was done. She said the MDS nurse was responsible for entering the PASRR 1 Evaluation into the system. The ADM stated the potential harm if a resident with a diagnosis of a mental illness who had a negative PASRR 1 Evaluation, and no subsequent level two evaluation was the residents could potentially go without services. During an interview with the MDS nurse on 10/19/23 at 11:25am, she stated Residents #8, #35, and #59 did not have PASRR 2 Evaluations as all of the Residents had negative PASRR I Evaluations. The MDS nurse stated Residents #8, #35, and #59 do not have accurate PASRR 1 Evaluations as the residents have a diagnosed mental illness. The MDS nurse stated it was her responsibility to ensure every resident entering the facility had a completed and accurate PASRR 1 Evaluation. The MDS nurse stated she did not know why #8, #35, and #59 did not have positive PASRR 1 Evaluations due to having had a mental illness diagnosis. The MDS nurse stated the potential negative outcome for residents not having an accurate PASRR 1 Evaluation and subsequent PASRR 2 Evaluations would be the residents may not be offered the services they may need for their diagnosis. Preadmission Screening and Resident Review (PASRR) Policy Revised 7/18/2018: The facility policy for PASARR states all applicants to a Medicaid-certified nursing facility must have a Level I PASRR completed to screen for possible mental illness. Residents with positive PASRR Level I cannot be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those Residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 4 of 4 (Residents #19, #26, #59, and #171) and 5 of 7 (LVN A, CNA A, CNA C, CNA E, and CNA F) staff reviewed for infection control. 1. LVN A failed to wear gloves while checking the blood sugar for Resident #26 or perform hand hygiene after the procedure. 2. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #19. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #171. 4. CNA E and CNA F failed to perform hand hygiene between glove changes when providing incontinent care for Resident #59. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #26 A record review of Resident #26's face sheet, dated 10/18/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include generalized osteoarthritis (bone disease), depression (mental illness), and type 2 diabetes mellitus (high blood sugar). Record review of Resident #26's comprehensive Minimum Data Set (MDS) assessment, dated 08/21/23, revealed Resident #26 had a BIMS of 03 which indicated the resident's cognition was severely impaired. During an observation on 10/17/23 at 11:52 AM, LVN A checked the blood sugar for Resident #26 and did not wear gloves. LVN A did not perform hand hygiene after checking Resident #26's blood sugar and before going back into the medication cart. During an interview on 10/17/23 at 2:20 PM with LVN A, she stated had been trained to wear gloves when doing blood sugar checks and to wash hands after providing care to the resident. LVN A stated she forgot to wear gloves and wash her hands after providing care because she was nervous. LVN A stated the potential negative outcome to the resident was possible infection. Resident #19 Record review of face sheet for Resident #19, dated 10/18/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: covid-19 (respiratory infection), unspecified dementia (cognitive loss), and type 2 diabetes (high blood sugar). Record review of Resident #19's comprehensive MDS, dated [DATE] revealed Resident #19 had a mental assessment by staff which indicated the resident's cognition was moderately impaired. The MDS revealed Resident #19 required total dependence with one person assist for toilet use and total dependence with one person assist for personal hygiene. The MDS further revealed Resident #19 was always incontinent of bladder and bowel. During an observation on 10/18/23 at 6:25 AM, CNA A was providing incontinent care for Resident #19 with the help of CNA B. CNA A washed her hands with soap and water and donned clean gloves. CNA A wiped Resident #19's groin area, removed her gloves and donned a pair of clean gloves. Resident #19 was turned and CNA A wiped her buttocks, removed her gloves and donned a pair of clean gloves. CNA A applied barrier cream to Resident #19's buttocks, removed her gloves and donned a pair of clean gloves. CNA A then placed a clean brief on Resident #19. CNA A did not perform hand hygiene between any of the glove changes. During an interview on 10/18/23 at 7:08 AM with CNA A, she stated she has been trained to perform hand hygiene between glove changes. CNA A stated they do skills check off's but cannot remember the last time it was done. CNA A stated she should have done performed hand hygiene between glove changes but forgot to take ABHR in the room with her. CNA A stated the potential negative outcome to the residents was a risk of infection. Resident #171 Record review of face sheet for Resident #171, dated 10/18/23, revealed a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease (lung disease), dementia (cognitive loss), muscle weakness, and essential hypertension (high blood pressure). Record review of Resident #171's comprehensive MDS, dated [DATE] revealed Resident #171 had a BIMS of 01 which indicated the resident's cognition was severely impaired. Resident #171 required extensive assistance with one person assist with toilet use and personal hygiene. Resident #171 was always incontinent of bladder and bowel. During an observation on 10/18/23 at 6:40 AM, CNA C was providing incontinent care for Resident #171 with the help of CNA D. CNA C washed her hands with soap and water and donned clean gloves. CNA C wiped Resident #171's groin area, removed her gloves and donned a pair of clean gloves. Resident #171 was turned on her side and CNA C wiped her buttocks, removed her gloves and donned a pair of clean gloves. CNA C then placed a clean brief on Resident #171. CNA C did not perform hand hygiene between any of the glove changes. During an interview on 10/18/23 at 8:20 AM with CNA C, she stated she has been trained to perform hand hygiene between glove changes. CNA C stated she does not remember the last time she was trained. CNA C stated she just forgot to perform hand hygiene between the glove changes. CNA C stated the potential negative outcome to the residents is contamination between clean and dirty and bad germs. Resident #59 Record review of face sheet for Resident #59, dated 10/18/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: acute embolism and thrombosis of deep veins of right lower extremity (blood clot in leg), gastro-esophageal reflux disease (acid reflux), urinary tract infection, and hyperlipidemia (high cholesterol). Record review of Resident #59's MDS, dated [DATE] revealed Resident #59 had a mental status assessment performed by staff and which indicated the resident had modified independence with cognitive skills for daily decision making. Resident #59 required total dependence with two-person assist for toilet use and extensive assist with two-person assist for personal hygiene. Resident #59 had a catheter and was always incontinent of bowel. During an observation on 10/18/23 at 6:46 AM, CNA E and CNA F provided catheter care and incontinent care for Resident #59. CNA E and CNA F washed their hands with soap and water and donned clean gloves. CNA E wiped Resident #59's groin area and provided catheter care to his indwelling catheter. CNA E removed her gloves and donned a pair of clean gloves. Resident #59 was turned, and CNA E wiped a bowel movement from his buttocks, removed gloves, and donned a pair of clean gloves. Resident #59 was turned to the other side and CNA F then wiped the excess bowel movement from his buttocks. CNA F removed gloves and donned a pair of clean gloves. A clean brief was then placed under Resident #59. CNA E and CNA F did not perform hand hygiene between any of the glove changes. During an interview on 10/18/23 at 7:02 AM, CNA E and CNA F stated they have been trained to perform hand hygiene between glove changes. CNA E and CNA F stated they didn't think about hand hygiene between glove changes because they were nervous. CNA E and CNA F stated the potential negative outcome to the resident is it could cause infection. During an interview on 10/18/23 at 3:05 PM, the ADON stated herself and the DON were both responsible for monitoring staff for infection control concerns. The ADON stated she expects the nurses to wear gloves and perform hand hygiene when doing blood sugar checks on residents. The ADON stated she was really big on handwashing and expected the CNAs to perform hand hygiene between glove changes. The ADON stated LVN A and the CNAs were probably nervous and that is why they messed up. The ADON stated the nurses and CNA's do handwashing competencies yearly but was unsure the last time it was done and stated she would have to pull those records. The ADON stated the risk to the residents with not wearing gloves during blood sugar checks and not performing hand hygiene after providing resident care or between glove changes was the staff could be spreading infection and bacteria everywhere. During an interview on 10/19/23 at 8:47 AM, the DON stated she expects the nurses to wear gloves anytime they are dealing with resident's blood or bodily fluids. The DON stated she expects staff to perform hand hygiene after resident procedures and between glove changes, no exception. The DON stated she did not know why the nurse did not perform hand hygiene after the blood sugar check or wear gloves to check the resident's blood sugar as blood was involved. The DON stated she thought the CNAs were nervous and that is why they failed to perform hand hygiene between glove changes, but that was still no excuse. The DON stated the ADON and she are responsible for monitoring staff for infection control. The DON stated the staff has completed competencies and she would have to pull them to be reviewed. The DON stated the potential negative outcome to the residents is possible infection or urinary tract infections. During an interview on 10/19/23 at 9:40 AM, The Assistant ADM stated she expected staff to wash hands before and after providing patient care. The Assistant ADM stated she expected staff to wear gloves when dealing with blood or body fluids. The Assistant ADM stated she did not know why LVN A did not wear gloves or perform hand hygiene after the blood sugar check. The Assistant ADM stated she expected the CNAs to wash their hands or use hand sanitizer between glove changes. The Assistant ADM stated she did not know why the CNAs did not perform hand hygiene between glove changes and stated they were probably nervous. The Assistant ADM stated the DON and the ADON were responsible for monitoring staff for infection control. She stated the risk to the residents with the lack of gloves and lack of hand hygiene was they could spread infection. Record review of competency assessment: Obtaining a fingerstick glucose level for LVN A revealed satisfactory completion was demonstrated on 09/27/22 and included wearing gloves and performing hand hygiene after care. Record review of initial/annual nurse aide competency review for LVN A, dated 06/24/23, revealed satisfactory completion of handwashing, perineal care, and when handwashing should be performed checklist. Record review of initial/annual nurse aide competency review for LVN C, dated 07/15/23, revealed satisfactory completion of handwashing, perineal care, and when handwashing should be performed checklist. Record review of initial/annual nurse aide competency review for LVN E, dated 07/15/23, revealed satisfactory completion of handwashing, perineal care, and when handwashing should be performed checklist. Record review of initial/annual nurse aide competency review for LVN F, dated 06/24/23, revealed satisfactory completion of handwashing, perineal care, and when handwashing should be performed checklist. Record review of the facility's policy titled, Infection Prevention and Control Program, with a revised date of 12/21, reflected the following: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections Record review of the facility's policy titled, Obtaining a Fingerstick Glucose Level, with a revised date of 12/11, reflected the following: Purpose: The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level . Steps in Procedure 5. Wear clean gloves . 19. Remove gloves and discard into designated container 20. Wash hands Record review of the facility's policy titled, Personal Protective Equipment - Using Gloves, with a revised date of 06/05, reflected the following: Purpose: To guide the use of gloves. Objectives: 1. To prevent the spread of infection; 3. To protect hands from potentially infectious material; and 4. To prevent exposure to the HIV (AIDS) and hepatitis B (HBV) viruses from blood or body fluids. Miscellaneous: 4. Use non-sterile gloves primarily to prevent the contamination of the employee's hands when providing treatment or services to the patient and when cleaning contaminated surfaces. 5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) When to use gloves: 1. When touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin Record review of the facility's policy titled, Handwashing-Hand Hygiene Policy and Procedures, with a revised date of 10/20, reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies . 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. when hands are visibly soiled; and b. after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. before and after direct contact with residents; j. after contact with blood or bodily fluids; m. after removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of gloves use along with routine. 10. hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 11. single-use disposable gloves should be used: b. when anticipating contact with blood or body fluids . Applying and Removing Gloves: 1. Perform hand hygiene before and after applying non-sterile gloves

Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 26 (Resident #26) residents in that: LVN A failed to provide Resident #26 privacy during a blood sugar check. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: A record review of Resident #26's face sheet, dated 10/18/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include generalized osteoarthritis (bone disease), depression (mental illness), and type 2 diabetes mellitus (high blood sugar). Record review of Resident #26's Comprehensive Minimum Data Set (MDS) assessment, dated 08/21/23, revealed Resident #26 had a BIMS of 03 which indicated the resident's cognition was severely impaired. During an observation on 10/17/23 at 11:52 AM, LVN A was checking the blood sugar for Resident #26 in her room. LVN A did not close the door or pull the privacy curtain closed to provide privacy for Resident #26. Several people were observed passing by in the hallway and looking in the room while LVN A was checking the blood sugar for Resident #26. During an interview on 10/17/23 at 2:20 PM with LVN A, she stated she had been trained to provide privacy by shutting the door and pulling the curtain closed during procedures. LVN A stated she did not think about closing the door or pulling the privacy curtain closed due to the resident being alone in the room. LVN A stated the potential negative outcome to the resident was not preventing dignity concerns. During an interview on 10/19/23 at 8:47 AM with the DON, she stated she expected staff to provide privacy and dignity regardless of the procedure the resident was having. The DON stated she thought LVN A was nervous and that was why she forgot to provide privacy and dignity for Resident #26's blood sugar check. The DON stated the risk to the resident was they could have exposure of body parts they did not want exposed or other's may be able to know of the resident's specific health problems. During an interview on 10/19/23 at 9:40 AM with the Assistant ADM, she stated dignity should be a high priority with staff. The Assistant ADM stated the curtain should be pulled and the door closed when staff enter a room to provide care. The Assistant ADM stated she did not know why the nurse did not provide dignity during the blood sugar check. The Assistant ADM stated herself and the DON were responsible for ensuring staff provide dignity during care. The Assistant ADM stated the potential negative outcome to the residents was they (the residents) could be affected emotionally due to being exposed physically. Record review of the facility's policy titled, Quality of Life - Dignity, dated February 2020, reflected the following: Policy Statement: Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times . 10. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures

Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 26 residents (Residents #18 and #39) reviewed for care plans as follows: 1. Resident #18 did not have a care plan for indwelling catheter. 2. Resident #39 did not have a care plan for activities of daily living/rehabilitation potential, urinary incontinence, nutritional status, pressure ulcer risk or pain. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Resident #18 Record review of Resident #18's face sheet, dated 10/17/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses to include atrial fibrillation (irregular heartbeat, pneumonia (lung infection), diabetes (high blood sugar), pain, muscle weakness and hypertension (high blood pressure). Record review of Resident #18's Comprehensive Minimum Data Set, dated dated [DATE], revealed Resident #18 had a BIMS score of 11 which indicated Resident #18's cognition was moderately impaired. Resident #18's bladder and bowel assessment revealed Resident #18 had an indwelling catheter. The Care Area Assessment (problem areas) revealed indwelling catheter was a care area that would be addressed in the care plan and was marked on the care area assessment to be care planned. Record review of Resident #18's care plan, dated 09/19/23, revealed no care plan for indwelling catheter. During an interview on 10/18/23 03:20 PM with Resident #18, she stated she had foley catheter when she was admitted to the facility. She stated she was not sure if staff provide catheter care. She stated the staff might clean the catheter when they change her brief and she was not aware they were providing catheter care. Resident #39 Record review of Resident #39's face sheet, dated 10/17/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include hypertension (high blood pressure), atrial fibrillation (irregular heartbeat), heart failure, COPD (lung disease), major depression disorder (mental illness), and muscle weakness. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #39 had a BIMS of 15 which indicated the resident's cognition was not impaired. The functional status section revealed Resident #39 requires limited one person assistance with bed mobility, dressing, and personal hygiene. This section further revealed Resident #39 required extensive assistance with one person assistance for transfers, locomotion on and off unit, toilet use and bathing. Bladder and bowel revealed Resident #39 was always incontinent of urine and bowel. Swallowing and nutritional status revealed Resident #39 had a swallowing disorder (coughing and choking during meals or when swallowing medications). It further revealed resident had a mechanically altered - therapeutic diet. Skin condition section revealed Resident #39 was at risk for pressure ulcers. Section - Health conditions revealed Resident #39 received as needed pain medication and had pain almost constantly. The Care Area Assessment (problem areas) revealed ADL (activity of daily living) functional/rehabilitation potential, urinary incontinence, nutritional status, pressure ulcer and pain were care areas that should be addressed in the care plan and was marked on the care area assessment to be care planned. Record review of a care plan dated 09/20/23 for Resident #39 did not reveal a care plan for ADL functional/rehabilitation potential, urinary incontinence, nutritional status, pressure ulcer or pain. During an interview on 10/18/23 at 02:00 PM Resident #39 stated she eats in the assisted dining room because she was a choking risk. She stated her food was chopped up in small pieces and she needs gravy with every meal. She stated there has been several times she did not receive the gravy with her meal. She stated she would have to request it after receiving her meal. She stated she was incontinent of bowel and bladder and requires assistance from staff. She stated her pain was controlled with pain medications. She stated she was receiving physical therapy. During an interview on 10/18/23 03:07 PM the DON stated Resident #39 triggered care areas was not care planned. She stated all that was care planned was code status, medication allergies, actual fall, and psychotropic medications. During an interview on 10/19/23 at 09:05 AM the DON stated there was no care plan for indwelling catheter for Resident #18. She stated the MDS nurse had been doing care plans, but she had recently took then back and she was responsible care plans. She stated all CAA (care area assessment) areas should be care planned unless it was determined it's not an issue for the resident. She stated all missing CAA for Resident #18 and #39 should have been care planned. She stated that Resident #39 had a basic care plan, but no comprehensive care plan has been completed yet. She stated that she has done an audit of all care plans in the facility and has not had time to complete the missing care plans. She stated that the care plan was information used to take care of residents. She stated everyone uses the care plans. She stated the potential negative outcome was not knowing how to care for resident. She stated you could transfer someone wrong or not provide the right ADL's if the information was not there. She stated everything should be care plan related to resident care, behaviors, and special conditions. She stated her expectations were for all CAAs to be care planned along with ADL information. She stated that she has been trained on care plans. During an interview on 10/19/23 09:15 AM the ADM stated the DON was responsible for care plans. She stated that all CAA areas should be care planned. She stated the potential negative outcome could be residence not receiving care they needed and could cause harm by not receiving the proper care. She stated the care plan was used for individualized care for each resident so everyone's on the same page and knows how to care for that resident. She stated her expectations were for the care plans to be accurate and applicable for that resident so we can provide the highest quality of care possible. Record review of the provided facility's policy titled Care Plans, Comprehensive Person-Centered, revised [DATE], revealed: Policy Statement - a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical mental and psychosocial well-being. c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights including the right to refuse treatment .

Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 2 of 2 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 1 of 3 food forms served (Regular, Mechanical soft and pureed) at 2 of 2 meal observed (10/17/23 and 10/18/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During an observation on 10/17/23 at 11:00 AM Cook A prepared puree fried chicken, corn, and green beans. Surveyor tasted fried chicken had a powder texture on tongue with large chunks that had to be chewed. The corn had large pieces of corn skin and greens with strings. During an observation on 10/18/23 at 12:45 AM surveyor tested a puree test tray with the following items: pork riblets, okra, roll and watermelon. It was found pork riblets not smooth had large chunks that had to be chewed. Okra had large okra seeds that had to be chewed and watermelon with large chunks and thickener flavor. During an interview on 10/19/23 at 08:30 AM Cook A stated puree should not have chunks in it. She stated it should be smooth as baby food. She stated they did not have any cream style corn was the reason she used whole kernel corn. She stated the potential negative outcome could be chocking because resident cannot swallow. She stated she has been trained on how to prepare puree foods. During an interview on 10/19/23 at 11:30 AM DM stated puree food should be smooth with no lumpy texture. She stated all staff have been trained on how to prepare puree foods. She stated they currently only have 2 residents who requires a puree diet, but one was in the hospital. She stated the potential negative outcome could be a choking hazard and hard for resident to swallow. During an interview on 10/19/23 09:15 AM the ADM she stated puree food should be smooth. She stated all staff have safe server certificates. She stated her expectations are for puree to be smooth. She stated the potential negative outcome was chocking or difficulty swallowing food. Record review of the facility policy titled Diets and Texture: Pureed Texture, dated 2019, revealed the following documentation, Description The Pureed texture is a mechanical modification of the Regular Diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and a poor ability to protect their air way. This texture allows pureed food (pudding like consistency) that is smooth and easily stays together. Food should be avoided if they require chewing. Coarse and dry textures, raw fruits and vegetables, breads and nuts should also be avoided . It is critical that standardized recipes be followed when preparing pureed foods to ensure nutritional quality is maintained . Vegetables should be soft, well cooked and pureed without lumps, husk, or seeds . All fruit that can pureed to a smooth consistency without pulp, seeds, skin, or chunks .

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of seven residents (Resident #1) reviewed for quality of care. The facility staff left Resident #1, who had four pressure ulcers, sitting up in her wheelchair for approximately five hours on the night shift on 4/28/2023 isolated in her room. These failures could place residents at risk for complications including skin break down, infection, or decreased physical and mental functioning. The findings included: Record review of Resident #1's face sheet, dated 05/01/023, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, stage four Secondary Malignant Neoplasm of Bone (a cancer that has started in another part of the body and has spread (metastasized) to the bone via the bloodstream or lymph nodes), Follicular Lymphoma (cancer in spine), disease of spinal cord, cord compression, chronic pain, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris (reduction of oxygen-rich blood supply to the heart muscle), Chronic Obstructive Pulmonary Disease (obstructed airflow from the lungs), Reduced Mobility, Restless Legs Syndrome, Lack of Coordination, Hypertension (high blood pressure), Anxiety Disorder. Record reviewed Resident #1's admission MDS assessment dated [DATE] revealed the following: BIMS score of 15 out of 15 (indicated cognition was intact); Activities of Daily Living (ADL) Assistance: Total dependence, two-person assistance with transferring (mechanical lift) and bathing, one-person assist with locomotion on & off unit; Extensive assistance, two-person assist with bed mobility, dressing, toilet use and personal hygiene; uses a wheelchair for mobility and is incontinent of bladder and bowel; Skin Conditions: admitted with Unhealed Pressure Ulcers/Injuries = 3 stage 2 pressure ulcers and 1 stage 3 Record reviewed Resident #1's progress notes dated 03/28/2023, LVN #1 reflected resident returned to facility with foley catheter. Record reviewed Resident #1's progress notes dated 03/28/2023, LVN #2 reflected resident returned to facility oxygen at 2 liters per minute via nasal cannula as needed. Record reviewed Resident #1's progress notes dated 03/29/2023, Wound Care RN reflected resident returned to facility three pressure ulcers to left buttock and one to coccyx (tail bone) have declined and have worsened. The three ulcers on the buttock are now stage three due to slough (base of ulcer is covered by yellow, tan, gray, green or brown) to wound bed. Resident states that she was not turned while at the hospital. Record reviewed Resident #1's quarterly MDS assessment dated [DATE] revealed the following: Resident #1 now has an indwelling catheter, has four Stage 3 pressure ulcers (admitted with three stage 2 and one stage 3), and on oxygen therapy Record reviewed Resident #1's physician orders: Order Date 04/20/2023: Keep HOB (head of bed elevation) at 10 degrees except for meals; rotate between right and left side every 2 hours. Order Date 04/27/2023: Resident to be out of bed for all meals and is to return to bed after meals three times a day. Record reviewed Resident #1's care plan dated 03/20/2023 and revised on 04/05/2023 reflected: Focus: Pressure Ulcers (pu) stage 2 on left lower buttock, stage 2 to left mid buttock, stage 2 to left upper buttock, stage 3 to coccyx. -03/29/2023 readmitted from hospital and the stage 2 pu were upstaged to a Stage 3 -04/07/2023-Stage 3 pu to left mid buttock merge stage 3 lower upper buttock Interventions/Task: Resident needs assistance to turn/reposition at least every 2 hours, more often as needed or requested. In an interview and observation on 05/01/2023 at 4:30 PM, Resident #1 stated she was left in her wheelchair last Friday (4/28/2023) until after 2:00 AM in her room with the door shut. Her call light was at the top of the bed in the middle of the pillow, and she could not reach it. The wheelchair pedals stuck out to far and she cannot lean over because of the cancer in her spine. She could not get over to the door for her roommate had a fall mat on the floor and she could not roll the wheelchair over it. Resident #1 continued stating last time she had seen a staff member, or anybody was at 9:30 PM that evening. She stated no one came to her room until after she called her family member at about 2:00 AM (04/29/2023) and then they came in and asked her are you still up in your chair. Resident #1 stated she was in severe pain in her back, her butt, and her bladder (observed resident wiping tears from her eyes). She stated she was really scared that no one came in the room even when she was screaming for help. She stated due to some recent health issues with her heart and lungs, she was afraid for something like that to happen again and no one was there to help her. Resident #1 stated the catheter was causing a lot of pain and she asked the nurse to take it out and in which that relieved some of the pressure and pain. In an interview on 05/01/2023 at 5:05 PM, the wound care RN stated the pressure ulcers were not any worse after the resident was left in her wheelchair for 5 plus hours, however, she was not happy about the situation. In an interview on 05/01/2023 at 5:10 PM, the DON stated she found out about the incident with Resident #1 in her wheelchair for five plus hours this morning (05/01/2023) at 8:30 AM. The DON stated confirmed the nurse on the night shift (04/28-29/2023) was an agency nurse. She stated she had been calling the that particular agency nurse to question the agency nurse related to the incident with Resident #1 of no one checking on the residents, however, the agency nurse was not answering the phone or returning the phone messages. The DON stated Resident #1 did admit with three stage 2 pressure ulcers and one stage 3. The DON stated the night shift tonight was the shift that worked 04/28-29/2023 and she planned on speaking with them all. In an interview on 05/01/2023 at 6:58 PM, CNA #2 stated she (CNA #2) did work 04/28-29/2023. She stated CNA #1 came in late for her shift at 6:00 PM, she came in about 8:00 PM and then she left about 9:30 PM. CNA #2 stated CNA #1 asked her to watch for call light on her hall (Hall 3). She stated she did not put Resident #1 back to bed but did go in the room when the nurse asked for them to help her. She stated Resident #1 was in a lot of pain in her bladder, legs, and butt. She was crying when they got in the room. In an interview on 05/01/2023 at 7:15 PM, CNA #3 stated CNA #1 got the facility about 8:00 PM for her shift and then CNA #3 took a break about 9:00 and got back to facility about 11:30 PM. She stated CNA#2 asked her to help with Hall 3. She stated she did help put Resident #1 back to bed. She stated Resident #1 was in a lot of pain and crying. In an interview on 05/01/2023 at 7:43 PM, CNA #4 stated she normally works the day shift, but CNA #1 was coming in late, and she stayed to help until CNA #1 came into work. She stated when CNA #1 came in she said there were three residents had not been laid down, Resident #1 was one of them. She stated Resident #1 was waiting for friend to come by. CNA #4 stated per the wound care RN orders, Resident #1 needs to be turned every two hours and not in her wheelchair longer than two hours. During in observation on 05/02/2023 at 10:00 AM, Resident #1 was lying in bed on her right side. In an interview on 05/02/2023 at 12:20 PM, DON stated she has not been able to reach the agency nurse from the night shift 04/28-29/2023. She stated I am very upset with situation. I expect more from my staff. A resident should be seen every hour; CNA rounds every two hours and the nurse rounds on the opposite two hours. She stated that particular agency nurse will not be coming back to the facility. In an interview on 05/02/2023 at 2:03 PM, Resident #1 stated she did not know the facility's number and all she could think of was to call her family member for help. In an interview on 05/02/2023 at 3:16 PM, Resident #1's family member stated she received three calls from Resident #1. First call came in at 2:02 AM with a voicemail, Resident #1 was crying saying she had been up for about 5 hours; second call came 2:08 AM; and third call and voicemail came at 2:24 AM. She stated when she heard Resident #1's voice crying and telling her what was going on, she immediately called the nurses' station and talked to the nurse. The next morning, she spoke with Resident #1 and Resident #1 told her she really had been up in her wheelchair since before dinner last night, approximately 10 hours. In an interview on 05/02/2023 at 3:38 PM, CNA #1 stated she drives from another town, and she let the facility know she was going to be late for her shift. She stated CNA #4 had covered for her until she got to the facility. CNA #4 reported to her a couple of the residents wanted to stay up, Resident #1 and her roommate. CNA #1 stated about 9:30 PM, she went to Resident #1's room and changed her roommate and put her to bed and Resident #1 was waiting for a friend and wanted to stay up a little bit longer. CNA #1 stated she took her break at 10:00 PM and told CNA #2 to catch her call lights until she got back. She stated when she returned from break it was about 1:00 AM by the time she got to Resident #1's room and was shocked Resident #1 was still sitting in her wheelchair. CNA #1 stated she apologized to resident for not getting her to bed and Resident #1 stated she wanted to call her family member and wheeled herself to the nurse's station. In an interview on 05/02/2023 at 5:15 PM, the administrator stated, the situation was unacceptable, and the CNA #1 will be terminated. She stated there has been training with all staff of monitoring residents during the day and night. In an interview on 05/02/2023 at 5:25 PM, the DON stated she has already revamped her orientation/training for all agency staff. She stated she had also started competency check with all staff. Record reviewed facility policy title Repositioning Level II (revised date May 2013) states the following: Purpose The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed - or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Interventions 3. Residents who are in bed should be on at least an every two (q2 hour) repositioning schedule. 5. Residents who are in a chair should be on every one-hour (q1 hour) repositioning schedule. Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated. 3. Report other information in accordance with facility policy and professional standards of practice.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 3 of 3 staff (Dietary staff A and B and Dietary Manager), in that: 1)The facility failed to ensure Dietary staff (Dietary Manager and Dietary staff A) used sanitizers as directed and sanitizer levels were maintained according to manufacturer recommendations, 2) The facility failed to ensure Dietary staff (Dietary staff A) used good hygienic practices during dietary duties (handwashing/glove changes), 3) The facility failed to ensure foods and food contact equipment were protected from possible contamination during processing and service (Dietary Manager and Dietary staff A and B) These failures could place residents at risk for food contamination and foodborne illness. The findings include: The following observations were made during a kitchen tour that began on 8/23/22 at 10:57 AM and concluded at 11:29 AM: The red bucket solution in the tea station area had a quaternary sanitizer level of 100 ppm. It was tested by the Dietary Manager. Record review of the label on the Solution QA Ultra AutoChlor quaternary sanitizer stated that the level to maintain in order to sanitize food equipment was 200 to 400 ppm. On 8/23/22 at 11:00 AM the Dietary Manager stated during an interview that she prepared the quaternary sanitizer in the tea station red bucket that morning. The following observations were made during a kitchen tour that began on 8/23/22 at 11:45AM and concluded at 12:24 PM: On 8/23/22 at 12:00 PM Dietary staff A used the wiping cloths from the tea station area red bucket and wiped off a rear preparation table. The tea station area red bucket solution was tested , and the quaternary sanitizer level was 100 ppm and the water was dirty and had wet wiping cloths stored in the water. ~ The following observations were made during a kitchen tour that began on 8/23/22 at 3:48 PM and concluded at 4:30 PM: Purée preparation was observed. The Dietary Manager placed soup into the processor and then puréed the mixture. She poured the mixture into three bowls and then took the processor parts to the three-compartment sink and rinsed the parts with water only and failed to sanitize the parts. The inside of the processor still had bits of food and was wet on the interior. Dietary staff A then placed scoops of macaroni salad and milk into the wet processor and puréed the mixture. He took the mixture and poured it into three bowls. Dietary staff A then took the parts to the dishwasher and sprayed them with water from the soiled side of the dishwasher. He then rinsed the parts in the three compartment sink along with the pitcher that he used for milk. The parts were only rinsed with clear water. The parts were still wet and Dietary staff A placed scoops of tuna salad and water in the processor and purée the mixture. He poured the mixture into three bowls. Dietary staff A was observed wiping off the prep table where the processor was and the exterior of the processor by using wiping cloths from a solution in a green bucket. After using the wiping cloth, he placed it in the red bucket sanitizing solution that were both located at the front of the kitchen. On 8/23/22 at 4:14 PM an interview was conducted with Dietary staff A regarding the sanitizer and contents of the red and the green buckets. He stated, both buckets had sanitizer in it. He was asked to test the sanitizer concentration in the buckets and the green bucket had less than 100 ppm quaternary sanitizer and the red bucket had 100 ppm quaternary sanitizer. Both buckets had wiping cloths stored in them. After testing the sanitizer concentration in the buckets Dietary Staff A (Cook) failed to change the sanitizer in the buckets. On 8/23/22 at 5:35 PM Dietary staff A was observed dropping a paper tray ticket on the floor at the service line. He picked it up with his gloved hand and then removed that soiled glove and set it on the cart next to pans of tuna and macaroni salad. He then donned another glove by using the gloved hand that removed the soiled glove. He then continued serving meal trays. He failed to wash his hands before donning the glove or completely changing his other glove and washing his hands. On 8/23/22 at 6:02 PM an interview was conducted with Dietary staff A. He stated he did not know what the correct concentration was for quaternary sanitizer and that the bucket solutions were already made/set up by the time he arrived to work. He stated that he did not sanitize the processor because some days he would run it through the dishwasher and sometimes not. He stated these errors occurred because he tried to do too many things at once and was nervous. He stated he had been trained on the correct sanitizer levels in the past. He added that he had not changed the sanitizer in the buckets because it was usually changed when he got to work. He further stated he had been trained to sanitize the processor after use and between uses with food. He stated there would be extra germs and contaminated food if unsanitized equipment and incorrect levels of sanitizer were used. He also stated that his initial dietary department orientation and training was three days and he shadowed the Dietary Manager and Dietary staff C. He added that he had worked in the dietary department about a month and a half. The following observations were made during a kitchen tour that began on 8/24/22 at 11:40AM and concluded at 12:34 PM: The Dietary Manager was observed preparing purée food. She placed scoops of fried okra and water in the processor and pureed the mixture. She poured the mixture into three bowls. She took the processor parts to the dishwasher and ran it through the dishwasher. After removing it from the dishwasher there were still bits of food on the blade. The processor was not allowed to air dry, and the processor blade and pot were wet on the interior. She then placed scoops of shepherd's pie and water in the processor and purée the mixture. She placed it in bowls. She then took the parts and ran them through the dishwasher. The dishwasher cycle ended at 11:55 AM. At 11:56 AM the processor blade and pot were wet on the interior and Dietary staff B added milk and three squares of cake into the processor and puréed the mixture. He placed it in three bowls. Observation and record review of the dishwasher chlorine sanitizer label AutoChlor Super 8 revealed the following, . Sanitizing Food Contact Surfaces 5. Drain and allow food contact surfaces and equipment to air dry On 8/25/22 at 10:07 AM an interview was conducted with the Administrator. She was asked who was responsible for ensuring foods were served in a sanitary manner. She stated dietary trainers and the Administrator. She stated, infection control issues, E. coli and Salmonella could result from the dietary issues that were observed. She stated, she expected dietary staff to follow policy and procedures and report issues. On 8/25/22 at 10:54 AM an interview was conducted with the Dietary Manager. She was asked why there were incorrect sanitizing levels , poor hygienic practices and staff not sanitizing equipment. She stated dietary staff try to keep a routine and all be on the same page. She stated that she saw Dietary staff A rushing and drop the tray ticket. She added that staff knew they should be checking the sanitizer and keeping their areas clean. She was asked who was responsible for ensuring that food was prepared and served in a sanitary manner. She stated the cook and the Dietary Manager. She was asked how she ensured that these processes were conducted. She stated she monitors and corrects staff. She was also asked if she had conducted any in-services with the dietary staff. She stated she held a meeting a week ago and went over dishwashing operations, cleaning, and handwashing. She further added that she did not document this meeting. She stated, residents could get sick from the food and contract foodborne illness as a result of the dietary sanitation issues observed. Record review of the facility policy labeled Handwashing/Hand Hygiene, Revision Date 3/1/2020 revealed the following documentation, Handwashing/Hand Hygiene. Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. 1. All personnel shall be trained regularly and in-serviced on the importance of hand hygiene and preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap, (antimicrobial or non-antimicrobial) in water for the following situations. f. Before donning sterile gloves. m. After removing gloves. o. Before and after eating or handling food. 10. Hand hygiene is recognized as the best practice for preventing healthcare associated infections. Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. Record review of the current undated dietary department training information/guidelines revealed the following documentation, Sanitation and Safety. Protection Against Bacteria. 3. Kill Bacteria. B. Sanitize. The term sanitize means to kill disease causing bacteria. Certain chemicals also kill bacteria. You must follow the guidelines for sanitizing listed on the chemicals listed in the dietary training manual for dishes, utensils, pots and pans. All surfaces should be sanitize using the information in the Sanitizing Pail Training. Record review of the current undated facility dietary department training materials revealed the following documentation, Sanitizer Pails. All working surfaces in the kitchen need to be not only clean but sanitized. Cleaning with only soap and water doesn't kill the germs or in scientific terms bacteria. In order to kill the bacteria, we must clean with a product that kills the bacteria. This is process is called sanitizing. One of the most efficient ways to sanitize surfaces is with the quaternary product that we use to sanitize the pots and pans. The quaternary chemical must be at least 200 ppm. When you come to work, one of the first things on your get ready to work is to fill your sanitizer pail. Fill the pail with the sanitizer from the pot and pan sink, or from the quaternary dispenser in your mop room. Test the sanitizer with the test strip. It must be at least the color green that is next to the 200 ppm Your cleaning cloth should be in the cleaning pail when you are not using it. This keeps the cloth wet with the sanitizing chemicals, so that the area that you are wiping down will be sanitized. The chemical in your pail should be changed every 4 to 6 hours. If you are wiping up large spills, the chemical will be diluted, and then you are no longer sanitizing. Test the water after wiping up the spill, if it is below 200 color, empty your pail and refill it. Record review of the facility's current undated dietary department training materials/guidelines revealed the following documentation, AutoChlor Chemicals. Quat sanitizer - in the pot and pan sink dispenser, used to sanitize all countertops, table tops and of course pots and pans. Put in pail Quat. Test the chemical with the green strips. Must test between 200 and 400 ppm. If the chemical doesn't test at this level, tell supervisor. Keep rags in the solution at all times. Change solution every four hours .

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 6 of 6 residents (Resident #'s 9, 15, 30, 36, 49 and 118), in that: The facility failed to ensure 6 residents received the correct portions that were called for on the menu. These failures could place residents at risk for unwanted weight loss and hunger. The findings include: Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #15 had a physician's diet order of enhanced diet mechanical soft texture, thin consistency, revision date 8/17/22 Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #118 had a physician's diet order of regular diet purée texture, thin consistency. Revision date 8/18/22. Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #30 had a physician's diet order of regular diet purée texture, then consistency, fortified foods related to dysphasia, oral pharyngeal phase. The revision date was 8/5/21 Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #9 had a physician's diet order of enhance that regular texture, then consistency. Revision date was 8/17/22. Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #49 had a physician's diet order of regular diet mechanical soft texture, thin consistency, super cereal at breakfast for supplement with a revision date of 8/05/21. Record review of the facility's Order Listing Report dated 8/23/22 revealed that Resident #36 had a physician's diet order of regular diet purée texture, thin consistency with a revision date of 6/21/22 On 8/23/22 at 5:06 PM an observation tour was conducted in the kitchen and concluded at 6:02 PM: On the service line there was: Vegetable soup served with a 4-ounce ladle Tuna salad served with a # 16 (1/4 cup) scoop and on ice Macaroni salad served with a # 16 (1/4 cup) scoop and on ice Chicken soup served with a 4-ounce ladle Green beans served with a 4-ounce ladle Potatoes and ham dish served with a 4-ounce ladle. The chicken soup, green beans and potato and ham dish were the alternate meal. Fruit cocktail was already distributed in bowls. Observation of the meals served by Dietary staff A revealed all regular and mechanical soft diets were served one 4-ounce ladle of the vegetable soup and then at times Dietary staff A would add another partial ladle of vegetable juice to the serving. He also served one #16 (1/4 cup) scoop of macaroni salad and one #16 (1/4 cup) scoop of tuna salad. There was no pureed bread observed or served from the service line. Record review of the Tuesday (facility) SS 2022 SHR Week 3 diet evening meal menu revealed that: Residents on regular diet should have received: 6 ounces of garden vegetable soup 1/3 cup tuna salad 1/2 cup of macaroni salad. Residents on a regular purée diet should have received: 6 fluid ounces of puréed garden vegetable soup 1/3 cup puréed tuna salad 1/2 cup puréed macaroni salad 1/4 cup puréed bread and 1/3 cup puréed fruit. Residents on regular mechanical soft diet should have received: 6 fluid ounces of garden vegetable soup 1/3 cup tuna salad 1/2 cup macaroni salad Record review of the meal tray ticket for a Resident #49 revealed that the resident was on a regular/Mechanical soft diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin garden vegetable soup, 1/3 cup tuna salad, 1/2 cup macaroni salad. Observation on 8/23/22 at 5:11 PM Resident #49 was served a 4-ounce bowl of vegetable soup, one #16 scoop (1/4 cup) of macaroni salad, one #16 scoop of tuna salad and a bowl of fruit cocktail. The resident should have received 6 ounces of garden vegetable soup, 1/2 cup of macaroni salad and 1/3 cup tuna salad as called for on the menu. Record review of the meal tray ticket for Resident #15 revealed she was on a regular/mechanical soft diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin garden vegetable soup, 1/3 cup tuna salad, 1/2 cup macaroni salad. Observation on 8/23/22 at 5:15 PM Resident #15 was served a 4-ounce bowl of vegetable soup, one #16 scoop of macaroni salad, one #16 scoop of tuna salad and crackers. The resident should have received 6 ounces of garden vegetable soup, 1/3 cup tuna salad, and 1/2 cup of macaroni salad as called for on the menu. Record review of the meal tray ticket for Resident #9 revealed that she was on an enhance/regular diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin garden vegetable soup, 1/3 cup tuna salad, 1/2 cup macaroni salad. Observation on 8/23/22 at 5:29 PM Resident #9 received a 4-ounce bowl of vegetable soup, one #16 scoop of macaroni salad, and one #16 scoop of tuna salad. The resident should have received 6 ounces of garden vegetable soup, 1/3 cup tuna salad, and 1/2 cup of macaroni salad as called for on the menu. Record review of the meal tray ticket for Resident #30 revealed that she was on an enhanced/puréed diet dated for Supper: Tuesday, August 23, 2022. The resident should have received six fluid ounces thin purée garden vegetable soup, 1/3 cup pureed tuna salad, 1/2 cup puréed macaroni salad, and 1/4 cup puréed bread slice. Observation on 8/23/22 at 5:47 PM Resident #30 received puréed tuna, puréed fruit, puréed macaroni salad and applesauce in bowls. The resident did not receive puréed soup or puréed bread as called for on the menu. Record review of the meal tray ticket for Resident #36 revealed she was on a regular NAS (no added salt)/puréed diet dated for Supper: Tuesday, August 23, 2022. The resident should have received 6 fluid ounces thin purée garden vegetable soup, 1/3 cup puréed tuna salad, 1/2 cup puréed macaroni salad and 1/4 cup puréed bread slice. Observation on 8/23/22 at 5:49 PM Resident #36 received bowls of puréed macaroni salad, puréed tuna salad, puréed fruit. She was fed by staff. The resident did not receive any puréed bread or puréed soup as called for on the menu. On 8/23/22 at 5:52 PM Resident #118 was observed in her room. The resident received bowls of puréed soup, puréed tuna salad, puréed fruit and puréed macaroni salad. She did not receive any puréed bread as called for on the menu. She also received water and was fed by staff. On 8/23/22 at 6:02 PM an interview was conducted with Dietary staff A . He stated he used incorrect scoops because he mixed up the scoops and put away the correct scoops that had been set out and used the wrong scoops. He stated he just grabbed a scoop without thinking about the size so he did not use the 6 ounce ladle. He was also asked why he had not served any puréed bread. He stated they usually do not prepare pureed bread and had not seen anyone prepare it. He added that they usually serve 3 foods at meals: 2 hot and one cold. He stated he had been employed in the facility for approximately one and a half months. At that time the surveyor asked why two residents did not receive any puréed soup (Resident #30 and 36). Dietary staff A went to the steamer and there were still two bowls of puréed soup in the warmer. He stated he did not know how he missed it. He stated he made the menu errors because he tried to do too many things at once and was nervous. He stated malnutrition and weight loss could result from residents not receiving the correct servings of food and lesser amounts of foods. He stated his initial dietary department training was three days of training and he shadowed the Dietary Manager and Dietary staff C. On 8/24/22 at 11:40 AM an observation tour was conducted in the kitchen and concluded at 12:34 PM: The Dietary Manager was observed preparing purée food. She prepared pureed fried okra, and pureed shepherd's pie. Dietary staff B prepared pureed carrot cake. No additional bread was observed pureed or added to one of these pureed foods. Observation of the steamtable revealed the following foods were present: Rolls Shepherd's pie served with a 4-ounce ladle Fried okra served with a #8 scoop (1/2 cup) Carrot cake served in approximately 2-inch squares Puréed carrot cake in bowls in the refrigerator Puréed shepherd's pie and pureed fried okra were in bowls in the steamer. There was also soup, ribs and cabbage served with a #8 scoops as an alternate meal. Observation on 8/24/22 at 12:05 PM revealed the meal service started and the Dietary Manager was serving the meal trays. Observation of the meal service revealed that residents on regular and mechanical altered diets received one 4-ounce ladle of shepherd's pie and at times she would add one and a half scoops randomly. These residents also received one #8 scoop of fried okra. Observations at this time revealed that the utensil drawer had an 8-ounce ladle and a 6-ounce ladle available. Record review of the facility's Wednesday (facility) SS 2022 SHR Week 3 menu revealed that: Residents on a regular diets should have received: 3/4 cup of shepherd's pie 1/2 cup of fried okra One roll One square of carrot cake with cheese cream cheese icing. Residents and regular purée diets should have received: 3/4 cup puréed shepherd's pie 1/3 cup puréed vegetable 1/4 cup purée dinner roll 1/2 cup puréed carrot cake with cream cheese icing. Residents on Regular/mechanical soft diet should have received: 3/4 cup shepherd's pie 1/2 cup fried okra One dinner roll One square carrot cake with cream cheese icing. Record review of the meal tray ticket for Resident #15 revealed the resident was on a regular/mechanical soft diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 3/4 cup of shepherd's pie. Observation on 8/24/22 at 12:16 PM Resident #15 received ½ cup fried okra, roll, cake, 4 ounces shepherd's pie. The resident should have received 3/4 cup of shepherd's pie as called for on the menu. Record review of the meal tray ticket for Resident #9 revealed that the resident was on an enhanced/regular diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 3/4 cup shepherd's pie. Observation on 8/24/22 at 12:19 PM Resident #9 received 4 ounces shepherd's pie, ½ cup fried okra, rolls, and cake. The resident should have received 3/4 cup of shepherd's pie as called for on the menu. Record review of the meal tray ticket for Resident #30 revealed she was on an enhanced/purée diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 1/3 cup puréed barbecue pork riblet, 1/3 cup puréed vegetable, and 1/4 cup puréed dinner roll. Observation on 8/24/22 at 12:34 PM Resident #30 received puréed cake, purée shepherd pie, and puréed okra but did not receive any puréed roll as called for on the menu. Record review of the meal tray ticket for Resident #36 revealed she was on a regular NAS/purée diet dated for Lunch: Wednesday, August 24, 2022. The resident should have received 3/4 cup shepherd's pie, 1/3 cup vegetable, and 1/4 cup puréed dinner roll. Observation on 8/24/22 at 12:35 PM Resident #36 received puréed okra, puréed shepherd's pie, and puréed cake but did not receive a puréed roll as called for on the menu. Record review of the meal tray ticket for Resident #118 dated Lunch: Wednesday, August 24, 2022, revealed the resident was on a regular/purée diet and should have received 3/4 cup of puréed shepherd's pie, 1/3 cup puréed vegetable, 1/4 cup puréed dinner roll. Observation on 8/24/22 at 12:37 PM Resident #118 received puréed shepherd's pie, and puréed okra. The resident did not receive any puréed roll or puréed cake as called for on the menu. The purée cake was later served. On 8/24/22 at 12:55 PM an interview was conducted with the Dietary Manager, and she was asked why no puréed bread was prepared or served to residents. She stated the rolls were small and she was unsure of how many to use to make the purée. She stated she did not serve 6 ounces of shepherd's pie to the regular and mechanical soft diets because she did not know she had a 6-ounce scoop. On 8/25/22 at 10:07 AM an interview was conducted with the Administrator. She stated she ensured the menu was followed through staff triple checking meal trays, by dietary, nursing and aides. She stated residents could have weight loss if the menu was not followed. She added she expected staff to follow the triple check system and serve the diet as ordered. On 8/25/22 at 10:27 AM an interview was conducted with the DON regarding staff not following the menu. She stated that if the menu was not followed the result could be residents losing weight. She added staff conduct triple checks of meal trays by nurses and nurse aids. On 8/25/22 at 10:54 AM an interview was conducted with the Dietary Manager. She stated the Dietary Manager, cook and those involved in the triple check of trays (nursing) was responsible for ensuring the menus were followed. She stated they check the menu to ensure the menus were followed. She added if the menu was not followed it could leave residents at risk for weight loss. She stated she expected staff to communicate and serve the menu/diet as ordered and documented. She stated she conducted a meeting a week ago and covered dishwashing operations, cleaning, sanitizing your hands. She further added that she did not document this meeting.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for any resident using 4 of 4 common baths (Halls 100, 200, 300 and 400), in that: Chemicals were stored next to and above resident toiletries, uncovered disposable brief, boxes of gloves and bath linens in 4 of 4 common baths. These failures could place residents at risk for injuries related to chemical contact. The findings include: On 8/24/22 at 11:04 AM an observation was made of the hall 200 common bath. There was a spray bottle of disinfectant cleaner stored with the resident toiletries which included hair brushes, deodorant, combs, lotion, conditioner and shampoo in a cabinet. The cleaner was Auto Chlor DC 33 Detergent Disinfectant. The label stated, Do Not Drink Avoid eye and prolonged skin contact. Avoid breathing mist The spray bottle of cleaner was also stored on a shelf above an open box of gloves and resident disposable briefs. On 8/24/22 at 1:30 PM an observation of the cabinet in the hall 300 shower revealed, there was a spray bottle of DC 33 disinfectant on the top shelf inside of bins with a dirty unlabeled hairbrush, shampoo, toiletries, denture cleaner. The spray bottle was also stored on the shelf above open boxes of gloves and toiletries. On 8/24/22 at 1:37 PM observation of bath 100 there were two spray bottles of DC 33 disinfectant on the upper shelves on both sides of the cabinet unit. They were stored next to shaving cream and toiletries. They were also stored above toiletries an open box of gloves and resident disposable briefs. On 8/24/22 at 3:15 PM an interview was conducted with CNA A on Hall 100 regarding the resident common bath in Hall 100. At that time there were toiletries stored with the DC 33 cleaner as was on 8/24/22 at 1:37 PM. She stated they had not been told how to store these chemicals. She stated, they were told to give it back to housekeeping. She added she thought staff could leave the disinfectant in the cabinet but separated. She was also asked what could result if chemicals were stored with resident toiletries. She stated chemicals could be used on the resident or spilled. She also added that she did not want the chemicals to leak. On 8/24/22 at 3:25 PM an interview was conducted with CNA B on Hall 300 regarding the resident common bath 300. She was shown the DC 33 spray cleaner stored among the toiletries in the cabinet. She stated the chemicals should not be mixed in with the toiletries; they should be with the towels. She added they were told not to store them with toiletries. She stated that she was told someone used spray chemical on the wrong item prior to her working at the facility. She then took the spray bottle of disinfectant and moved it to the adjacent cabinet area and placed it next to resident wash cloths. The CNA was asked what could happen if the spray bottle spilled or leaked onto the washcloths. She stated disinfectant could be used on the resident. On 8/24/22 at 3:37 PM an interview was conducted with the DON in the hall 400 resident common bath . She was shown the spray bottles of DC33 disinfectant stored amongst the resident toiletries. She stated, staff should not have spray cleaners with toiletries. She stated staff were told not to put chemicals with toiletries and to keep them out of reach of residents. She added residents could have skin issues if chemicals were not stored with resident toiletries. She further stated she and ADON were responsible for ensuring chemicals were stored safely in the baths; they make rounds to monitor this. She added she verbally tells staff, has skill days and one on one training. She was also asked why the chemicals were stored in an unsafe manner. She stated, after showers staff just stuck everything in the cabinet. On 8/25/22 at 10:07 AM an interview was conducted with the Administrator regarding the resident common baths . Regarding the storage of chemicals, she was asked why staff stored chemicals with resident toiletries. She stated staff just put them out of sight. She was asked who was responsible for ensuring that chemicals were stored properly, she stated, nursing was. She was also asked what could result from the chemicals being stored in an unsafe manner. She stated that chemicals could spill on items. She stated she expected staff to store the chemicals separate from resident use items. Record review at the facility policy titled Safety and OSHA Compliance Manual, April 2009, 5.10.1, revised 6/2015, Hazard Communication, OSHA Standard 1910.1200, revealed the following documentation, This OSHA standard applies to: all employees who may be exposed to hazardous chemicals when working, whether it's part of their job duties, or by possible or accidental exposure. Employees Responsibilities: comply with chemical safety requirements of this program. General Chemical Safety. Assume all chemicals are hazardous. Chemical Storage. The separation of chemicals (solids or liquids), during storage is necessary to reduce the possibility of unwanted chemical reactions caused by accidental mixing.

Based on observation, interviews and record review the facility failed to consult or notify the primary care physician of need to alter treatment and failure to notify the physician or legal representative of a significant change in health status for 1 of 12 residents (Residents #1) reviewed for changes in condition as evidenced by: A. failure to notify Resident #1 ' s primary care physician that the psychiatrist prescribed [MEDICATION NAME] 25 mg twice daily and failure to notify the primary care physician, psychiatrist or POA of Resident #1 ' s increased drowsiness and decreased fluid intake after starting on [MEDICATION NAME]. This failure could affect seven residents receiving antipsychotic medications, placing them at risk of health compromise due to a lack of physician awareness of changes in condition. The findings include: A. Resident #1 Closed record review of Resident #1's Physician order [REDACTED].#1 was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of a PASRR (Preadmission Screening and Resident Review) Level 1 Screening dated [DATE] completed by the facility indicated Resident #1 did not have a mental illness. Record review of Resident #1's Quarterly MDS dated [DATE] revealed no BIMS score (resident unable to participate in the interview) and a staff assessment of mental status which documented Resident #1 had short and long term memory problems; inability to recall current season, location of own room, staff names and faces, that she is in a nursing home; and her cognitive skills for daily decision-making was severely impaired. The MDS documented Resident #1 had behavior symptoms not directed toward others, that we wandered daily and was totally dependent on staff for all of her activities of daily living. Record review of a telephone order dated [DATE] revealed an order for [REDACTED]. Record review of Resident #1 ' s Medication Flowsheet (MAR) dated [DATE]-[DATE] revealed 36 doses (25 mg each dose) of [MEDICATION NAME] were administered to her between [DATE] and [DATE]. Record review of Resident #1's Medication Flowsheets (MAR) dated [DATE]-[DATE] revealed the facility did not document monitoring or tracking the side effects and behaviors once the [MEDICATION NAME] was started. In an interview on [DATE] at 3:10 p.m., RN A said the [MEDICATION NAME] tracking probably didn't get put on the January Medication Flow Sheet because the flow sheet was printed at the first of January and the medication was not started until [DATE] and would not be on the February Medication Flow Sheet because the medication was discontinued before February 1st. RN A said nursing staff should have written the tracking on the Medication Flow Sheet (MAR). Record review of Resident #1 ' s Medication Flowsheet dated [DATE] to [DATE] revealed Resident #1 was receiving 40 mg. of [MEDICATION NAME] ([MEDICATION NAME]) two times daily for heart failure from [DATE] through [DATE]. Record review of Resident #1 ' s fluid intake from [DATE] to [DATE] revealed, prior to facility administering the [MEDICATION NAME], Resident #1 averaged a fluid intake of 798 cc per day (26 oz/day) from [DATE] through [DATE]; her intake from [DATE] through [DATE] averaged 702 cc per day (24.4 oz/day), her intake from [DATE] through [DATE] averaged 381 cc per day (12 oz/day), and she had no fluid intake from [DATE] until [DATE] when I.V. fluids were started after family made the request on [DATE]. Record review of the Nursing Documentation Record from [DATE] through [DATE] revealed no documentation to indicate Psychiatrist C was notified of Resident #1 ' s change in condition. There was no documentation to indicate facility notified the primary care physician (PCP A) of Resident #1 ' s change in condition and decreased fluid intake until [DATE]. Record review of the Twenty-Four Hour Report from [DATE] to [DATE] revealed no documentation to indicate Psychiatrist C was notified of Resident #1 ' s change in condition. There was no documentation to indicate facility notified PCP A of Resident #1 ' s change in condition and decreased fluid intake until [DATE]. Record review of a physician order [REDACTED].#1 was admitted to Hospice on [DATE]. Record review of a Resident Discharge Summary (Recapitulation of Stay) revealed Resident #1 expired on [DATE] with a discharge [DIAGNOSES REDACTED]. In interviews on [DATE] at 10:45 a.m. and at 3:45 p.m., POA (Power of Attorney) for Resident #1 said Resident #1 was seeing Psychiatrist A in the past and that is when she requested the [MEDICATION NAME] to be stopped due to making Resident #1 lethargic. The POA said she was not notified that Resident #1 ' s condition had changed until the facility called her on [DATE] to say she was lethargic and had not been eating or drinking. In an interview on [DATE] at 4:20 p.m., Psychiatrist C said she last saw Resident #1 on [DATE] via telemedicine (face-time). Psychiatrist C said she took over the case in [DATE] and first saw Resident #1 in [DATE]. Psychiatrist C said she was not notified of any changes in Resident #1's condition. Psychiatrist C said she instructed the facility staff to call back if Resident #1 became overly sedated. Psychiatrist C said she never heard back from the facility regarding Resident #1's condition and if she had known she was having increased drowsiness, she probably would have lowered the dose or said to hold it. In an interview on [DATE] at 4:45 p.m., the Family Nurse Practitioner (FNP) working with Resident #1's primary care physician (PCP A) said she did not know Resident #1 had been placed on [MEDICATION NAME] until she saw Resident #1 in the facility on [DATE]. The FNP said she was not notified of Resident #1 ' s change in condition until the facility notified her on [DATE] that Resident #1 was acting sleepy, and I told them to hold the [MEDICATION NAME]. I told them they needed to call Psychiatrist C, the physician who prescribed the [MEDICATION NAME]. In an interview on [DATE] at 8:28 a.m. the FNP said that neither she nor PCP A see the orders from other physicians until the Physician order [REDACTED]. The FNP said they would not have seen the order for the [MEDICATION NAME] until the next month's Physician order [REDACTED]. The FNP said something should have been sent to at least notify us of the order for [MEDICATION NAME]. In an interview on [DATE] at 2:25 p.m. Psychiatrist B, who saw Resident #1 until Psychiatrist C (who works in his practice) took over the case in [DATE], said he would expect the facility to notify us if Resident #1 became sedated or there was no change in behaviors. Surveyor asked Psychiatrist B if he knew the family had stopped [MEDICATION NAME] in the past due to making Resident #1 lethargic. Psychiatrist B said he did not have that information, but if he or Psychiatrist C had been aware of that information they would have either reduced the frequency to one time/day at bedtime or discontinue the medication. In an interview on [DATE] at 2:55 p.m., LVN B (who documented the increased drowsiness on [DATE]) said Resident #1 received her first dose of [MEDICATION NAME] on the evening of [DATE] and the next day she was able to tell her (LVN B), that she had no pain. LVN B said she didn't know specifics of the length of time Resident #1 could talk. LVN B said prior to the initiation of [MEDICATION NAME], Resident #1 was alert but did not talk, then after the [MEDICATION NAME] Resident #1 was drowsy in the morning, would perk up in afternoon--just spurts of able to talk and would kind of wake up to talk a little. She appeared drowsy, no labored breathing. Nothing alarming. LVN B said Resident #1 started getting to where she wasn't eating or drinking as much--got order for Glucerna--at times in the morning the aides would have to wake her up to eat and take bites. Ability would come and go. Would sit with flat affect and doze in and out. I don't think there was anything we could have done differently. Survey asked LVN B when Resident #1 ' s behavior changed but LVN B could not provide dates or times. In an interview on [DATE] at 3:00 p.m., CNA C said she reported to LVN D that Resident #1 was not speaking, eating or drinking and was sleeping more. CNA C said LVN D told her Resident #1 was on a new med and they wanted to see if it was helping her to quieten down. CNA C could not say when she reported to LVN D. In an interview on [DATE] at 3:00 p.m., CNA D said after the [MEDICATION NAME] was started Resident #1 wouldn't eat--just changed-just saw her going down . CNA D said she reported the change to charge nurses LVN B, LVN C, and LVN D a week after the medication was started. CNA D said Resident #1 started sleeping more--when we could get her up, she'd put her head down--quit eating. Very little response after medication--seems like medication relaxed her, dropped her. In an interview on [DATE] at 3:10 p.m., CNA E, said prior to Resident #1 starting [MEDICATION NAME], she would yell out a lot. CNA E said toward the end of January she was quiet. CNA E said she reported to LVN D that Resident #1 was not eating and was drowsy. CNA E said LVN D told her the psychologist came and changed her medication. In an interview on [DATE] at 3:30 p.m., LVN C said Resident #1 would yell out every now and then but yelling increased and was louder in [DATE]. LVN C said after starting [MEDICATION NAME], Resident #1 was quieter. She said about mid- January she noticed she was quieter. LVN C said one staff reported to her that Resident #1's blood sugar may be low because she was drowsy. LVN C said she checked her blood sugar but did not document it and could not remember the result. LVN C said she was never assigned to care for Resident #1. Record review of Resident #1 ' s Diabetic Flowsheet from [DATE] through [DATE] revealed Resident #1 ' s blood sugar results ranged from 63 to 398. In an interview on [DATE] at 3:45 p.m., CNA F said prior to Resident #1 starting [MEDICATION NAME] she screamed out. CNA F said after starting [MEDICATION NAME], she would scream out every now and then. CNA F noticed the changes of sitting quietly, not responding like before, appeared to have increased drowsiness and decrease in drinking and eating ,[DATE] days after starting medication. CNA F said she reported the changes to LVN B. CNA F said LVN B checked her vital signs and blood sugar and said everything was okay. CNA F said LVN D called Resident #1's physician but unsure of when, which physician or what the response was from the physician. In an interview on [DATE] at 3:55 p.m., CNA G said prior to Resident #1 starting [MEDICATION NAME] she was loud. She made a lot of noise, not constant but occurred most of the day. CNA G said after [MEDICATION NAME] was started Resident #1 was quiet and her appetite decreased. She was not sure when she noticed the changes in Resident #1. CNA G said she notified LVN D of Resident #1 being quieter and not wanting to wake up. In interviews on [DATE] at 3:56 p.m. and [DATE] at 3:20 p.m. LVN D (who works the 6a-6p shift) said Resident #1 was kinda very loud, anxious, sort of screamed a lot, bothered some of the residents . LVN D said she felt it was behavioral and not medical causing her to yell. LVN D said I kept her by me and would give her something to drink . LVN D said after the [MEDICATION NAME] was started Resident #1 was more alert, not as loud, she'd look around and stuff, then she got real quiet, didn't want to eat and would stare off into space . LVN D could not recall the dates that Resident #1 ' s behaviors changed. LVN D said The last weekend, I reported it to the FNP and when I came back to work she was on Hospice. LVN D said after starting the medicine she was not sleeping more, seemed like she slept less. Started not eating-like she wasn't hearing anything around her, in her own world. LVN D said she thought Resident #1 was doing well on the medicine, but a few days before she passed away she was not eating, so she reported to FNP who ordered to hold the [MEDICATION NAME]. LVN D said after the [MEDICATION NAME] was stopped, Resident #1 did not want to eat and remained lethargic and drowsy. In an interview on [DATE] at 3:15 p.m. DON A said he was unaware of any increased drowsiness on [DATE] and said he didn't notice Resident #1 being sedated. DON A said he heard when she was hollering and several nurses (LVN B and LVN D) heard her talking. Record review of the Nursing Documentation Record from [DATE] when the increased drowsiness was documented to [DATE] when Resident #1 expired revealed: [DATE] 6a-6p Pt remains on [MEDICATION NAME], pt does appear to have increased drowsiness but will continue to monitor. No bump noted to head, no tenderness, no signs/symptoms distress noted. POA informed. Will continue to treat and monitor. Signed by LVN B. There was no documentation after [DATE] until [DATE]. [DATE] 6a-6p FNP in facility. No new orders noted at this time. Signed by LVN D. There was no documentation after [DATE] until [DATE]. [DATE] Family voiced concerns regarding patient weight, informed of 2 pound wt gain, request supplement to be given, informed of current order for med pass, continue to request supplement shake. FNP informed, new order for glucerna obtained, will continue to treat and monitor. Signed by LVN B. [DATE] 6a-6p Res becoming less alert since AM. Throughout shift Res leaning forward in wheelchair with flat affect. At lunch Res pocketing food. Blood sugar is high, fluids encouraged, Res will not swallow. Assessed by oncoming 6p shift .1900 (7:00 p.m.) spoke with FNP to hold [MEDICATION NAME] continue to monitor. Signed by LVN D. [DATE] 6a-6p Res less alert. Consumes very little at meals at times holding food in her mouth. Consumed medication. Res is lethargic or staring into space. Continue to hold [MEDICATION NAME]. Signed by LVN D. [DATE] 8:30 Res consumed a few sips of juice, couple bites of breakfast. Res did not consume meds .1250 (12:50 p.m.) Res consumed a few bites of lunch and holding some in her mouth. 1300 (1:00 p.m.) FNP notified. Signed by LVN D. Record review of the Nursing Documentation Record from [DATE] to [DATE] revealed documentation of Resident #1's further decline in function until she expired on [DATE] at 7:35 a.m. Record review of the Twenty-Four Hour Report from [DATE] to [DATE] revealed no documentation related to Resident #1 ' s increased drowsiness or decreased fluid intake. The 24-Hour Report dated [DATE] contained the following entry: ,[DATE]-Resident #1-D/C [MEDICATION NAME]-N.O. [MEDICATION NAME] with N.O. labs Day, time and/or shift not documented. The 24-Hour Report dated [DATE] contained the following entry: [DATE] Resident #1-ID (initial dose) [MEDICATION NAME] 25 mg on pm shift. D/C [MEDICATION NAME] (Time and/or shift not documented). The 24-Hour Report dated [DATE] contained the following entry: [DATE] Resident #1-D/C (discontinue) [MEDICATION NAME]. N.O. (new order) Seroquil (Time and/or shift not documented). The 24-Hour Report dated [DATE] contained the following entry: ,[DATE]-Resident #1,-Hold [MEDICATION NAME] (Time and/or shift not documented). The Twenty-Four Hour Report dated [DATE] contained the following entry: ,[DATE] Hold [MEDICATION NAME] per FNP (Time and/or shift not documented). The Twenty-Four Hour Reported dated [DATE] contained the following entry: ,[DATE]-Hold [MEDICATION NAME] per FNP Record review of Resident #1 ' s lab values for kidney function revealed the following: [DATE] Resident #1 had a BUN (blood urea nitrogen) level of 43 mg/dL-normal range is ,[DATE]. Resident #1's creatinine level was 1.30 mg/dL-normal range 0XXX,[DATE].3. [DATE] Resident #1 had a BUN level of 52 mg/dL and her creatinine level was 1.66 mg/DL [DATE] (three days after initiation of [MEDICATION NAME]), labs drawn for this date did not assess BUN and creatinine. [DATE] Resident #1 had a BUN level of 193 mg/DL and her creatinine level was 5.20 mg/dL Per the lab that analyzed Resident #1 ' s blood, the normal range for BUN was ,[DATE] mg/dL and the normal range for creatinine was 0XXX,[DATE].3 mg/dL. Information obtained from the Mayo Clinic website accessed on [DATE] at <http://www.mayoclinic.org/tests-procedures/blood-urea-nitrogen/basics/definition/prc- 239> explains the significance of BUN: A common blood test, the blood urea nitrogen (BUN) test reveals important information about how well your kidneys and liver are working. A BUN test measures the amount of urea nitrogen that's in your blood. Here's how your body typically forms and gets rid of urea nitrogen: · Your liver produces ammonia - which contains nitrogen - after it breaks down proteins used by your body's cells. · The nitrogen combines with other elements, such as carbon, hydrogen and oxygen, to form urea, which is a chemical waste product. · The urea travels from your liver to your kidneys through your bloodstream. · Healthy kidneys filter urea and remove other waste products from your blood. · The filtered waste products leave your body through urine. A BUN test can reveal whether your urea nitrogen levels are higher than normal, suggesting that your kidneys or liver may not be working properly. Information obtained from Healthline website accessed on [DATE] at <http://www.healthline.com/health/bun> explains the meaning of lab results for BUN: Higher BUN levels can indicate: · [MEDICAL CONDITION] or recent [MEDICAL CONDITION] · [MEDICAL CONDITION] · high protein levels · kidney disease · kidney failure · dehydration · obstruction in the urinary tract · shock Information from the Mayo Clinic website accessed on [DATE] at <http://www.mayoclinic.org/tests-procedures/creatinine-test/home/ovc- 389> Explains the significance of creatinine: High serum creatinine levels in the blood indicate that the kidneys aren ' t functioning properly. Your serum creatinine levels may be slightly elevated or higher than normal due to: · a blocked urinary tract · a high-protein diet · dehydration · kidney problems, such as kidney damage or infection · reduced blood flow to the kidneys due to shock, [MEDICAL CONDITION], or complications of diabetes Review of information from the Food and Drug Administration website accessed on [DATE] at <http://www.fda.gov/downloads/drugs/drugsafety/ucm 6.pdf> revealed the following: · Medication Guide [MEDICATION NAME] (SER-oh-[MEDICATION NAME]) (quetiapine [MEDICATION NAME]) · What is the most important information I should know about [MEDICATION NAME]? · [MEDICATION NAME] may cause serious side effects, including: 1. risk of death in the elderly with dementia. Medicines like [MEDICATION NAME] can increase the risk of death in elderly people who have memory loss (dementia). [MEDICATION NAME] is not for treating [MEDICAL CONDITION] in the elderly with dementia. · [MEDICATION NAME] can cause serious side effects, including: · stroke that can lead to death can happen in elderly people with dementia who take medicines like [MEDICATION NAME] Review of information at Drugs .com website accessed on [DATE] at <http://www.drugs.com/sfx/[MEDICATION NAME]-side-effects.html> revealed: Renal side effects have included acute kidney failure Review of information from Medscape website accessed on [DATE] at <http://www.medscape.com/viewarticle/ 7> revealed: (Updated Aug. 20, 2014) Atypical antipsychotic medications are linked to acute kidney injury (AKI) in elderly patients, new research suggests, causing investigators to call for their use in this population to be reevaluated. A population-based study examining medical records for nearly 200,000 adults older than [AGE] years showed that those who received a prescription for quetiapine ([MEDICATION NAME], AstraZeneca Pharmaceuticals LP), [MEDICATION NAME] ([MEDICATION NAME], Janssen Pharmaceuticals, Inc), or [MEDICATION NAME] had an almost 2-fold increased risk for hospitalization for AKI within the next 90 days vs those who did not receive these prescriptions. In addition, patients who received 1 of these oral atypical antipsychotics had increased risk for acute [MEDICAL CONDITIONS], and even death. Record Review of the facility's Policy and Procedure for Change of Condition-Observing, Reporting and Record dated ,[DATE] revealed: Policy-It is the policy of this home to inform the resident, the resident's physician and if indicated the resident's responsible party of the following: 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications . Procedure-Observing, Reporting and Documenting a Change in Condition: 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as possible as feasible if the resident is stable (change in condition is resolved such as a fall without injury or head trauma). If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director (if not the attending or alternative physician), or the emergency room physician . 5. Notify the resident's responsible party . Documentation: 1. Date, time condition change was identified 2. Pertinent assessment findings 3. Who was notified and when 4. Disposition of resident 5. Update care plan if indicated with any determined interventions to mitigate further incidents if applicable Communication: 1. The change in condition and interventions related to the change will be documented on the 24-Hour Report form on the shift that the change occurred. 2. The licensed nurse(s) and nursing assistant will communicate to the oncoming shift orally and through the 24-Hour report, the change in condition and interventions. 3. The Director of Nurses/designee will report the change in conditions, interventions, and response to the appropriate Q & A Committee. Record Review of facility's Medication Administration General Guidelines dated ,[DATE] revealed: 7.1 General Guidelines Policy: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 7. Note any allergies [REDACTED]. Documentation: 7. Observe resident for medication actions/reactions and record in the nurses notes as appropriate. Any noted adverse consequences should be reported to the prescriber and/or attending physician. A report printed by the facility on [DATE] at 3:35 p.m. revealed 7 residents receiving antipsychotics.

Based on observation, interviews, and record review the facility failed to ensure 3 of 11 residents (#s 1, 9, 10) reviewed for psychoactive medication use remained free from unnecessary drugs as evidenced by: A. failure to provide clinical indication for the use of [MEDICATION NAME] (antipsychotic) and failure to document monitoring of specific target behaviors and side effects associated with the use of [MEDICATION NAME] for Resident #1. B. failure to provide clinical indication for the use of [MEDICATION NAME] (antipsychotic), failure to clarify the route of administration between two orders for [MEDICATION NAME], and administering [MEDICATION NAME] daily to Resident #9 without a physician's order [REDACTED].>C. continued to administer [MEDICATION NAME] (antidepressant) to Resident #10 in the presence of adverse side effects. This failure could potentially affect seven residents receiving antipsychotic medications, sixteen residents receiving antidepressants, six residents diagnosed with [REDACTED]. Findings Included: A. Resident #1 Closed record review of Resident #1's Physician order [REDACTED].#1 was an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Record review of a PASRR (Preadmission Assessment and Resident Review) Level 1 Screening dated [DATE] completed by the facility indicated Resident #1 did not have a mental illness. Record review of Resident #1's Quarterly MDS dated [DATE] revealed no BIMS score (resident unable to participate in the interview) and a staff assessment of mental status which documented Resident #1 had short and long term memory problems; inability to recall current season, location of own room, staff names and faces, that she is in a nursing home; and her cognitive skills for daily decision-making was severely impaired. The MDS documented Resident #1 had behavior symptoms not directed toward others, that she wandered daily and was totally dependent on staff for all of her activities of daily living. Record review of Resident #1's Care Plans revealed the facility did not update the Comprehensive Care Plan dated [DATE] to include a care plan for managing an antipsychotic medication ([MEDICATION NAME]) after the medication was started on [DATE]. Record review of Resident #1 ' s MAR indicated [REDACTED]. Record review of a Social Worker Progress Note dated [DATE] revealed, When Resident #1 is awake and ambulating she does yell out almost constantly. I believe this is her way of communicating. Record review of a Social Service Review dated [DATE] revealed, .She yells out a good part of the day. Resident does not appear to be in any pain and/or distress. In an interview on [DATE] at 1:22 p.m., an interested party said Resident #1 laughs loud and they (the facility) pressured the family to take Resident #1 off of her Alzheimer's medication and put her on antidepressants, then told the family Resident #1 needs to be moved . Record review of a Progress Note from Psychiatrist A, dated [DATE] revealed, Assessment: 1. Dementia of the Alzheimer's Type, Late Onset with Depression 2. Dementia of the Alzheimer's Type, Late Onset with Delusions I was re-consulted on this patient. Will discontinue her [MEDICATION NAME] . Record review of a Progress Note by Psychiatrist A dated [DATE] revealed: The patient is doing well after discontinuation of [MEDICATION NAME]. Record review of a Referral/Response Letter dated [DATE] by Psychiatrist C revealed: .continues to have significant symptoms dealing with [MEDICAL CONDITION]. She is also being treated for [REDACTED]. The patient has had a partial response to treatment Per nursing report, the patient's yelling has continued to increase. Her yelling upsets other residents. She is unable to communicate her needs. Staff have tried giving her Tylenol and covering her with blankets, but neither intervention resulted in any change. A family meeting was held and the family was told that if her yelling continues, she may receive a 30 day notice and have to find an alternative nursing home She yells out several times during the interview .All of the history was provided by the staff .The patient does not have problems with anger or irritability. She has a history of being combative, but no recent physical aggression. Anxiety level has been stable. The patient does not have psychotic or manic symptoms .Disoriented to person, place and time. No acute [MEDICAL CONDITION] .Risks and benefits of the medications were discussed with the patient and nursing staff .Plan: Start [MEDICATION NAME] 25 mg po (by mouth) bid (twice daily). Staff to call back if patient is overly sedated or if yelling persists with [MEDICATION NAME] . Record review of a telephone order dated [DATE] revealed [MEDICATION NAME] 25 mg, 1 BID was ordered by Psychiatrist C. Record review of Resident #1 ' s MAR indicated [REDACTED]. Record review of Resident #1's Medication Flowsheets (MAR) dated [DATE]-[DATE] revealed no documentation the facility monitored or tracked the side effects and behaviors once the [MEDICATION NAME] was started. Record review of Resident #1 ' s Nursing Documentation Record from [DATE] to [DATE] revealed one entry on [DATE] documenting increased drowsiness. There was no documentation about Resident #1 ' s condition after [DATE] until [DATE] when staff documented that the FNP was in the facility-no new orders. There was no documentation after [DATE] until [DATE] when the family requested Glucerna and then on [DATE] when staff documented Resident #1 was becoming less alert . In an interview on [DATE] at 1:00 p.m., RN A said the facility tracks the side effects and behaviors for residents taking antipsychotics. RN A said prior to initiating an antipsychotic, tracking of behaviors is done in the nurses notes (Nursing Documentation Record). Once the antipsychotic is started, the tracking is put on the MAR (Medication Flowsheet). In an interview on [DATE] at 1:30 p.m. the DON said facility staff monitors initial doses of antipsychotics three days-72 hours same as any, every shift for a new med or change in condition . The DON said that no one reported to him that Resident #1 was having increased drowsiness. From what I was told she talked for the first time in months and behavior improved. By that time wouldn't be monitoring--might not see documentation for months because they're stable. In an interview on [DATE] at 3:10 p.m., RN A said the [MEDICATION NAME] tracking probably didn't get put on the January Medication Flow Sheet because the flow sheet was printed at the first of January and the medication was not started until [DATE] and would not be on the February Medication Flow Sheet because the medication was discontinued before February 1st. RN A said nursing staff should have written the tracking on the Medication Flow Sheet (MAR). Record review of a physician order [REDACTED].#1 was admitted to Hospice on [DATE]. Record review of a Resident Discharge Summary (Recapitulation of Stay) revealed Resident #1 expired on [DATE] with a discharge [DIAGNOSES REDACTED]. In interviews on [DATE] at 10:45 a.m. and at 3:45 p.m., POA (Power of Attorney) for Resident #1 said she knew about Resident #1 seeing Psychiatrist A in the past and that is when she requested the [MEDICATION NAME] to be stopped due to making Resident #1 lethargic. (Resident #1) was on [MEDICATION NAME] in the past and I stopped it because she became lethargic. I only agreed to the use of [MEDICATION NAME] because I was told if she (Resident #1) was not put on [MEDICATION NAME] she would be discharged from the facility. The POA said that two days before the [MEDICATION NAME] was started on [DATE] (Resident #1) was joyful, spent most of her time in her room. The POA said during the last care plan meeting (POA unable to provide the date of the meeting), she was told they were going to have to medicate (Resident #1) or she would be discharged . The POA said the Administrator told her that her (Resident #1 ' s) yelling could be reported to the State as harassment and that she needed to consent to the [MEDICATION NAME]. The POA said, I felt forced to consent to the [MEDICATION NAME]. They didn't want to call it a chemical restraint but that's what it was-- to calm (Resident #1) down. I felt like (Resident #1) was being punished even though she's the one who got slapped. Another resident slapped (Resident #1) and (Resident #1) was punished by being medicated. POA said she was not notified that Resident #1 ' s condition had changed until the facility called her on [DATE] to say she was lethargic and had not been eating or drinking. Record Review of Care Plan Conferences and Communication from [DATE] to [DATE] revealed no communication/documentation addressing Resident yelling out until [DATE]: [DATE] Cont with DNR status. Talked to FNP about changing meds-referred to Psy. Discussed discharging planning with daughter if meds not effective. Has appointment with Psychiatrist C ([DATE]) psy phy . Signature of author of this note not legible. Record review of the Nursing Documentation Records (Nurse ' s Notes) revealed the following entry: [DATE] 11 a.m. met with daughter (POA) about resident behaviors-she is willing to allow us to notify physician about changing her meds-notified FNP, and she is going to review her orders and get back with us. In an interview on [DATE] at 4:45 p.m., the Family Nurse Practitioner (FNP) working with Resident #1's primary care physician (PCP A) said The Administrator called me (was unable to recall the date) wanting me to put her (Resident #1) on medication, but I refused because it was not appropriate and nothing works in her body. In an interview on [DATE] at 4:05 p.m. Psychiatrist B said he had seen Resident #1 a couple of times and then another psychiatrist that he supervised (Psychiatrist C) began seeing her. Psychiatrist B said the family is always welcome to attend the telemedicine sessions and they would be willing to wait until a family member could attend. Psychiatrist B said there are medicines we can use--medicines of choice are dependent on situation and patient specific and we need a good history from the nursing staff, to specifically match the needs of the patient. Psychiatrist B said there are no medications that wouldn ' t/shouldn't be used in the elderly. He said he was aware of the Black Box warning for the use of [MEDICATION NAME] in the elderly, but in the real world it is used frequently and at the end stage of Alzheimer's they are at the end of their life anyway. Psychiatrist B said the standard of care is keeping them comfortable and keeping behaviors under control. Psychiatrist B said in Resident #1's case, behaviors were extremely disruptive. We just get info from the nursing home from what the facility has on the chart. End-stage Alzheimer's can be difficult--challenging, we take a full medical and psychological history and take into account how large the patient is. In an interview on [DATE] at 2:25 p.m. Psychiatrist B said he would expect the facility to notify us if Resident #1 became sedated or there was no change in behaviors. Surveyor asked Psychiatrist B if he knew the family had stopped [MEDICATION NAME] in the past due to making Resident #1 lethargic. Psychiatrist B said he did not have that information, but if he or Psychiatrist C had been aware of that information they would have either reduced the frequency to one time/day at bedtime or discontinue the medication. In an interview on [DATE] at 1:15 p.m. the Administrator said We set up a care plan meeting and family agreed to have Psychiatrist C look at her. They didn't want a medication that makes mom sleep all the time. Would monitor and if they (family) felt like the medicine was not working, to let us know, we were not trying to sedate her. The Administrator said due to Resident #1's constant yelling out, a meeting was called with Psychiatrist C to address it and the [MEDICATION NAME] was ordered to stop Resident #1 from yelling out. Record review of the Nursing Documentation Records (Nurse ' s Notes) revealed the following entry: [DATE] 4:50 p.m. Noted visit with Psychiatrist C via face-time, new orders received .d/c (discontinue) [MEDICATION NAME]. [MEDICATION NAME] 25 mg. 1 p.o. (by mouth) BID (twice daily), call back in one week if sedated or no change in behaviors .spoke with (POA), aware of new orders. In an interview on [DATE] at 4:20 p.m., Psychiatrist C said she last saw Resident #1 on [DATE] via telemedicine (face-time). Psychiatrist C said she took over the case in [DATE] and first saw Resident #1 in [DATE]. Psychiatrist C said she only saw Resident #1 four times. Psychiatrist C said Resident #1 was continuously confused yelling quite a bit upsetting other residents. Psychiatrist C said the facility staff told her if Resident #1 did not get better they were giving her a 30-day notice-she can't communicate her needs and they were trying to cover all their bases. Psychiatrist C said if Resident #1 did not stop yelling she was going to have to leave the nursing home, so I ordered [MEDICATION NAME] 25 mg two times daily. Psychiatrist C said she was not notified of any changes in Resident #1's condition. Psychiatrist C said she instructed the facility staff to call back if Resident #1 became overly sedated. Psychiatrist C said she never heard back from the facility regarding Resident #1's condition and if she had known she was having increased drowsiness, she probably would have lowered the dose or said to hold it. Record review of the Nursing Documentation Record on [DATE] revealed Resident #1 was having increased drowsiness. Record review of the Nursing Documentation Record from [DATE] through [DATE] revealed no documentation to indicate if the drowsiness resolved or continued. There was no documentation indicating Psychiatrist C was notified of Resident #1 ' s change in condition. Record review of the Twenty-Four Hour Report from [DATE] to [DATE] revealed nursing staff did not document information related to the increased drowsiness on [DATE] or communication with Psychiatrist C regarding Resident #1's change in condition. In an interview on [DATE] at 4:45 p.m., the Family Nurse Practitioner (FNP) said Resident #1 had liver and kidney problems. The FNP said she heard the facility tell Resident #1's family that they needed to either place Resident #1 on medication or she would be discharged . The FNP said she did not know Resident #1 had been placed on [MEDICATION NAME] until she saw Resident in the facility on [DATE]. The FNP said she was not of Resident #1 ' s change in condition until the facility notified her on [DATE] that Resident #1 was acting sleepy, and I told them to hold the [MEDICATION NAME]. I told them they needed to call Psychiatrist C, the physician who prescribed the [MEDICATION NAME]. The FNP said, She dehydrated, her kidneys shut down and her discharge [DIAGNOSES REDACTED]. Record review of Resident #1 ' s MAR indicated [REDACTED]. of [MEDICATION NAME] ([MEDICATION NAME]) two times daily for heart failure from [DATE] through [DATE]. Record review of Resident #1 ' s fluid intake from [DATE] to [DATE] revealed, prior to facility administering the [MEDICATION NAME], Resident #1 averaged a fluid intake of 798 cc per day (26 oz/day) from [DATE] through [DATE]; her intake from [DATE] through [DATE] averaged 702 cc per day (24.4 oz/day), her intake from [DATE] through [DATE] averaged 381 cc per day (12 oz/day), and she had no fluid intake from [DATE] until [DATE]. The family requested IV fluids on [DATE] and it was started on [DATE]. Record review of the Nursing Documentation Records and Twenty-Four Hour Reports from [DATE] to [DATE] revealed no documentation to indicate the PCP A was notified of Resident #1 ' s decreased fluid intake until [DATE]. In an interview on [DATE] at 1:52 p.m., CNA B said a couple of days after starting [MEDICATION NAME] Resident #1 would respond Si. CNA B said three to four days after starting [MEDICATION NAME] Resident #1 would fall asleep in her chair when we'd get her up to eat. We had to wake her up to take bites then she would fall asleep again-slowly deteriorated. Not screaming as much but still had some outbursts. CNA B said at first we thought the medicine was working but it didn't. In an interview on [DATE] at 2:50 p.m., LVN A said Resident #1 would yell out. After starting [MEDICATION NAME], she really quieted down. LVN A said he noticed this a few days after starting the [MEDICATION NAME]. LVN A said no staff reported anything abnormal to him regarding Resident #1. He said he was never assigned to care for Resident #1 but thought she was eating and drinking ok. He didn't notice any drowsiness. He said Resident #1 would just look at me and sometimes yell out. In an interview on [DATE] at 2:55 p.m., LVN B (who documented the increased drowsiness on [DATE] on the 6 a-6p shift) said Resident #1 received her first dose of [MEDICATION NAME] on the evening of [DATE] and the next day she was able to tell her (LVN B), that she had no pain. LVN B said she didn't know specifics of the length of time Resident #1 could talk. LVN B said prior to the initiation of [MEDICATION NAME], Resident #1 was alert but did not talk, then after the [MEDICATION NAME] Resident #1 was drowsy in the morning, would perk up in afternoon--just spurts of able to talk and would kind of wake up to talk a little. She appeared drowsy, no labored breathing. Nothing alarming. LVN B said Resident #1 started getting to where she wasn't eating or drinking as much--got order for Glucerna--at times in the morning the aides would have to wake her up to eat and take bites. Ability would come and go. Would sit with flat affect and doze in and out. I don't think there was anything we could have done differently. Surveyor asked LVN B when Resident #1 ' s behavior changed but LVN B could not provide dates or times. In an interview on [DATE] at 3:45 p.m., CNA F (who works the 6a-6p shift) said prior to Resident #1 starting [MEDICATION NAME] she screamed out. CNA F said after starting [MEDICATION NAME], she would scream out every now and then. CNA F noticed the changes of sitting quietly, not responding like before, appeared to have increased drowsiness and decrease in drinking and eating ,[DATE] days after starting medication. CNA F said she reported the changes to LVN B at that time. CNA F said LVN B checked her vital signs and blood sugar and said everything was okay. CNA F said LVN D called Resident #1's physician but unsure of when, which physician or what the response was from the physician. CNA F said Resident #1 didn't talk but would scream out especially around lunch. In an interview on [DATE] at 3:00 p.m., CNA C (who works the 6a-6p shift) said prior to starting [MEDICATION NAME] Resident #1 would yell out a lot. After starting [MEDICATION NAME], she calmed down and did not yell or call out as much. CNA C said she reported to LVN D that Resident #1 was not speaking, eating or drinking and was sleeping more. CNA C said LVN D told her Resident #1 was on a new med and they wanted to see if it was helping her to quieten down. CNA C said Resident #1 would look at me but did not speak. In an interview on [DATE] at 3:00 p.m., CNA D (who works the 6a-6p shift) said after the [MEDICATION NAME] was started Resident #1 wouldn't eat--just changed-just saw her going down. Reported to charge nurses LVN B, LVN C, and LVN D a week after the medication was started. CNA D said Resident #1 started sleeping more--when we could get her up, she'd put her head down--quit eating. Very little response after medication--seems like medication relaxed her, dropped her. In an interview on [DATE] at 3:10 p.m., CNA E (who works the 6a-6p shift) said prior to starting [MEDICATION NAME], Resident #1 yell out a lot. CNA E said toward the end of January she was quiet. CNA E said she reported to LVN D that Resident #1 was not eating and was drowsy. CNA E said LVN D told her the psychologist came and changed her medication. CNA E said Resident #1 normally spoke Spanish but once her medication was changed, she stopped speaking. In an interview on [DATE] at 3:30 p.m., LVN C (who works the 6a-6p shift) said Resident #1 would yell out every now and then but yelling increased and was louder in [DATE]. LVN C said after starting [MEDICATION NAME], Resident #1 was quieter. She said about mid- January she noticed she was quieter. LVN C said one staff reported to her that Resident #1's blood sugar may be low because she was drowsy. LVN C said she checked her blood sugar but did not document it and could not remember the result. LVN C said she was never assigned to care for Resident #1. Record review of Resident #1 ' s Diabetic Flow Sheet (MAR) from [DATE] through [DATE] revealed Resident #1 ' s blood sugar results ranged from 63 to 398. In an interview on [DATE] at 3:55 p.m., CNA G (who works the 6a-6p shift) said prior to Resident #1 starting [MEDICATION NAME] she was loud. She made a lot of noise, not constant but occurred most of the day. CNA G said after [MEDICATION NAME] was started Resident #1 was quiet and her appetite decreased. She was not sure when she noticed the changes in Resident #1. CNA G said she notified LVN D of Resident #1 being quieter and not wanting to wake up. In interviews on [DATE] at 3:56 p.m. and [DATE] at 3:20 p.m. LVN D (who works the 6a-6p shift) said Resident #1 was kinda very loud, anxious, sort of screamed a lot, bothered some of the residents . LVN D said she felt it was behavioral and not medical causing her to yell. LVN D said I kept her by me and would give her something to drink . LVN D said after the [MEDICATION NAME] was started Resident #1 was more alert, not as loud, she'd look around and stuff, then she got real quiet, didn't want to eat and would stare off into space . LVN D could not recall the dates that Resident #1 ' s behaviors changed. LVN D said The last weekend, I reported it to the FNP and when I came back to work she was on Hospice. LVN D said after starting the medicine she was not sleeping more, seemed like she slept less. Started not eating-like she wasn't hearing anything around her, in her own world. LVN D said she thought Resident #1 was doing well on the medicine, but a few days before she passed away she was not eating, so she reported to FNP who ordered to hold the [MEDICATION NAME]. LVN D said after the [MEDICATION NAME] was stopped, Resident #1 did not want to eat and remained lethargic and drowsy. In an interview on [DATE] at 3:15 p.m. DON A said he was unaware of any increased drowsiness on [DATE] and said he didn't notice Resident #1 being sedated. DON A said he heard when she was hollering and several nurses (LVN B and LVN D) heard her talking. Record review of the Nursing Documentation Record from [DATE] when the [MEDICATION NAME] was started to [DATE] when Resident #1 expired revealed: [DATE] 4:50 p.m. Noted visit with Psychiatrist C via face-time, new orders received .d/c (discontinue) [MEDICATION NAME]. [MEDICATION NAME] 25 mg. 1 p.o. (by mouth) BID (twice daily), call back in one week if sedated or no change in behaviors .spoke with daughter (POA), aware of new orders. Signed by ADON. [DATE] 11 p.m. I.D. (initial dose) [MEDICATION NAME] 25 mg when med arrived. No A/R (allergic/adverse reaction) to med at this time. Res slept all night after med given . Signature not legible. [DATE] 6p-6a Pt resting in bed with eyes closed. Pt seems to have improvement with sleeping and assisting better with ADLs since change in medication. (D/C of [MEDICATION NAME], N.O. of Seroquil). Pt crying out seems to have lessened. Pt answers most questions asked. Needs will be anticipated . Signed by LVN F. [DATE] 6a-6p late entry Pt did have a decrease in frequency of yelling and outburst this shift. Pt did help in shower room by grabbing handrails. Pt did make full sentence when asked if she had pain and denied pain. Pt daughter did ask how her mother was doing with med change . . Signed by LVN B. [DATE] 6a-6p Pt remains on [MEDICATION NAME], pt does appear to have increased drowsiness but will continue to monitor . Signed by LVN B. There was no documentation in the Nursing Documentation Record from [DATE] until [DATE]. [DATE] 6a-6p FNP in facility. No new orders noted at this time. Signed by LVN D. [DATE] Family voiced concerns regarding patient weight, informed of 2 pound wt gain, request supplement to be given, informed of current order for med pass, continue to request supplement shake. FNP informed, new order for glucerna obtained, will continue to treat and monitor. Signed by LVN B. Record review of the Nursing Documentation Record revealed there was no documentation after [DATE] to indicate follow-up assessment of Resident #1's condition related to the increased drowsiness documented on [DATE], or changes in behavior until [DATE] when the following information was documented: [DATE] 6a-6p Res becoming less alert since AM. Throughout shift Res leaning forward in wheelchair with flat affect. At lunch Res pocketing food. Blood sugar is high, fluids encouraged, Res will not swallow. Assessed by oncoming 6p shift .1900 (7:00 p.m.) spoke with FNP to hold [MEDICATION NAME] continue to monitor. Signed by LVN D. [DATE] 6a-6p Res less alert. Consumes very little at meals at times holding food in her mouth. Consumed medication. Res is lethargic or staring into space. Continue to hold [MEDICATION NAME]. Signed by LVN D. [DATE] 8:30 Res consumed a few sips of juice, couple bites of breakfast. Res did not consume meds .1250 (12:50 p.m.) Res consumed a few bites of lunch and holding some in her mouth. 1300 (1:00 p.m.) FNP notified. Signed by LVN D. Record review of the Nursing Documentation Record from [DATE] to [DATE] revealed documentation of Resident #1's further decline in function until she expired on [DATE] at 7:35 a.m. Record review of the Twenty-Four Hour Report from [DATE] to [DATE] revealed 6 pages with multiple entries for Resident #1. Nursing staff did not document information related to the increased drowsiness on [DATE] or change in condition after [DATE]. The 24-Hour Report dated [DATE] contained the following entry: ,[DATE]-Resident #1-D/C [MEDICATION NAME]-N.O. [MEDICATION NAME] with N.O. labs (Day, time and/or shift not documented). The 24-Hour Report dated [DATE] contained the following entry: [DATE] Resident #1-ID (initial dose) [MEDICATION NAME] 25 mg on pm shift. D/C [MEDICATION NAME] (Time and/or shift not documented). The 24-Hour Report dated [DATE] contained the following entry: [DATE] Resident #1-D/C (discontinue) [MEDICATION NAME]. N.O. (new order) Seroquil (Time and/or shift not documented). The 24-Hour Report dated [DATE] contained the following entries: ,[DATE]-Resident #1-family requested glucerna with meals Time and/or shift not documented. ,[DATE]-Resident #1,-Hold [MEDICATION NAME] (Time and/or shift not documented). The Twenty-Four Hour Report dated [DATE] contained the following entries: ,[DATE]-Resident #1-family request glucerna w/meals Time and/or shift not documented. ,[DATE] Hold [MEDICATION NAME] per FNP (Time and/or shift not documented). The Twenty-Four Hour Reported dated [DATE] contained the following entries: ,[DATE]-Resident #1-family requested glucerna w/meals' ,[DATE]-Hold [MEDICATION NAME] per FNP Observation of a [MEDICATION NAME] pill packet (bubble pack) #2 of 2 labeled with Resident #1's name revealed Box Warning. May cause drowsiness. May cause dizziness. In an interview on [DATE] at 12:53 p.m., Pharmacist A with the pharmacy that sent out the [MEDICATION NAME] to the facility said when the medication goes out for retail to the public they include the Black Box warning on an additional leaflet, but said they do not put the Black Box warning label on medications when delivering those medications to healthcare facilities or providers. Pharmacist A said when they send out medication to other healthcare providers the receiving provider should be familiar with the medication and other warnings and specifics about the medication . Pharmacist A said the prescriber should know about the medication. In an interview on [DATE] at 3:15 p.m. the DON said his expectations for nursing staff to monitor antipsychotic drugs with Black Box Warnings depends on the drug. The pharmacy consultant reviews and makes recommendations to the doctor. Record review of the Consultant Pharmacist's Medication Regimen Review forms from [DATE] through [DATE] revealed no communication from the pharmacist to the physician or facility related to the Black Box Warning for [MEDICATION NAME]. In an interview on [DATE] at 10:30 a.m., the facility ' s Pharmacy Consultant said he would expect the facility to have a care plan that addresses the medication ' s Black Box warning, and to monitor for side effects and targeted behaviors. The Pharmacy Consultant said he would look at the medication order and the [DIAGNOSES REDACTED]. The Pharmacy Consultant said the facility ' s QA (Quality Assurance) committee told him they do not have to follow the CMS guidelines for administering antipsychotics to the elderly with dementia if they have good documentation as to why the medication is ordered. The Pharmacy Consultant said he was aware of the additional criteria that must be met to administer medications with a Black Box warning to the elderly with dementia, but would need to review it further. The Pharmacy Consultant said the pharmacies that deliver these types of medications do not generally add the Black Box warning label as they assume the facility staff has knowledge about the use and side effects of the medication. The Pharmacy Consultant said some facilities have a pharmacist on their QA committee to review medications and consider the situations, but not many facilities can afford to have a pharmacist on staff. In an interview on [DATE] at 12:56 p.m., Psychiatrist C said the [DIAGNOSES REDACTED].#1 was primarily agitation due to dementia . The following are the responses obtained from interviews with the nursing staff in which they were asked what is meant by a Black Box Warning on certain medications: [REDACTED] [DATE] 3:32 p.m. LVN A said no, what is that? [DATE] 3:35 p.m. LVN C said no, I don't know. I've heard of it. When surveyor explained the Black Box warning and asked if she saw this warning on a medication in the future, what would she do, LVN C said I would put it on the 24-hour report and put it on the MAR (medication administration record). [DATE] 3:35 p.m. LVN D said she was not familiar with Black Box Warning. [DATE] 3:40 p.m. LVN E said heard it before-has to stay in the med room I think, if I told you I'd be guessing. When surveyor explained the Black Box warning and asked if she saw this warning on a medication in the future, what would she do, LVN E said immediately contact the DON (director of nursing). [DATE] 3:45 RN B said he has never seen facility or policy guidelines for a Black Box Warning. Review of Indications for the use of [MEDICATION NAME] on the Food and Drug Administration website accessed on [DATE] at <http://www.fda.gov/downl

Based on interviews and record review the facility failed to ensure one (Resident #11) of 16 residents, whose medication regiments were reviewed, were free of significant medication errors. A. The facility failed to administer Resident # 11's Xarelto (an anticoagulant administered to reduce the risk of blood clots and stroke) as ordered. Four doses were not administered on 12/3/15 (5 p.m.), 12/4/15 (5 p.m.), and 12/5/15 (8 a.m. and 5 p.m.). B. The facility failed to administer Resident #11's [MEDICATION NAME] (platelet inhibitor -used for risk of blood clots and stroke) as ordered. The Resident was administered an extra dose on 12/5/15. An Immediate Jeopardy (IJ) was identified on 12/21/15. While the IJ was removed on 12/23/15, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. These failures placed the 16 residents receiving anticoagulants at risk for medication errors, which could result in a worsening of the clot, [MEDICAL CONDITION] embolism, stroke and death. The findings included: Review of Resident #11 ' s closed record included the following: Resident #11 was admitted to the facility on [DATE] at 1:30 p.m., and discharged on [DATE]. Record review of a Local Hospital history and Physical report dated 11/27/15 at 10:27 a.m., revealed Resident #11 was admitted to the medical center on 11/16/15 and was found to have a deep vein thrombus (blood clot) right upper extremity. Record review of Resident #11's Medication Administration Record [REDACTED]. His [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS] occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body .[MEDICAL CONDITION] is a serious condition because blood clots in your veins can break loose, travel through your bloodstream and lodge in your lungs, blocking blood flow (pulmonary embolism). <http://www.mayoclinic.org/diseases-conditions/deep-vein-[MEDICAL CONDITION]/basics/definition/con- 922>. Accessed 1/6/16. The U.S. National Library of Medicine identified a thrombus as . a blood clot that forms in a vessel and remains there and an embolism as a clot that travels from the site where it formed to another location in the body. <https://www.nlm.nih.gov/medlineplus/ency/imagepages/ .htm>. Accessed 1/6/16 The U.S. National Library of Medicine defined a [MEDICAL CONDITIONS] as a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a [MEDICAL CONDITION] that breaks loose and travels through the bloodstream to the lung.If a clot is large, or if there are many clots, [MEDICAL CONDITION] embolism can cause death. <https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=pulmonary+embolism>. Accessed 1/6/16. Record review of Resident #11's Start up Orders (initial physician's orders [REDACTED]. Xarelto 15 mg tablets orally twice a day at 8:00 a.m. and 5:00 p.m. [MEDICATION NAME] 75 mg tablet orally every day on Monday, Wednesday and Fridays at 8:00 a.m. The Drugs.com identified Xarelto as a medication used to reduce the risk of stroke and blood clots . also used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] embolism, and to help reduce the risk of these conditions occurring again. The Drugs.com also indicated to take Xarelto exactly as prescribed. Do not change the dosage or stop taking Xarelto unless your doctor tells you to http:// www. drugs.com /xarelto.html>. The Drugs.com identified [MEDICATION NAME] as a medication used prevent blood clots after a recent [MEDICAL CONDITION] or stroke, and in certain disorders of the heart or blood vessels. Drugs.com also indicated people prescribed [MEDICATION NAME] should Take [MEDICATION NAME] exactly as directed. Do not take larger or smaller amounts of it or take it or for more than recommended by your doctor. < <http://www.drugs.com/[MEDICATION NAME].html> Record review of the Nursing Documentation Record for Resident #11 revealed the following documentation on 12/03/15 at 2:30 p.m. Medication orders faxed to pharmacy. Record review of the Nursing Documentation Record for Resident #11 revealed the following documentation on 12/03/15 at 5:00 p.m. FNP A here to assess resident and check medications. Record review of Resident #11's Medication Administration Record [REDACTED]. On the identified dates the squares on the MAR indicated [REDACTED]. On 12/05/15 the 8:00 a.m. dose and the 5:00 p.m. dose were initialed and each square was circled. On 12/06/15 the 8:00 a.m. dose and the 5:00 p.m. dose were initialed and each square was circled. Further review of the MAR indicated [REDACTED]. Record review of the Nursing Documentation Record for Resident #11 revealed the following documentation on 12/05/15 at 4:30 p.m. revealed the following documentation: Resident does not have Xarelto on cart. Will continue to monitor. Signed LVN F. Record review of the Nursing Documentation Record for Resident #11 revealed the following documentation on 12/06/15 at 10:50 a.m. revealed the following documentation: Resident still does not have Xarelto on cart. Will get with staff and get Xarelto ordered and sent as soon as possible. FNP A in facility and questioning medication administration advised that Xarelto has not been given to FNP A and facility (Director of Nurses) DON. Will continue to monitor and wait for the medication to be sent. Signed LVN D. Record review of the Nursing Documentation Record for Resident #11 revealed the following documentation on 12/06/15 at 1:10 p.m. revealed. Xarelto administered to resident . signed LVN D. Record review of the 24 hour report for the dates the Xarelto was not administered 12/4/15 through 12/6/15 revealed no documentation related to the missed doses of medication. In an interview on 12/18/15 at 11:54 a.m. when questioned about the missing doses of Xarelto, FNP A said Resident #11 was admitted to the facility because he had a blood clot in his upper arm and that the clot could have broken loose and killed him or caused some damage. FNP A said Resident #11 had a PICC line (peripherally inserted central catheter, is a form of intravenous access that can be used for a prolonged period of time) for antibiotics. FNP A said that she came to check on Resident #11 and found that the Xarelto had not been given and not only did he miss two or three doses of Xarelto that was in the building (In the medication room) the whole time, but his [MEDICATION NAME] was given wrong. Resident 11's [MEDICATION NAME] was ordered three times a week on Monday, Wednesday and Friday. Resident #11 came into the building on Thursday (12/3/15) and one dose should have been given but two doses had been given from his card when I (FNP A) checked them on Sunday. FNP A said that she questioned the LVN D who first said that she had not given the [MEDICATION NAME], but after I (FNP A) showed her the medication card and that two doses had been given, the LVN D said that she must have given it. FNPA said that this is not the first time she has had problems with significant medication errors in this facility. FNP A said that she moved Resident #11 for his safety. She said that the facility did not notify the family about the medication errors and that she contacted the family about moving the resident and accidently told them about the medication error. In an interview on 12/18/15 at 4:50 PM the ADON stated she could not locate any incident reports regarding medication errors involving Resident #11. She was aware of the missed doses of Xarelto. ADON said that the Administrator ' s last day was 12/4/15 and the DON ' s last day to work was 12/14/15 and that currently the facility did not have a new DON. In an interview on 12/21/15 with ADON at 1:05 p.m. during a review of the MAR for Resident #11 the ADON said that the resident was admitted on [DATE] at 1:30 p.m., the MAR indicated [REDACTED]. On 12/5/15 the 8 a.m. dose and the 5:00 p.m. dose of Xarelto were initialed and circled. The ADON said that the circled initials meant the dose had not been given. The ADON said that the Xarelto had been found in a bottle in the medication room, and it had been in the facility. In an interview with LVN D (Works for Agency) on 12/21/15 at 2:17 p.m. said that she had been the nurse assigned to the Hall 1 medication cart where Resident #11 received his medication from. LVN D said that on 12/4/15 the Xarelto was not on the cart so she circled the medication and gave him his other medication. LVN D said that she did not report not having the medication to anyone. LVN D said that on the next day 12/5/15 the medication again was not on the cart so I circled the medication, meaning that I had not given the Xarelto. When questioned as to why she did not tell anyone about the missing medication; LVN D had no answer. On 12/6/15 the FNP came to the facility to check on Resident #11 and questioned me about the medications and I told her I had not given the Xarelto. She had me give her all the medication cards for Resident #11 and the FNP found that I had also given an extra dose of Resident #11's [MEDICATION NAME], it was ordered Monday, Wednesday and Friday and I gave a dose on Saturday. The MAR indicated [REDACTED]. Review of the MAR Start Up Orders for Resident #11 (undated) revealed [MEDICATION NAME] 75 mg q day Monday - Wednesday - Friday set to be administered at 8 a.m. There were initials on the 4th (Friday 12/4/15), 5th (Saturday 12/5/15) and 6th (Sunday 12/6/15). The initials on the 5th had an ' X ' over them, and the initials on the 6th were circled. Record review of the facility's policy entitled Medication-Unusual Occurrences, effective 01/2008 and revised 03/2012, revealed the policy of the facility is to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. The policy indicated a medication error occurs when a medication is administered in any manner that is not consistent with the physician's orders [REDACTED]. The policy identified the following procedures: 1. Unusual occurrences may be medication errors . Medication errors . shall be immediately report to the resident's physician and the Director of Nursing. 2. An entry of the incident shall be made in the resident's medical record and a report shall be completed and filed in the administrative files. 4. Licensed nurses who observe such unusual occurrences are to. b. Report the incident immediately to the Director of Nursing. c. Make the appropriate records and notifications required above. Review of the CMS 2567 dated 09/03/15, F333 was cited and an IJ had been identified due to the facility's failure to administer multiple doses of an anticoagulant to a resident. In an interview on 12/18/15 at 11:40 a.m. RNC A said that since the IJ (in September 3, 2015) the staff was to count anticoagulants like narcotics. In an interview on 12/18/15 at 11:23 a.m. LVN G said that she passed medications on Halls 1 and part of Hall 2 (this cart is where Resident #11 received his medication). LVN G stated she had 3 residents on anticoagulants. LVN G said that she did not count anticoagulants, just the narcotics and said I never have counted them (Anticoagulants). Observation of the medication cart for Halls 1 and part of Hall 2 on 12/18/15 at 11:23 a.m. revealed no anticoagulants locked in the narcotic drawer and no count sheets for the anticoagulant medications. In an interview on 12/18/15 at 11:14 a.m. LVN A stated that he had not cared for Resident #11 during his stay. LVN A said that he passed medications on Hall 4 and part of Hall 2. LVN A verified that the anticoagulant medications were locked in the narcotic drawer of the medication cart and that a count sheet was made for the medications. Observation of the medication cart for Hall 4 and part of Hall 2 on 12/18/15 at 11:14 a.m. revealed anticoagulants locked in the narcotic drawer and a count sheet for the medications. In an interview on 12/18/15 at 11:28 a.m. LVN H stated that she had not cared for Resident #11 during his stay. LVN H said that he medicated Hall 3 and part of Hall 2. LVN H verified that the anticoagulant medications were locked in the narcotic drawer of the medication cart and that a count sheet was made for the medications. Observation of the medication cart for Hall 3 and part of Hall 2 on 12/18/15 at 11:28 a.m. revealed anticoagulants locked in the narcotic drawer and a count sheet for the medications. In an interview on 12/18/15 at 11:40 a.m. when questioned about the missed doses of Xarelto, RNC A said that the facility had in-serviced on 12/7/15 and included medication administration, ordering medications and the policy on what to do when the medications are not in the building. RNC A said that the facility used agency nurses to fill in schedule holes and that he could not speak to their training on the medication carts. RNC A said that agency needed to be trained on the facility medication policies and procedures, including not to just circling omitted medication, to call the Administrator, DON, ADON, Pharmacy and doctor before a medication is circled. The staff has been told to get the medication from a local pharmacy and to call the pharmacy to verify that the medication is coming. The staff should have called and not circled the medication or at least asked someone else to see if it was in the building. In an interview on 12/18/15 at 11:50 a.m. when questioned about the missed doses of Xarelto, the ADON said that she had been in-servicing the staff and agency nurses including how to orders medications, verification of medication delivery, five medication rights, and documentation and policies that included not just circling and moving on. Call someone about the medications. The ADON said she had been walking the agency nurses room-to-room giving a report on each of the residents that they were assigned to, giving training on the medication cart they were assigned to and facility policies before they could give medications. Record review of medication administration in-service dated 12/7/15 revealed policy on medications including how to orders medications, verification of medication delivery, five medication rights, and documentation. Immediate Jeopardy (IJ) was identified on 12/21/15 at 1:55 p.m. and the Administrator, ADON, and Regional Nurse Consultants were notified. The fourth version of the Plan of Removal was accepted on 12/23/15 at 9:15 a.m. The plan was as follows: Problem: Significant medication errors. Plan: 1. All resident Medication Administration records have been reviewed by RNC/designee to determine that all residents ' medication is being administered according to physician order, documented and available. Physician will be notified immediately of errors found on MARs by RNC/designee. MARS will be reviewed daily x 2 weeks by the ADON/designee to insure compliance. The RNC will monitor during each visit to the home x 3 months. Any identified issues will be addressed through training/disciplinary action immediately. Completion date: 12/22/15. 2. When Medication errors are found, Medication Error Report will be written by ADON/designee for errors found and appropriate parties notified to include: physician, and responsible party. Completion date: 12/22/15 and on-going. 3. Results of the MAR indicated [REDACTED]. Weekend RN will review MARs for accuracy on Saturday and Sunday. Errors will be communicated to the Administrator/designee immediately. MAR indicated [REDACTED]. Completion date: 12/22/15. 4. Licensed nursing staff has been in-serviced by RNC/designee on medication administration procedure to include 5 rights of medication administration, documentation at time of administration and procedure to use if drug is not available. In-service has been completed with Nursing staff, will report to administrator/DON if medication is not available. Staff not present for training will not be allowed to work until the training has been presented to them by RNC/designee. Agency staff that has not received training in the home will receive the same training before they are allowed to work first shift. Completion date: 12/22/15 and on-going. 5. The MDS nurse will check new telephone orders and new admission orders [REDACTED]. Errors found will be rectified immediately by correcting transcription, clarifying orders with physician as necessary and procuring the medication if it is not available. Report will be given to Administrator each morning with the results of the audit. Any issues identified will be addressed immediately through training/disciplinary action as needed. Completion date: 12/22/15 and on-going. 6. Monitoring of all processes above will be done by ADON/designee daily x2 weeks, then 3 x weekly x 2 weeks, 1 x weekly x 4 weeks. Audit results will be brought to the QAA x 3 months. Completion date: 12/22/15 and on-going. 7. Medical Director was notified of the IJ situation at 3:35 p.m. on 12/21/15. Ad hoc QA meeting held via telephone at 3:35 p.m. on 12/21/15 with Plan of Removal discussed. 8. Residents receiving blood thinning agent have been added to an individual count sheet on 012/21/15 by RNC/designee. The anticoagulant count for each resident is reconciled at the end of each shift during shift change. Any count that is found to be incorrect will be reported immediately to the Administrator/DON/designee at shift change. Completion date: 12/22/15 and on-going. 9. In-service training has been provided to all licensed nurses on the Lab Monitoring Process to include: tracking, scheduling, and obtaining results by RNC/designee on 12/22/15. Nurses not present during in-service will be in-serviced during their next shift to work. Care Plans have been completed for all residents receiving anticoagulants on 12/22/15 by RNC/designee. 10. A list has been given to the MDS nurse on 12/22/15 by RNC so that the MDS Sections N0400 has been verified and indicates the use of anticoagulants. Any error found in the coding has had a significant correction MDS completed. Completion date: 12/22/15. Plan of removal was verified through the following observations, interviews, and record reviews conducted by the surveyors on 12/22/15 through 12/23/15. Interviews with six nurses from various shifts, revealed staff had been in-serviced on multiple areas, including medication administration, change of condition, notification of physician, and anticoagulants monitoring. The interviewed staff was able to discuss the facility's policies and procedures for the identified areas, including the changes being made by the facility. The staff was able to confirm new procedures, such as reviewed the MARs after each shift and anticoagulant counting at shift change, were being put into practice. Record review of the 16 residents on anticoagulants' MARs for 12/18/15 through 12/23/15 revealed no concerns related to medications not being administered as ordered. Record review of in service Training Report dated 12/22/15 revealed the following trainings were conducted by the facility and attended by the facility's nursing staff: Medication Administration, 5 rights of medication administration, documentation at time of administration and procedure to use if drug is not available On 12/23/15 at 1:45 p.m. the Administrator was informed the IJ was removed effective 12/23/15. The facility remained out of compliance at a level of no actual harm at a pattern due to the facility needed to monitor their plan for effectiveness. Record review of physician's orders [REDACTED].

Based on interview and record review, the facility failed to notify the resident's physician, legal representative or interested family member of a significant change in the resident's condition for one (Residents #3) of 15 residents reviewed for notification of changes. A. On 10/23/15 Resident #3 began displaying symptoms of a change in condition that continued until he was sent to the hospital on [DATE] where he was diagnosed with [REDACTED]. LVN G did not notify Resident #3's physician or responsible party when Resident #3 began experiencing the change in condition. This failure resulted in harm to Resident #3 and could affect any of the other 32 residents cared for by LVN G by preventing the resident's physician and/or interested family member from making informed care decisions regarding the resident. The findings included: Record review of Resident #3's Physician order [REDACTED]. His [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed Resident #3 was able to make himself understood and usually understand others. The MDS also revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. The MDS also revealed Resident #3 has an indwelling catheter. Record review of Resident #3's Nursing Documentation Record (nurse's notes) revealed the following entries: 10/18/15 (no time) Pt (patient) c/o (complains of) severe pain to R (right) groin . Pt urine was foul in odor & (and) cloudy (with) large amount white sediment noted (FNP A) informed order obtained for UA (urinalysis) in AM (morning), oncoming shift was informed Signed by LVN F 10/22/15 (no time) N.O. (new order) obtained for p.o. (physician order) ABX (antibiotics)-sent/faxed to (local pharmacy) Signed by LVN F 10/23/15 (no time) v/s (vital signs) 129/82 (blood pressure) 111 (resting pulse), 18 (respiration) 97.8 (temperature . c/o of coldness. Skin warm et (and) red to touch . Resident continues to c/o pain in inguinal (groin) region cloudy yellow urine draining freely into FC (foley catheter) bag. Will continue to TX (treat) et monitor. Signed by LVN G 10/24/15 6p (evening) - 6a (morning) v/s (vital signs) 130/52 (blood pressure) 118 (resting pulse) 22 (respiration) 98.6 (temperature) . Respirations shallow. Resident leaning to R (right) side (with) food spilled down length of shirt. (Increased) tremors in BUE (bilateral upper extremities) C/O severe pain to groin. Continues ABTs for UTI (urinary tract infection . Will continue to monitor closely. Signed by LVN G 10/25/15 6:30 AM Rec'd (received) report residents resp. (respirations 30. O2 (oxygen) sats (saturation) dropping to 85 on 2L (liters) NC (nasal cannula). Upon entering room Res had shallow respirations. Wheezes auscultated Bil (bilateral) lobes. ABD (abdomen) distended (with) absent bowel sounds. Res not easily aroused and is breathing through mouth.7:00 (AM) Notifed (FNP A) rec'd NO sent to ER (emergency room ) for eval. 7:05 (AM) EMS (emergency medical services) called for transport. 7:10 (AM) Report called to ER by night nurse. She also notified daughter . 7:30 (AM) Res taken OOF (out of facility) by EMS to (local hospital). Signed by LVN B Record review of Resident #3's hospital records from the local hospital he was transferred to on 10/25/15 revealed the following vital signs during his stay: 10/28/15 - 109/50 (blood pressure), 78 (pulse), 18 (respiration) 10/30/15 - 113/80 (blood pressure), 84 (pulse), 22 (respiration) Record review of Resident #3's Admission/Readmission Data Summary, dated 11/03/15, revealed Resident #3's vital signs were 108/62 (blood pressure), 78 (pulse), and 18 (respiration). In an interview on 11/19/15 at 10:30 AM LVN G confirmed she was the nurse for Resident #3 on 10/24/15 from 6:00 PM to 6:00 AM. She stated that he began to show a change in condition after dinner on 10/24/15. LVN G stated that she took Resident #3's vitals when giving him 8:00 PM medications. LVN G attributed his symptoms (trembling, decreased alertness, leaning to one side, pain) to his UTI. She stated he had just begun his antibiotics. LVN G stated that she couldn't find anything clinically wrong with Resident #3 so she did not notify the physician. LVN G stated by clinically wrong she meant problems with his vital signs. LVN G stated she has only been a nurse for two months. LVN G stated she did have the weekend RN check Resident #3 when she arrived between 5:00 AM and 5:30 AM. LVN G stated the weekend RN indicated FNP A was scheduled to come to the facility later that day, and could examine Resident #3 then. In an interview on 11/18/15 at 1:30 PM LVN B stated when she came in to work on 10/25/15 at 6:00 AM the supervising RN grabbed her and took her to Resident #3's room to observe his condition. LVN B stated Resident #3 was basically non-responsive. LVN B stated she was told by the nurse going off shift (LVN G) that the resident's condition had been declining for the last couple of hours. LVN B stated that the day before (10/24/15) Resident #3 had been sleepy and difficult to wake. LVN B stated Resident #3 reported he felt bad. LVN B could not remember if she had passed this on at shift change, but did confirm that she had not contacted the physician regarding Resident #3's condition on 10/24/15. In an interview on 11/18/15 at 12:45 PM the DON stated after she reviewed the nurse's notes for Resident #3 beginning on 10/23/15, she believed LVN G should have notified Resident #3's physician on the evening of 10/24/15 and not waited until the morning of 10/25/15. In an interview on 11/18/15 at 1:00 PM the ADON stated after she reviewed the nurse's notes for Resident #3 beginning on 10/23/15, she believed LVN G should have notified Resident #3's physician on the evening of 10/24/15 and not waited until the morning of 10/25/15. In an interview on 11/18/15 at 3:00 PM FNP A stated she was not notified regarding Resident #3 experiencing a change in condition until the morning of 10/25/15. Record review of the facility provided policy and procedure entitled Change of Condition-Observing, Reporting, and Recording, dated 01/2008 and revised 03/2012, revealed it the policy of the facility to informs (sp) the resident, the residents physician and if indicted (sp) the residents responsible party of the following. 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications; . A need to alter treatment significantly. PROCEDURE . 3. The attending physician should be notified as soon as possible if immediate attention is required or a s soon as feasible if the resident is table . If you are unable to reach the attend physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director . or the emergency room physician. In an interview on 11/24/15 at 3:55 PM the DON confirmed LVN G was responsible for 33 residents on the night shift.

Based on interview and record review, the facility failed to ensure two of nine residents (Residents #3 and #8) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: A) On 10/23/15 Resident #3 began displaying symptoms of a change in condition that continued until he was sent to the hospital on [DATE] where he was diagnosed with [REDACTED]. LVN G did not notify Resident #3's physician or responsible party when Resident #3 began experiencing the change in condition. B) Residents #8 did not have thorough assessments upon return from [MEDICAL TREATMENT] since his admission 01/13/15. This failure resulted in harm to Resident #3 and could have the other 32 residents receiving care from LVN G and the three residents who receive [MEDICAL TREATMENT], which included Resident #8. This failure put the identified residents at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings include: Resident #3 Record review of Resident #3's Physician order [REDACTED]. His [DIAGNOSES REDACTED]. Record review of Resident #3's Minimum Data Set (MDS), dated [DATE], revealed Resident #3 was able to make himself understood and usually understands others. The MDS also revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. The MDS also revealed Resident #3 has an indwelling catheter. The National Institute of Medicine identified a catheter as a tube placed in the body to drain and collect urine from the bladder. The National Institute of Medicine identified an indwelling catheter as one that is left in the bladder. An indwelling catheter collects urine by attaching to a drainage bag. https://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm Record review of Resident #3's Care Plan, reviewed and continued on 10/10/15, revealed the care plan identified the resident's indwelling catheter as a problem area, with a start date of 09/29/15. The goals related to this problem included resident will not exhibit symptomatic UTI (urinary tract infection) as evidence by no fever, no dysuria, no worsening of mental or function status. The approaches for achieving this goal included Monitor residents for signs/symptoms of UTI-which include fever, change in my mental or functional status, c/o (complaints of) bladder or catheter pain, flank pain, change in color or clarity of urine. Record review of Resident #3's Nursing Documentation Record (nurse's notes) revealed the following entries: 10/18/15 (no time) Pt (patient) c/o (complains of) severe pain to R (right) groin . Pt urine was foul in odor & (and) cloudy (with) large amount white sediment noted (FNP A) informed order obtained for UA (urinalysis) in AM (morning), oncoming shift was informed Signed by LVN F 10/22/15 (no time) N.O. (new order) obtained for p.o. (physician order) ABX (antibiotics)-sent/faxed to (local pharmacy) Signed by LVN F 10/23/15 (no time) v/s (vital signs) 129/82 (blood pressure) 111 (resting pulse), 18 (respiration) 97.8 (temperature . c/o of coldness. Skin warm et (and) red to touch . Resident continues to c/o pain in inguinal (groin) region cloudy yellow urine draining freely into FC (foley catheter) bag. Will continue to TX (treat) et monitor. Signed by LVN G 10/24/15 6p (evening) - 6a (morning) v/s (vital signs) 130/52 (blood pressure) 118 (resting pulse) 22 (respiration) 98.6 (temperature) . Respirations shallow. Resident leaning to R (right) side (with) food spilled down length of shirt. (Increased) tremors in BUE (bilateral upper extremities) C/O severe pain to groin. Continues ABTs (antibiotics) for UTI (urinary tract infection) . Will continue to monitor closely. Signed by LVN G 10/25/15 6:30 AM Rec'd (received) report residents resp. (respirations 30. O2 (oxygen) sats (saturation) dropping to 85 on 2L (liters) NC (nasal cannula). Upon entering room Res had shallow respirations. Wheezes auscultated Bil (bilateral) lobes. ABD (abdomen) distended (with) absent bowel sounds. Res not easily aroused and is breathing through mouth.7:00 (AM) Notifed (FNP A) rec'd NO sent to ER (emergency room ) for eval. 7:05 (AM) EMS (emergency medical services) called for transport. 7:10 (AM) Report called to ER by night nurse. She also notified daughter . 7:30 (AM) Res taken OOF (out of facility) by EMS to (local hospital). Signed by LVN B Record review of Resident #3's hospital records from the local hospital he was transferred to on 10/25/15 revealed the following vital signs during his stay: 10/28/15 - 109/50 (blood pressure), 78 (pulse), 18 (respiration) 10/30/15 - 113/80 (blood pressure), 84 (pulse), 22 (respiration) Record review of Resident #3's Admission/Readmission Data Summary, dated 11/03/15, revealed Resident #3's vital signs were 108/62 (blood pressure), 78 (pulse), and 18 (respiration) when he returned to the facility from the local hospital. In an interview on 11/19/15 at 10:30 AM LVN G confirmed she was the nurse for Resident #3 on 10/24/15 from 6:00 PM to 6:00 AM. She stated that he began to show a change in condition after dinner on 10/24/15. LVN G stated that she took Resident #3's vitals when giving him 8:00 PM medications. LVN G attributed his symptoms (trembling, decreased alertness, leaning to one side, pain) to his UTI. She stated he had just begun his antibiotics. LVN G stated that she couldn't find anything clinically wrong with Resident #3 so she did not notify the physician. LVN G stated by clinically wrong she meant problems with his vital signs. LVN G stated she has only been a nurse for two months. LVN G stated she did have the weekend RN check Resident #3 when she arrived between 5:00 AM and 5:30 AM. LVN G stated the weekend RN indicated FNP A was scheduled to come to the facility later that day, and could examine Resident #3 then. In an interview on 11/18/15 at 1:30 PM LVN B stated when she came in to work on 10/25/15 at 6:00 AM the supervising RN grabbed her and took her to Resident #3's room to observe his condition. LVN B stated Resident #3 was basically non-responsive. LVN B stated she was told by the nurse going off shift (LVN G) that the resident's condition had been declining for the last couple of hours. LVN B stated that the day before (10/24/15) Resident #3 had been sleepy and difficult to wake. LVN B stated Resident #3 reported he felt bad. LVN B could not remember if she had passed this on at shift change, but did confirm that she had not contacted the physician regarding Resident #3's condition on 10/24/15. In an interview on 11/18/15 at 12:45 PM the DON stated after she reviewed the nurse's notes for Resident #3 beginning on 10/23/15, she believed LVN G should have notified Resident #3's physician on the evening of 10/24/15 and not waited until the morning of 10/25/15. In an interview on 11/18/15 at 1:00 PM the ADON stated after she reviewed the nurse's notes for Resident #3 beginning on 10/23/15, she believed LVN G should have notified Resident #3's physician on the evening of 10/24/15 and not waited until the morning of 10/25/15. In an interview on 11/18/15 at 3:00 PM FNP A stated she was not notified regarding Resident #3 experiencing a change in condition until the morning of 10/25/15. Record review of the facility provided policy and procedure entitled Change of Condition-Observing, Reporting, and Recording, dated 01/2008 and revised 03/2012, revealed it the policy of the facility to informs (sp) the resident, the residents physician and if indicted (sp) the residents responsible party of the following. 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental or psychosocial status, in life-threatening conditions or clinical complications; . A need to alter treatment significantly. PROCEDURE . 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible if the resident is stable . If you are unable to reach the attend physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director . or the emergency room physician. Resident #8 Review of Resident #8 ' s Resident Admission Record, undated, revealed he was an [AGE] year old male admitted to the facility 01/13/15 with a readmission date of [DATE]. Resident #8 ' s [DIAGNOSES REDACTED]. www.Freemedicaldictionary.com <http://www.Freemedicaldictionary.com>), Disorder of Adult Personality and Behavior, Dysphagia (difficulty swallowing), Shortness of Breath, Pain, Anxiety, Dementia with Behavioral Disturbance, Fatigue, Amnesia (loss of memory), [MEDICAL CONDITION], Hypertension (high blood pressure), [MEDICAL CONDITIONS] of Native Coronary Artery, Constipation, [MEDICAL CONDITION] and Kidney Failure. Review of Resident #8 ' s Physician order [REDACTED].Check [MEDICAL TREATMENT] catheter site after return from [MEDICAL TREATMENT] to ensure clean and dry M-W-F Once a day on Mon., Wed., Fri; 6:00 a.m.-6:00 p.m. Review of Resident #8 ' s Nurse ' s Notes dated 09/09/15 at 4:20 p.m. revealed, Resident back in facility from [MEDICAL TREATMENT] .VS (vital signs) WNL (within normal limits) . No documentation of Resident #8 ' s vital sign numbers or assessment of his [MEDICAL TREATMENT] catheter was found. Review of Resident #8 ' s Nurse ' s Notes dated 09/21/15 at 8:00 a.m. revealed, Left facility to [MEDICAL TREATMENT] . No assessment of Resident #8 ' s [MEDICAL TREATMENT] catheter was found. Review of Resident #8 ' s Nurse ' s Notes dated 10/02/15 at 9:00 a.m. revealed, Resident out to [MEDICAL TREATMENT] . Review of Resident #8 ' s Nurse ' s Notes dated 10/02/15 at 5:45 p.m. revealed Resident arrived from [MEDICAL TREATMENT] . No documentation of Resident #8 ' s vital signs or assessment of his [MEDICAL TREATMENT] catheter was found. Review of Resident #8 ' s Nurse ' s Notes dated 10/09/15 6:00 p.m.-6:00 a.m. revealed, .Assessed shunt site, Rt (right) upper arm. Removed dressing. Rt upper arm bruised. Big hard bubble at shunt site. Thrill (vibration felt over an arteriorvenous fistula, http://medical-dictionary.thefreedictionary.com/thrill) was heard at shunt site. Review of Resident #8 ' s Nurse ' s Notes dated 10/30/15 at 12:10 p.m. revealed, (Name) from [MEDICAL TREATMENT] phoned requesting a copy of the residents DNR (Do Not Resuscitate) D/T (due to) they don ' t have one on file, his BP (blood pressure) was low at [MEDICAL TREATMENT], their physician notified. Review of Resident #8 ' s Nurse ' s Notes dated 10/30/15 at 3:00 p.m. revealed, Returned back from [MEDICAL TREATMENT]. No documentation of Resident #8 ' s vital signs or assessment of his [MEDICAL TREATMENT] catheter site was found. Review of Resident #8 ' s Nurse ' s Notes dated 11/11/15 at 8:00 a.m.-5:00 p.m. revealed, Res. (resident) had been out of facility at [MEDICAL TREATMENT], before this nurse ' s arrival. Res. back in facility at approx. 3:15 p.m. No documentation of Resident #8 ' s vital signs or assessment of his [MEDICAL TREATMENT] catheter was found. In an interview on 11/16/15 at 5:00 p.m., the ADON said the facility sent a form for [MEDICAL TREATMENT] to fill out, but the facility did not usually get it back, so staff nurses would call and get a verbal report of Resident #8 ' s condition during [MEDICAL TREATMENT]. When asked where the report was documented, the ADON replied the report would be documented in Resident #8 ' s Nurse ' s Notes. The ADON said the bruit (a swooshing sound and vibration felt when listened to with a stethoscope, http://medical-dictionary.thefreedictionary.com) and thrill of the [MEDICAL TREATMENT] catheter were to be documented on the MAR or TAR. The ADON and LVN A checked the MAR and TAR of Resident #8 ' s clinical record. No documentation of the bruit or thrill of the [MEDICAL TREATMENT] was found. In an interview on 11/17/15 at 9:42 a.m., Medical Records A said she had checked Resident #8 ' s entire clinical record but did not find any of the [MEDICAL TREATMENT] Communication Forms. Review of the facility ' s undated [MEDICAL TREATMENT] Communication Form revealed pre-[MEDICAL TREATMENT] documentation spaces for temperature, pulse, blood pressure, access site, thrill and bruit, dressing status; [MEDICAL TREATMENT] unit documentation; and nursing facility post-[MEDICAL TREATMENT] documentation to include temperature, pulse, blood pressure, access site, thrill and bruit and dressing status. In an interview on 11/17/15 at 3:45 p.m., the DON said when a resident went to [MEDICAL TREATMENT], she expected the nurse to complete and send the [MEDICAL TREATMENT] Communication Form with the resident. The DON said upon return from [MEDICAL TREATMENT], the nurse was to take the resident ' s blood pressure, pulse and temperature and find out the resident ' s dry (post [MEDICAL TREATMENT]) weight and how the resident tolerated the procedure. Review of Resident #8 ' s Care Plan, [MEDICAL TREATMENT], dated 10/30/15 and signed by the DON, revealed, .Inspect and palpate graft site each day for thrill and auscultate for bruit .Communicate to [MEDICAL TREATMENT] center any concerns or change in condition .Obtain wet (pre-[MEDICAL TREATMENT]) and dry (post-[MEDICAL TREATMENT]) weights from [MEDICAL TREATMENT] center with each visit . Review of the facility ' s policy, [MEDICAL TREATMENT]-General Guidelines and Management, dated 03/12, revealed, .It is the policy of this home that [MEDICAL TREATMENT] residents will receive [MEDICAL TREATMENT] service as per physician orders [REDACTED].Access .Type .Arteriovenous Fistula and Graft .Nursing Implications. 1. Assess patency of fistula or graft by palpating or auscultating bruit. 2. Instruct resident to avoid compression of fistula by tight clothes or carrying objects with arm bent. 3. Assess for signs and symptoms of infection including pain, redness, swelling, or excessive warmth .Prior to [MEDICAL TREATMENT] treatments, assess vitals, [MEDICAL CONDITION], access site, mental status, complaints of pain/discomfort, blood sugar (if ordered), and administer meds as directed by the [MEDICAL TREATMENT] center . CMS 672 dated 11/16/15 revealed three residents receiving [MEDICAL TREATMENT]. In an interview on 11/24/15 at 3:55 PM the DON confirmed LVN G was responsible for 33 residents on the night shift.

Based on interview and record review, it was determined the facility failed to consult the resident's physician when the resident experienced a significant change in condition for one (Residents #9) of 14 residents reviewed for notification of changes in condition. A. Resident #9 experienced a change in condition beginning on 07/29/15 when his blood sugar was 49, outside of the parameters requiring physician notification. LVN H failed to ensure Resident #9's physician was notified, and Resident #9 continued to experience fluctuations in his blood sugar levels. On 07/30/15 Resident #9 became unresponsive and was sent to the emergency room via an ambulance. An Immediate Jeopardy (IJ) was identified on 08/11/15. While the IJ was removed on 08/13/15, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. These failures could place the facility's 16 residents who receive insulin at risk for not being adequately assessed with [REDACTED]. The findings included: Resident #9 Record review of Resident #9's Face Sheet, undated, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #9's Admission/Readmission Data Summary, dated 07/28/15, revealed Resident #9 was admitted from the hospital at 7:15 PM with a new surgical incision to the abdomen with staples. The summary revealed at the time of admission Resident #9's blood sugar was 233 and insulin was administered as ordered. Record review of Resident #9's Brief Interview for Mental Status, dated 07/30/15, revealed a score of 14, indicating he was cognitively intact. Record review of Resident #9's Admission Care Plan, dated 07/28/15, revealed diabetes was identified as an area of concern. The goal for the area was for there to be no complications. The interventions included blood sugar checked twice a day, medications as ordered, diet as ordered, observe signs/symptoms of [DIAGNOSES REDACTED] (low blood sugar)/[MEDICAL CONDITION] (high blood sugar)and lab work as ordered. Record review of Resident #9's Start Up Orders, undated, revealed he was ordered [MEDICATION NAME] ER tab 500 mg twice a day (8:00 AM and 8:00 PM), [MEDICATION NAME] Injection 35 units subcutaneously (under the skin) every morning (7:00 AM), and [MEDICATION NAME] Injection 15 units subcutaneously (under the skin) at nighttime (8:00 PM). According to the U.S. National Library of Medicine [MEDICATION NAME] is a medication used alone or with other medications, including insulin, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). [MEDICATION NAME] helps to control the amount of glucose (sugar) in your blood. [MEDICATION NAME] also increases your body's response to insulin, a natural substance that controls the amount of glucose in the blood. https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 5.html According to the U.S. National Library of Medicine [MEDICATION NAME] (Insulin [MEDICATION NAME]) is used to treat forms of diabetes and is a long-acting, man-made version of human insulin that works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 was ordered to have Accu-Cheks (machine used to measure blood sugar levels) twice a day (6:00 AM and 8:00 PM) and that if the blood sugar level was below sixty or above 300 the physician should be notified. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9's blood sugar level was checked on the following dates and times with the following results: 07/29/15 at 6:00 AM 63 07/29/15 at 8:00 PM 49 07/30/15 at 6:00 AM 66 Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 received [MEDICATION NAME] Injection of 35 units at 7:00 AM on 07/29/15 and 07/30/15. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 received [MEDICATION NAME] Injection of 15 units at 8:00 PM on 07/28/15. The MAR indicated [REDACTED]. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 received doses of [MEDICATION NAME] on the following dates and times: 07/28/15 at 8:00 PM, 07/29/15 at 8:00 AM, and 07/30/15 at 8:00 AM. The MAR indicated [REDACTED]. Record review of Resident #9's Nursing Documentation Record revealed the following entries: 07/29/15 3:00 PM Res (Resident) awake (and) alert . BSC (Blood Sugar Concentration) this AM 63. Accu (Chek) orders clarified (with) (FNP A). (Signed by LVN E) 07/29/15 4:00 PM Tx (treatment) nurse reports Res c/o (complains of) SOB (shortness of breath) (with) exertion. Standing approx. (approximately) 2 min (minutes). Resolved (after) sitting per Res Signed by LVN E) 07/30/15 4:35 AM resident rested in bed majority of shift. resp (respiration) even and unlabored accepted PO (by mouth) meds (with) difficulty. Denies pain or discomfort. BSL (blood sugar level) this PM 49 (07/29/15 at 8:00 PM) G (gastrostomy) tube flushed and patent. Patient had refused supper this evening. Did accept can of orange juice and ½ ham/cheese sandwich. Will cont (continue) to monitor (Signed by LVN H) 07/30/15 10:00 AM . Res. c/o diarrhea x (times) 1 . Refused snack-Denies pain ABD (abdomen) sutures in place (with) tx done (signed by LVN B) 07/30/15 11:30 AM CNA reports (Resident #9) does not want lunch-LVN explained (to) Res. Of all diabetic meds he was on and if he chose not (to) eat his BS (blood sugar) could drop and cause him to be unresponsive and even cause him to lapse into a coma. Res. Stated I know this ma'am and my stomach is rolling so I'm not eating . ask Res when his last [MEDICAL CONDITION] tx was, reports end of May . (Signed by LVN B) 07/30/15 5:30 PM (FNP A) in house Res. BS (down) 38 unresponsive-given [MEDICATION NAME] PO and IM (increased to) 39-911 called [MEDICATION NAME] .5 inj given-ER (emergency room ) notified-wife notified Res. OOF (out of facility) via ambulance to (local hospital) ER. (Signed by LVN B) According to the U.S. National Library of Medicine [MEDICATION NAME] is . used to raise very low blood sugar. [MEDICATION NAME] is usually given by injection beneath the skin, in the muscle, or in the vein. [MEDICATION NAME] should be administered as soon as possible after discovering that the patient is unconscious from low blood sugar. https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 0.html According to the Mayo Clinic [MEDICATION NAME] injection is a sterile solution used to provide your body with extra water and carbohydrates (calories from sugar). It is used when a patient is not able to drink enough liquids or when additional fluids are needed. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8a 9-bebf-4001-993a-f 8e04b8 07/30/15 7:00 PM Spoke (with) (FNP A) regarding residents return to facility from ER. New order received to check residents BS every 2 hours thru the night. Call if BSL is greater than 350 mg/dL or less than 60 mg/dL. May bolus (given a single dose) resident with 1 can of ensure (meal supplement) if he eats less than 50% of his meal. Will cont to monitor (Signed by LVN H) 07/31/15 3:00 AM Accu chk (chek) performed. Reading 44mg/dL. Phoned (FNP A) & notified her directly of (accu-chek) results. Also informed (FNP A), OJ (orange juice) had been given per resident request via PO. (FNP A) ordered to give him something with substance that will hold his bld (blood) sugar. Admin Ensure PO. (Signed by LVN N) 07/31/15 9:00 AM Rec'd (received) NO (new order) (from) (FNP A). Transfer to (local hospital). In an interview on 09/03/15 at 11:43 AM LVN H stated that she was the nurse caring for Resident #9 for part of the night on 07/29/15. LVN H stated that she remembers checking Resident #9's blood sugar that night and it being low. LVN H stated that she left a message at Resident #9's physician's office. LVN H stated that she was not aware that she was supposed to call FNP A for any emergencies. LVN H stated there were no orders signed by FNP A or instructions indicating FNP A was to be the one contacted. LVN H stated that she provided Resident #9 with a sandwich and juice and rechecked his blood sugar. LVN H stated Resident #9's blood sugar rose to the 90's. LVN H stated she believes she took Resident #9's blood sugar again, but can't remember the results or why it wasn't documented. LVN H stated when she arrived for her shift on 07/29/15 she was told that Resident #9 was changing to being the responsibility of the nurse assigned to the 100 Hall. LVN H stated Resident #9 switched to the care of LVN N after the med pass. LVN H stated she couldn't remember if she tried to contact the resident's physician again. In an interview on 08/07/15 at 4:10 PM FNP A stated she was not notified of the issues Resident #9 was having with his blood sugars. She stated she did not receive notice of his blood sugar being 49 (on 07/29/15 at 8:00 PM), and confirmed her parameters where to be contacted if the blood sugar was below 60. FNP A stated she was not notified that the resident refused to eat. FNP A stated she was in the facility making rounds on 07/30/15 and found the resident unresponsive in his room. FNP A stated she would have taken steps to prevent the incident of the resident becoming unresponsive. FNP A stated she could have withheld his medication, had him monitored more closely, and ordered bolus feedings through his [DEVICE]. FNP A indicated the situation was entirely avoidable and that the facility's failures resulted in her removing the resident from the facility. FNP A stated she did not feel her resident was safe in the facility. In an interview on 09/03/15 at 9:59 AM at LVN B stated she was the nurse for Resident #9 on 07/30/15. LVN B stated she worked the 6:00 AM to 6:00 PM shift and that day was the first time she worked with Resident #9. LVN B stated the night shift nurse, LVN N, told her about the resident having low blood sugar. LVN B stated she was told by LVN N and LVN H, the night nurse who cared for Resident #9 for the first part of the night shift, that they had faxed notification of the low blood sugar to Resident #9's doctor. LVN B stated she told LVN N and LVN H this was not appropriate. LVN B stated the facility's policy is to contact FNP A by phone. LVN B stated she made sure Resident #9 had eaten breakfast and then gave him morning insulin and medication. LVN B stated if she had known Resident #9 was so brittle she would have done another blood sugar check during the day. LVN B stated if she had known everything about Resident #9's needs she could have provided better care and could have met all his needs. LVN B stated she initially addressed the issue with FNP A's nurse, who was already in the facility, between 10:00 and 11:00 AM. LVN B stated it was sometime that afternoon that she contacted FNP A to obtain additional orders for Resident #9. LVN B stated shortly after getting the orders, FNP A arrived at the facility to check on the resident. LVN B stated it was at this time that FNP A found Resident #9 unresponsive. LVN B stated she did not document everything that occurred in Resident #9's chart because it all happened so quickly. LVN B stated if she had known Resident #9 was a brittle diabetic she would have handled his incidents of low blood sugar differently, and would have held his insulin until she spoke with FNP A. In an interview on 09/03/15 at 11:13 AM LVN E stated she was the nurse responsible for Resident #9 on 07/29/15 for the 6:00 AM to 6:00 PM shift. LVN E stated that she reviewed his chart and realized he was diabetic, but did not have any orders for blood sugar checks. LVN E stated she contacted FNP A and obtained orders for blood sugar checks. LVN E stated she was not told by anyone that Resident #9 was a brittle diabetic. LVN E stated that she did not receive a report at shift change regarding Resident #9. LVN E stated she checked Resident #9's blood sugar prior to contacting FNP A and believes it was 63. LVN E stated she received the parameters to contact FNP A if Resident #9's blood sugar was below 60 or above 350. LVN E stated she is normally assigned to the 400 Hall, but also is responsible for a few residents on the 200 Hall, including Resident #9. LVN E stated that she was not aware Resident #9 was diabetic until she began to review his chart. In an interview on 09/03/15 at 11:25 AM LVN P, office nurse with FNP A, stated Resident #9 had not been a patient's of FNP A prior to arriving at the facility and had never been treated by FNP A. LVN P stated she came to the facility on [DATE] around 10:00 AM to review Resident #9's chart since he was a new patient and new resident. LVN P stated LVN B informed her about Resident #9's low blood sugar and that the night nurse had not notified FNP A. LVN P stated LVN B also discussed concerns that Resident #9 was not eating his meals. LVN P stated based on her experience with FNP A, if FNP A had been aware of the low blood sugar levels she would have ordered additional treatment and monitoring. LVN P stated that FNP A would most likely have ordered the resident to be sent to the hospital if there was not improvement. LVN P stated she believed part of the issue was that the nurse kept changing. LVN P stated that given all of Resident #9's medical issues the staff should have treated him like a brittle diabetic and should have been more vigilant, especially if they were not aware of his full history. Record review of the Patient Transfer Form for Resident #9, dated 07/30/15 and provided when he transferred to the local hospital from the facility, revealed the description of the incident was BS (blood sugar) 36 and Refusing to eat. The transfer form was signed by LVN B. Review of the facility policy and procedure titled: Change of Condition- Observing, Reporting, and Recording, dated 3/2012, revealed the following; It is the policy of this home to inform the resident, the resident ' s physician and if indicated the resident ' s responsible party of the following: 1. An accident or incident involving the resident, which results in injury has the potential for requiring physician intervention. 2. A significant change in the resident ' s physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; . 4. A need to alter treatment significantly. Procedure Observing, Reporting and Documenting a Change of Condition; 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible. If the resident is stable (change in condition is resolved such as a fall without injury or head trauma). If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director (if not the attending or alternate physician) or the emergency room physician. 4. Complete an incident/accident report if indicated (fall, injury etc.) 5. Notify resident ' s responsible party . Documentation: 1. Date, time condition changes were identified 2. Pertinent assessment findings 3. Who was notified and when 4. Disposition of the resident 5. Update care plan if indicated with any determined interventions to mitigate further incidents if applicable. Communication: 1. The change in condition and interventions related to the change will be documented on the 24 hour report form on the shift that the change occurred. 2. The licensed nurse and nursing assistant will communicate to the oncoming shift orally and through the 24 hour report the change in condition and interventions. 3. The Director of Nurses/designee will report the change in condition, interventions, and response to the appropriate Q & A Committee. Review of the facility policy titled Medication Administration, Documentation dated 12/2012 revealed the following: 1.The individual who administers the medication dose, records the administration on the resident ' s MAR indicated [REDACTED]. 2. If a dose of regularly scheduled medication is withheld, refused, or given at other than the scheduled time (for example, the resident is no in the nursing care center at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record provided for PRN documentation. If two consecutive doses of a vital medication are withheld or refused, the physician is notified . Immediate Jeopardy (IJ) was identified on 08/11/15 at 4:06 PM and the Administrator, interim DON, ADON, and Regional Nurse Consultant were notified. The final version of the Plan of Removal was accepted on 08/13/15 at 5:57 PM and included the following: Problem: Failed to administer and document medication administration Failed to report change of condition to physician. Plan: (identified staff) have been in-serviced on medication administration documentation and notification of changes of condition to physician prior to retuning to work. These in-services had been completed by the regional nurse consultant or corporate RN. Included in the services, will be proper medication administration including right patient, right dose, right medication, right route, and right time. Requirement to document administration of medication as ordered by M.D., and initialing a Medication Administration Record [REDACTED].D. of change to allow prompt intervention based on identified change of condition. DON/ADON monitoring dailies with the use of 24-hour report (reviewing change of condition, admissions, and discharges) and incident reports followed by review of the clinic record to validate proper documentation has been done. Completion Date: 08/12/15 All licensed staff/agency staff have been in-serviced by DON/designee. Currently working and staff not present will be in-serviced before starting shift to include: Completion Date: 08/12/15-ongoing. Physicians will be notified by facility/agency staff when resident refuses routine medication/ insulin and CBGs are not within physician ' s ordered parameters. All facility/agency staff have been in-serviced. Diabetic residents who refuse meals or eat less than 50% of meals will be offered a substitute meal or supplement. Facility staff/agency have been in-serviced that physicians will be notified of resident ' s refusal of meal intake. Physician orders will be obtained regarding holding oral hypoglycemic agents and/or insulin. Notification of physician of all changes of condition. Administration of medication documentation on medication administration record. Proper notification of medication errors are to be reported to DON, administrator, physician, and family. All changes in orders, changes of condition are to be written on the 24-hour report to include med errors. Facility/agency staff have been in-serviced on reporting change of condition to include. CBGs not within physician ' s ordered parameters. [MEDICAL CONDITION]. Unusual or excessive bruising/bleeding. Abnormal vital signs. Shortness of breath, hypertension. Low O2 saturation. Decreased level of consciousness. Anxiety, agitation. Proper protocol on reviewing admission and readmission orders [REDACTED] Newly hired licensed nurses and med aides have been trained regarding proper medication administration and documentation, physician notification of changes of condition. Before the beginning of their shift, agency staff will receive an in-service on proper medication administration and do documentation notification of physician of all changes of condition prior to the beginning of their assigned shift. Agency staff will be in-serviced to notify physician when CBG is not within physician ' s ordered parameters x90 days and reevaluate q. month through QA process. Completion Date: 08/11/15 and ongoing. New admission, readmission, discharge charts have been reviewed by DON/designee/administrator in morning meeting to evaluate for any identified concerns where further training or disciplinary action is needed to validate the medication administration system notification of condition changes is accurate and completed. This process will be ongoing to monitor for any changes of conditions. Completion Date: 08/11/15 and ongoing. Medical Director was notified on 08/11/15, at 9:41 p.m., of IJ status. Administrator had QA conference held by telephone. Twenty four Hour Report has been reviewed in clinical meeting and will continue Monday through Friday by DON/ADON/ADM. Audited charts have been reviewed to assure changes of condition have been reported to family and physician. Weekend RN will review 24-hour reports and assure chart documentation. If completed, assuring notification is complete and report to DON/administrator as indicated. Administrator/DON/ADON will review twenty four hour report during morning routine/morning meeting five days a week, Monday through Friday, and weekend supervisor will review during weekend duty. Any change of condition noted will be reviewed to assure appropriate action was taken and physician notified. Regional nurse consultant (RNC) has done random chart/Medication Administration Record [REDACTED]. These random audits done by the RNC will continue during visits to the facility for the next 90 days. DON/ADON had begun audits of the medication administration records during their morning routine. Weekend RN will review and report findings to ADM/DON. A med error report will be written and DR and RP notified. Completion Date: 08/13/15 Plan of removal was verified through the following observations, interviews, and record reviews conducted by the surveyors on 08/12/15 through 08/17/15: Interviews with eight nurses from various shifts, including the weekend, revealed staff had been inserviced on multiple areas, including medication administration, change of condition, notification of physician, and insulin. The interviewed staff were able to discuss the facility's policies and procedures for the identified areas, including the changes being made by the facility. The staff were able to confirm new procedures, such as reviewed the MARs after each shift and blood sugar checks and insulin administration being done by the same nurse, were being put into practice. Record review of the facility's 24 hour reports for 08/14/15, 08/15/15, and 08/16/15 revealed changes in condition were identified and documented on the 24 hours report. Record review of all the residents' MARs for 8/11/15-08/17/15 through revealed no concerns related to medications not being administered as ordered or blood sugar checks not being performed. Any blanks in the MAR indicated [REDACTED] Record review of Inservice Training Report revealed the following trainings were conducted by the facility and attended by the facility's nursing staff: Weekend RN/24 hours report (08/12/15); CBG's (capillary blood glucose) (08/12/15); Meal Intake (related to) Diabetic Residents (08/12/15); Changes of Condition (08/12/15) The following inservices were also conducted on 8/11/15 and 8/12/15 instructing staff to review the attached policies related to the subject: Change in condition-observing, reporting and recording (8/11/15); Charge nurse duties (8/11/15); Medication Administration (08/11/15); Accu-Checks and Insulin Administration (8/12/15). Inservice sign in sheets were compared with list of employees and all LVNs and RNs were inserviced on the areas of concerns identified above. This was confirmed with in an interview with the interim DON. On 08/17/15 at 1:08 p.m. the Administrator was informed the IJ was removed effective 08/13/15. The facility remained out of compliance at a level of actual harm at a pattern due to the facility needed to monitor their plan for effectiveness. Record review of Physician's Orders by Category, dated 08/10/15 and provided by the ADON on 08/10/15, revealed 16 residents were prescribed insulin.

Based on interview and record review, the facility failed to ensure two (Residents #7 and #9) of 14 residents reviewed for quality of care were provided the necessary care and services to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care. A. Resident #9 experienced a change in condition beginning on 07/29/15, and facility nurses failed to: follow established parameters of when to contact the physician related to blood sugar levels, exercise appropriate nursing judgement to withhold medication related to his change in condition, and to assess and monitor a resident experiencing a change in condition. On 07/29/15 at 8:00 p.m. Resident #9's blood sugar was 49 and the phsician or nurse practitioner was not consulted. On 07/30/15 the resident was administered his routine 35 units of insulin at 7:00 a.m. and an oral diabetic medication at 8:00 a.m., despite a blood sugar of 66 at 6:00 a.m. and the resident was not eating. On 07/30/15 at 11:30 a.m. the facility nurse documented she spoke with Resident #9 about the importance of eating. There was no evidence the nurse further monitored or assessed the resident until 5:30 p.m. when he was found unresponsive, with a blood sugar of 38 and was sent to the emergency room via an ambulance. B. Resident #7 refused her 8:00 PM doses of anti-[MEDICAL CONDITION] medications on 05/09/15 and 05/10/15. LVN C did not attempt other efforts for Resident #7 to take her medication as ordered and the physician was not notified of the resident's refusal. On 05/10/15 an unknown nurse reported to LVN C at shift change that Resident #7 had been exhibiting muscle and vocal spasms throughout the day, but the resident's physician had not been notified. At approximately 12:20 AM on 05/11/15 Resident #7 had a [MEDICAL CONDITION] and had to be transported to the local hospital where blood test indicated her levels of anti-[MEDICAL CONDITION] medication were below therapeutic levels. An Immediate Jeopardy (IJ) was identified on 08/11/15. While the IJ was removed on 08/13/15, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. These failures had the potential to place 41 residents at risk for not receiving their medications and /or not receiving their medications timely as prescribed by their physician; not being adequately assessed with [REDACTED]. Findings included: Resident #9 Record review of Resident #9's Face Sheet, undated, revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #9's Admission/Readmission Data Summary, dated 07/28/15, revealed Resident #9 was admitted from the hospital at 7:15 PM with a new surgical incision to the abdomen with staples. The summary indicated Resident #9 had a [DEVICE], but was able to eat a mechanical soft diet independently. The summary revealed at the time of admission Resident #9's blood sugar was 233 and insulin was administered as ordered. Record review of Resident #9's Brief Interview for Mental Status, dated 07/30/15, revealed a score of 14, indicating he was cognitively intact. Record review of Resident #9's Admission Care Plan, dated 07/28/15, revealed diabetes was identified as an area of concern. The goal for the area was for there to be no complications. The interventions included blood sugar checked twice a day, medications as ordered, diet as ordered, observe signs/symptoms of [DIAGNOSES REDACTED] (low blood sugar)/[MEDICAL CONDITION] (high blood sugar)and lab work as ordered. Record review of Resident #9's Start Up Orders, undated, revealed he was ordered [MEDICATION NAME] ER tab 500 mg twice a day (8:00 AM and 8:00 PM), [MEDICATION NAME] Injection 35 units subcutaneously (under the skin) every morning (7:00 AM), and [MEDICATION NAME] Injection 15 units subcutaneously (under the skin) at nighttime (8:00 PM). According to the U.S. National Library of Medicine [MEDICATION NAME] is a medication used alone or with other medications, including insulin, to treat type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood). [MEDICATION NAME] helps to control the amount of glucose (sugar) in your blood. [MEDICATION NAME] also increases your body's response to insulin, a natural substance that controls the amount of glucose in the blood. <https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 5.html> According to the U.S. National Library of Medicine [MEDICATION NAME] (Insulin [MEDICATION NAME]) is used to treat forms of diabetes and is a long-acting, man-made version of human insulin that works by replacing the insulin that is normally produced by the body and by helping move sugar from the blood into other body tissues where it is used for energy. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 was ordered to have Accu-Cheks (machine used to measure blood sugar levels) twice a day (6:00 AM and 8:00 PM) and that if the blood sugar level was below sixty or above 300 the physician should be notified. Record review of Resident #9's Physician's Telephone Orders, dated 07/29/15, revealed FNP A ordered Accu-Checks twice a day and for the physician to be notified if the Blood Sugar Level (BSL) was below 60 or above 300. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9's blood sugar level was checked on the following dates and times with the following results: 07/29/15 at 6:00 AM 63 07/29/15 at 8:00 PM 49 07/30/15 at 6:00 AM 66 Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 received [MEDICATION NAME] Injection of 35 units at 7:00 AM on 07/29/15 and 07/30/15. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 received [MEDICATION NAME] Injection of 15 units at 8:00 PM on 07/28/15. The MAR indicated [REDACTED]. Record review of Resident #9's MARs, dated July 2015, revealed Resident #9 received doses of [MEDICATION NAME] on the following dates and times: 07/28/15 at 8:00 PM, 07/29/15 at 8:00 AM, and 07/30/15 at 8:00 AM. The MAR indicated [REDACTED]. Record review of Resident #9's Nursing Documentation Record revealed the following entries: 07/29/15 3:00 PM Res (Resident) awake (and) alert . BSC (Blood Sugar Concentration) this AM 63. Accu (Chek) orders (Refers to telephone order from 07/29/15) clarified (with) (FNP A). (Signed by LVN E) 07/29/15 4:00 PM Tx (treatment) nurse reports Res c/o (complains of) SOB (shortness of breath) (with) exertion. Standing approx. (approximately) 2 min (minutes). Resolved (after) sitting per Res Signed by LVN E) 07/30/15 4:35 AM resident rested in bed majority of shift. resp (respiration) even and unlabored accepted PO (by mouth) meds (with) difficulty. Denies pain or discomfort. BSL (blood sugar level) this PM 49 (07/29/15 at 8:00 PM) G (gastrostomy) tube flushed and patent. Patient had refused supper this evening. Did accept can of orange juice and ½ ham/cheese sandwich. Will cont (continue) to monitor (Signed by LVN H) (there was no documentation that the physician had been consulted regarding the blood sugar level of 49). 07/30/15 10:00 AM . Res. c/o diarrhea x (times) 1 . Refused snack-Denies pain ABD (abdomen) sutures in place (with) tx done (signed by LVN B) 07/30/15 11:30 AM CNA reports (Resident #9) does not want lunch-LVN explained (to) Res. Of all diabetic meds he was on and if he chose not (to) eat his BS (blood sugar) could drop and cause him to be unresponsive and even cause him to lapse into a coma. Res. Stated I know this ma'am and my stomach is rolling so I'm not eating . ask Res when his last [MEDICAL CONDITION] tx was, reports end of May . (Signed by LVN B) 07/30/15 5:30 PM (FNP A) in house Res. BS (down) 38 unresponsive-given [MEDICATION NAME] PO (by mouth) and IM (injection) (blood sugar increased to) 39-911 called [MEDICATION NAME] .5 inj given-ER (emergency room ) notified-wife notified Res. OOF (out of facility) via ambulance to (local hospital) ER. (Signed by LVN B) According to the U.S. National Library of Medicine [MEDICATION NAME] is . used to raise very low blood sugar. [MEDICATION NAME] is usually given by injection beneath the skin, in the muscle, or in the vein. [MEDICATION NAME] should be administered as soon as possible after discovering that the patient is unconscious from low blood sugar. <https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 0.html> According to the Mayo Clinic [MEDICATION NAME] injection is a sterile solution used to provide your body with extra water and carbohydrates (calories from sugar). It is used when a patient is not able to drink enough liquids or when additional fluids are needed. http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8a 9-bebf-4001-993a-f 8e04b8 07/30/15 7:00 PM Spoke (with) (FNP A) regarding residents return to facility from ER. New order received to check residents BS every 2 hours thru the night. Call if BSL is greater than 300 mg/dL or less than 60 mg/dL. May bolus (given a single dose) resident with 1 can of ensure (meal supplement) if he eats less than 50% of his meal. Will cont to monitor (Signed by LVN H) 07/31/15 3:00 AM Accu chk (chek) performed. Reading 44mg/dL. Phoned (FNP A) & notified her directly of (accu-chek) results. Also informed (FNP A), OJ (orange juice) had been given per resident request via PO. (FNP A) ordered to give him something with substance that will hold his bld (blood) sugar. Admin Ensure PO. (Signed by LVN N) 07/31/15 9:00 AM Rec'd (received) NO (new order) (from) (FNP A). Transfer to (local hospital). In an interview on 08/07/15 at 4:10 PM FNP A stated she was not notified of the issues Resident #9 was having with his blood sugars. She stated she did not receive notice of his blood sugar being 49 (on 07/29/15 at 8:00 PM), and confirmed her parameters where to be contacted if the blood sugar was below 60. FNP A stated she was not notified that the resident refused to eat. FNP A stated she was in the facility making rounds on 07/30/15 and found the resident unresponsive in his room. FNP A stated she would have taken steps to prevent the incident of the resident becoming unresponsive. FNP A stated if she had been notified of the low blood sugar she could have withheld his medication, had him monitored more closely, and ordered bolus feedings through his [DEVICE]. FNP A indicated the situation was entirely avoidable and that the facility's failures resulted in her removing the resident from the facility. FNP A stated she did not feel her resident was safe in the facility. In an interview on 09/03/15 at 9:59 AM at LVN B stated she was the nurse for Resident #9 on 07/30/15. LVN B stated she worked the 6:00 AM to 6:00 PM shift and that day was the first time she worked with Resident #9. LVN B stated the night shift nurse, LVN N, told her about the resident having low blood sugar. LVN B stated she was told by LVN N and LVN H, the night nurse who cared for Resident #9 for the first part of the night shift, that they had faxed notification of the low blood sugar to Resident #9's doctor. LVN B stated she told LVN N and LVN H this was not appropriate. LVN B stated the facility's policy is to contact FNP A by phone. LVN B stated checked Resident #9's blood sugar, which was 66, made sure Resident #9 had eaten breakfast, and then gave him morning insulin and medication. LVN B stated if she had known Resident #9 was so brittle she would have done another blood sugar check during the day. LVN B stated if she had known everything about Resident #9's needs she could have provided better care and could have met all his needs. LVN B stated she initially addressed the issue with FNP A's nurse, who was already in the facility, on 07/30/15 between 10:00 and 11:00 AM. LVN B stated it was sometime in the afternoon of 07/30/15 that she contacted FNP A to obtain additional orders for Resident #9. LVN B stated shortly after getting the orders, FNP A arrived at the facility to check on the resident. LVN B stated it was at this time that FNP A found Resident #9 unresponsive. LVN B stated she did not document everything that occurred in Resident #9's chart because it all happened so quickly. LVN B stated if she had known Resident #9 was a brittle diabetic she would have handled his incidents of low blood sugar differently, and would have held his insulin until she spoke with FNP A. In an interview on 09/03/15 at 11:13 AM LVN E stated she was the nurse responsible for Resident #9 on 07/29/15 for the 6:00 AM to 6:00 PM shift. LVN E stated that she reviewed his chart and realized he was diabetic, but did not have any orders for blood sugar checks. LVN E stated she contacted FNP A and obtained orders for blood sugar checks. LVN E stated she was not told by anyone that Resident #9 was a brittle diabetic. LVN E stated that she did not receive a report at shift change regarding Resident #9. LVN E stated she checked Resident #9's blood sugar prior to contacting FNP A and believes it was 63. LVN E stated she received the parameters to contact FNP A if Resident #9's blood sugar was below 60 or above 300. LVN E stated she is normally assigned to the 400 Hall, but also is responsible for a few residents on the 200 Hall, including Resident #9. LVN E stated that she was not aware Resident #9 was diabetic until she began to review his chart. In an interview on 09/03/15 at 11:25 AM LVN P, office nurse with FNP A, stated Resident #9 had not been a patient's of FNP A prior to arriving at the facility and had never been treated by FNP A. LVN P stated she came to the facility on [DATE] around 10:00 AM to review Resident #9's chart since he was a new patient and new resident. LVN P stated LVN B informed her about Resident #9's low blood sugar the night of 07/29/15, and that the night nurse had not notified FNP A. LVN P stated LVN B also discussed concerns that Resident #9 was not eating his meals. LVN P stated based on her experience with FNP A, if FNP A had been aware of the low blood sugar levels she would have ordered additional treatment and monitoring. LVN P stated that FNP A would most likely have ordered the resident to be sent to the hospital if there was not improvement. LVN P stated she believed part of the issue was that the nurse kept changing. LVN P stated that given all of Resident #9's medical issues the staff should have treated him like a brittle diabetic and should have been more vigilant, especially if they were not aware of his full history. In an interview on 09/03/15 at 11:43 AM LVN H stated that she was the nurse caring for Resident #9 for part of the night on 07/29/15. LVN H stated that she remembers checking Resident #9's blood sugar that night and it being low. LVN H stated that she left a message at Resident #9's physician's office on 07/29/15 at approximately 8:00 PM (after office hours). LVN H stated that she was not aware that she was supposed to call FNP A for any emergencies. LVN H stated there were no orders signed by FNP A or instructions indicating FNP A was to be the one contacted. LVN H stated that she provided Resident #9 with a sandwich and juice and rechecked his blood sugar. LVN H stated Resident #9's blood sugar rose to the 90's. LVN H stated she believes she took Resident #9's blood sugar again, but can't remember the results or why it wasn't documented. LVN H stated when she arrived for her shift on 07/29/15 she was told that Resident #9 was changing to being the responsibility of the nurse assigned to the 100 Hall. LVN H stated Resident #9 switched to the care of LVN N after the med pass. LVN H stated she couldn't remember if she tried to contact the resident's physician again. Record review of the Patient Transfer Form for Resident #9, dated 07/30/15 but not time stamped, and provided when he transferred to the local hospital from the facility, revealed the description of the incident was BS (blood sugar) 36 and Refusing to eat. The transfer form was signed by LVN B. Record review of the Resident #9's ER Nursing Assessment, dated 07/30/15 at 6:19 PM, revealed the following: 1755 (5:55 PM) 79 Y/O (year old) male presents to ED (emergency department) with c/o [DIAGNOSES REDACTED]. PT from (the facility) and was found to have decreased LOC (level of consciousness) approx 30 min (minutes) PTA (prior to admission). Reports PT refused to eat today and insulin was administered despite no PO intake. Initial glucose reported by nursing home was 38. Nursing home administered oral and IM (intramuscular) [MEDICATION NAME]. EMS (emergency medical service) administered 1 AMP ([MEDICATION NAME]/unit of measurement) D50 ([MEDICATION NAME] injection) in route to ER. PT arrives alert and oriented. Unable to report why he refused to eat.1835 (6:35 PM)-2 cans Ensure given via peg tube . Record review of Resident #9's facility clinical record revealed medical records, dated 07/28/15, from Resident #9's hospital stay prior to his admission to the facility. The hospital medical records revealed Resident #9's blood sugar was taken four to six times a day from 07/21/15-07/28/15. Resident #9's blood sugar fluctuated from 41 to 281 throughout his hospital stay. Nurses notes found in the hospital medical records revealed [MEDICATION NAME] 50% was administered multiple times to stabilize Resident #9's blood sugar. Resident #7 Record review of Resident #7's Face Sheet, undated, revealed she was a [AGE] year old woman admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #7's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #7 has unclear speech, is limited to making concrete request, and responds adequately to simple communications only. The MDS also revealed Resident #7 was not able to complete the Brief Interview for Mental Status due to rarely/never being understood. The MDS identified that Resident #7 has severely impaired cognitive skills, short and long term memory problems, and at times displays inattention, disorganized thinking, altered level of consciousness, and psychomotor [MEDICAL CONDITION]. The MDS indicated that Resident #7 does not have any behavioral issues, including rejection of care. The MDS revealed Resident #7 requires extensive assistance and the physical assistance of staff with bed mobility, transfers, eating, and personal hygiene, and total dependence on staff for locomotion, dressing, toileting, and bathing. Record review of Resident #7's care plan, dated 07/29/15, revealed one of the identified areas of concern was the resident's history of [MEDICAL CONDITION] and that she was at risk for injury related to a [DIAGNOSES REDACTED]. The approaches to achieving this goal included: monitor for warning signs-prior to [MEDICAL CONDITION]; give meds per order, monitor labs-report results to doctor; ensure direct care staff are aware of residents history; if a [MEDICAL CONDITION] occurs, protect form injury-inform doctor and responsible party. Record review of Resident #7's MAR, dated 05/01/15-05/31/15, revealed Resident #7 was ordered [MEDICATION NAME] (levetiracetam) 5 mL of 100 mg/mL solution twice a day (8:00 AM and 8:00 PM) for a [DIAGNOSES REDACTED]. The MAR indicated [REDACTED]. The start date for the order was 01/26/15. The MAR indicated [REDACTED]. According to the U.S. National Library of Medicine levetiracetam is a prescription medication used in combination with other medications to treat certain types of [MEDICAL CONDITION] in people with [MEDICAL CONDITION], and stopping levetiracetam suddenly may cause [MEDICAL CONDITION] to become worse. <https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 9.html> According to the U.S. National Library of Medicine [MEDICATION NAME] is a prescription medication used alone or in combination with other medications to control certain types of [MEDICAL CONDITION] in patients with [MEDICAL CONDITION] , and stopping levetiracetam suddenly may cause [MEDICAL CONDITION] to become worse. https://www.nlm.nih.gov/medlineplus/druginfo/meds/a 7.html Record review of Resident #7's MAR, dated 05/01/15-05/31/15, revealed the entries on the MAR for the 8:00 PM dose of [MEDICATION NAME] on 05/06/15, 05/09/15, and 05/10/15 were staff initials that were circled. The entries on 05/09/15 and 05/10/15 for Resident #7's 8:00 PM dose of [MEDICATION NAME] were also staff initials that were circled. Review of the backside of the MAR indicated [REDACTED]no [MEDICATION NAME] on hand to give. There were no other explanations of why doses of the medication were not administered. In an interview on 08/07/15 at 4:10 PM FNP A stated when she was notified of the lab results from Resident #7's visit to the emergency roiagnom on [DATE] that indicated Resident #7's [MEDICATION NAME] levels were low. FNP A stated after this incident she reviewed Resident #7's clinical record, including the MARs, and found the missed doses of [MEDICATION NAME] and [MEDICATION NAME]. FNP A stated she was never notified by the facility about the missed doses of medication. FNP A stated she believed Resident #7's [MEDICAL CONDITION] was a result of her not receiving the necessary medication. FNP A indicated that if she had been notified she could have provided other interventions to help prevent the [MEDICAL CONDITION]. Record review of Resident #7's medical records from the local hospital revealed Resident #7 was seen in the emergency room (ER) on 05/11/15. The Emergency Physician Record indicated the clinical impression was a [MEDICAL CONDITION], and that the resident's [MEDICATION NAME] was low. The medical record also contained ER Physician's Orders that ordered a one-time dose of [MEDICATION NAME] 300 mg for Resident #7. Further review of the medical records for Resident #7 revealed lab work results, dated 05/11/15, that indicated Resident #7's [MEDICATION NAME] level was 2.9. The lab results identified this level as low. The reference range identified on the lab results for the medication was 4.0-12 Ug/mL. In an interview on 08/10/15 at 5:00 PM LVN C confirmed she was the nurse for Resident #7 on 05/09/15 and 05/10/15 on the 6:00 PM to 6:00 AM shift. LVN C stated that she initialed and circled the initials on the MAR because Resident #7 refused her medication, and that is how she was taught to document refusals of medications. LVN C stated she did not notify the physician of the missed doses. LVN C stated she tried several times to get the resident to take her medication, but did not recall trying to get another nurse to try giving the medications. LVN C stated she was told by the aides Resident #7 would refuse medications if she didn't know the nurse. LVN C stated she was told at shift change by the off going nurse that Resident #7 had been jerking and yelling out throughout the day. LVN C stated Resident #7's yelling out and jerking kept getting worse so she contacted FNP A and then 911 around 12:20 on 05/11/15. Record review of Resident #7's nurses notes revealed no documentation from 04/24/15 through 05/10/15. There was no documentation regarding the missed doses of medication. The next entry on 05/11/15 at 12:20 AM stated Resident is having jerking motions every 45-60 secs (with) a squeal. Resident has not been able to rest or take meds. CNAs report this as out of the normal. Contacted FNP. Sending resident to ER to eval. The entry is signed by LVN C. Attempts were made to identify the nurse who worked the day shift on 05/10/15. In an interview on 08/11/15 at 3:35 PM the ADON stated she could not identify the initials of the person who administered medication to Resident #7 on 05/10/15. The ADON compared the initials on the MAR for 05/10/15 to the master signature sheet of nurses and thought it might be LVN E. Review of the punch detail for 05/10/15 revealed LVN E did not work on 05/10/15. In interviews on 08/11/15 at 3:40 PM LVN G and LVN D denied it was their signature on the MAR for 05/10/15. LVN G stated it could be the former MDS coordinator who covered the floor a lot. Record review of Resident #7's lab results revealed her [MEDICATION NAME] levels were tested on the following dates with the following results: 04/09/15 3.6 (normal range 4.0-12.0) 05/21/15 3.0 (normal range 4.0-12.0) 05/28/15 8.2 (normal range 4.0-12.0) Record review of the facility's Twenty-Four Hour Report for 05/09/15 and 05/10/15, the days of the missed doses of [MEDICATION NAME] and levetiracetam, revealed no documentation related to the missed doses of medication. Review of the facility policy and procedure titled: Change of Condition- Observing, Reporting, and Recording, dated 3/2012, revealed the following; It is the policy of this home to inform the resident, the resident ' s physician and if indicated the resident ' s responsible party of the following: 1. An accident or incident involving the resident, which results in injury has the potential for requiring physician intervention. 2. A significant change in the resident ' s physical, mental, or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications; . 4. A need to alter treatment significantly. Procedure Observing, Reporting and Documenting a Change of Condition; 1. After resident changes in condition including but not limited to falls, injuries, changes in health and psychosocial status conduct a thorough assessment and compare against baseline. 3. The attending physician should be notified as soon as possible if immediate attention is required or as soon as feasible. If the resident is stable (change in condition is resolved such as a fall without injury or head trauma). If you are unable to reach the attending physician, call the alternate physician or the physician on call. If you are unable to reach this physician, call the medical director (if not the attending or alternate physician) or the emergency room physician. 4. Complete an incident/accident report if indicated (fall, injury etc.) 5. Notify resident ' s responsible party 6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital by ambulance or appropriate transportation. o Complete a transfer form noting observations related to the change in condition, vital signs, and time of transfer. o Copy the residents face sheet, advance directive or other legal for directing care wishes of the resident, list or copy the current physician orders, and any other information that will assist the hospital/physician to treat the change in condition. o Assist the resident with any ADL ' s prior to transportation. Documentation: 1. Date, time condition changes were identified 2. Pertinent assessment findings 3. Who was notified and when 4. Disposition of the resident 5. Update care plan if indicated with any determined interventions to mitigate further incidents if applicable. Communication: 1. The change in condition and interventions related to the change will be documented on the 24 hour report form on the shift that the change occurred. 2. The licensed nurse and nursing assistant will communicate to the oncoming shift orally and through the 24 hour report the change in condition and interventions. 3. The Director of Nurses/designee will report the change in condition, interventions, and response to the appropriate Q & A Committee. Immediate Jeopardy (IJ) was identified on 08/11/15 at 4:06 PM and the Administrator, interim DON, ADON, and Regional Nurse Consultant were notified. The 7th version of the Plan of Removal was accepted on 08/13/15 at 5:57 PM and included the following: Problem: Failed to administer and document medication administration Failed to report change of condition to physician. Plan: (identified staff) have been in-serviced on medication administration documentation and notification of changes of condition to physician prior to retuning to work. These in-services had been completed by the regional nurse consultant or corporate RN. Included in the services, will be proper medication administration including right patient, right dose, right medication, right route, and right time. Requirement to document administration of medication as ordered by M.D., and initialing a Medication Administration Record [REDACTED].D. of change to allow prompt intervention based on identified change of condition. DON/ADON monitoring dailies with the use of 24-hour report (reviewing change of condition, admissions, and discharges) and incident reports followed by review of the clinic record to validate proper documentation has been done. Completion Date: 08/12/15 All licensed staff/agency staff have been in-serviced by DON/designee. Currently working and staff not present will be in-serviced before starting shift to include: Completion Date: 08/12/15-ongoing. Physicians will be notified by facility/agency staff when resident refuses routine medication/ insulin and CBGs are not within physician ' s ordered parameters. All facility/agency staff have been in-serviced. Diabetic residents who refuse meals or eat less than 50% of meals will be offered a substitute meal or supplement. Facility staff/agency have been in-serviced that physicians will be notified of resident ' s refusal of meal intake. Physician orders will be obtained regarding holding oral hypoglycemic agents and/or insulin. Notification of physician of all changes of condition. administration of medication documentation on medication administration record. Proper notification of medication errors are to be reported to DON, administrator, physician, and family. All changes in orders, changes of condition are to be written on the 24-hour report to include med errors. Facility/agency staff have been in-serviced on reporting change of condition to include. CBGs not within physician ' s ordered parameters. [MEDICAL CONDITION]. Unusual or excessive bruising/bleeding. Abnormal vital signs. Shortness of breath, hypertension. Low O2 saturation. Decreased level of consciousness. Anxiety, agitation. Proper protocol on reviewing admission and readmission orders [REDACTED] Newly hired licensed nurses and med aides have been trained regarding proper medication administration and documentation, physician notification of changes of condition. Before the beginning of their shift, agency staff will receive an in-service on proper medication administration and do documentation notification of physician of all changes of condition prior to the beginning of their assigned shift. Agency staff will be in-serviced to notify physician when CBG is not within physician ' s ordered parameters x90 days and reevaluate q. month through QA process. Completion Date: 08/11/5 and ongoing. New admission, readmission, discharge charts have been reviewed by DON/designee/administrator in morning meeting to evaluate for any identified concerns where further training or disciplinary action is

Based on interviews and record review the facility failed to ensure two (Resident #4 and Resident #9) out of 14 residents, whose medication regiments were reviewed, were free of significant medication errors. A. The facility failed to administer Resident # 4's Eliquis (an anticoagulant administered to reduce the risk of blood clots and stroke), as ordered, on 06/16/15, 06/20/15, 06/21/15, 06/25/15, 06/26/15, and 06/30/15. B. The facility failed to order and ensure delivery of Resident #9's [MEDICATION NAME] (used to treat life-threatening heart rhythm problems) resulting in missed doses on 07/28/15, 07/29/15, and 07/30/15. An Immediate Jeopardy (IJ) was identified on 08/11/15. While the IJ was removed on 08/13/15, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. These failures placed the 13 residents receiving anticoagulants and the 28 residents receiving antiarrhythmics at risk for medication errors, which could result in a worsening of their medical conditions and the need for further treatment and possible hospitalization . The findings included: Resident #4 Record review of Resident #4's Medication Administration Record (MAR), dated 07/01/15-07/31/15, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of a Consultation Report from a local medical center, dated 06/11/15, revealed Resident #4 was admitted to the medical center on 06/11/15 and was found to have a thrombus consistent with [MEDICAL CONDITIONS]. The U.S. National Library of Medicine identified a thrombus as . a blood clot that forms in a vessel and remains there and an embolism as a clot that travels from the site where it formed to another location in the body. <https://www.nlm.nih.gov/medlineplus/ency/imagepages/ .htm> The U.S. National Library of Medicine defined a [MEDICAL CONDITIONS] as a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a [MEDICAL CONDITION] that breaks loose and travels through the bloodstream to the lung.If a clot is large, or if there are many clots, [MEDICAL CONDITION] embolism can cause death. <https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=pulmonary+embolism> Record review of Resident #4's Start Up Orders (initial physician's orders), dated 06/15/15, revealed she was prescribed the following medication: Eliquis 5 milligram (mg) tablets po (by mouth) bid (twice a day) at 8:00 AM and 8:00 PM [MEDICATION NAME] 120 mg capsule po twice a day at 8:00 AM and 8:00 PM The Food and Drug Administration (FDA) identified Eliquis as a prescription medicine used to reduce the risk of stroke and blood clots in people who have [MEDICAL CONDITION] . treat blood clots in the . lungs (pulmonary embolism), and reduce the risk of them occurring again. The FDA indicated stopping Eliquis could cause an increased risk of forming a clot, and instructed people taking Eliquis not to change your dose or stop taking ELIQUIS unless your doctor tells you to. <http://www.fda.gov/downloads/Drugs/DrugSafety/UCM 1.pdf> The U.S. National Library of Medicine identified [MEDICATION NAME] as a medication used to treat high blood pressure and to control [MEDICAL CONDITION] (chest pain).High blood pressure is a common condition, and when not treated it can cause damage to the brain, heart, blood vessels, kidneys, and other parts of the body. The U.S. National Library of Medicine also indicated people prescribed [MEDICATION NAME] should (t)ake [MEDICATION NAME] exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Record review of Resident #4's MARs for 06/15/15-06/30/15 revealed facility staff failed to document administration of the 8:00 PM dose of Eliquis on the following six dates: 06/16/15, 06/20/15, 06/21/15, 06/25/15, 06/26/15, and 06/30/15. On each of the identified dates the square on the MAR where staff are to initial the medication has been administered was blank, and each blank square was circled. Further review of the MAR revealed no documentation indicating why the doses were missed, such as refusal or the medication not being available. Record review of the Nursing Documentation Record for Resident #4 revealed no documentation on the dates the Eliquis was not administered to indicate the medication was administered or why it was not administered. Record review of the 24 hour report for the dates the Eliquis was not administered revealed no documentation related to the missed doses of medication. In an interview on 08/07/15 at 2:40 PM LVN A confirmed she had been the nurse for resident #4 for part of her stay in the facility. LVN A stated she was the nurse who had circled the missing doses of Eliquis on the MAR and the issue had also been brought to her attention by FNP A. LVN A indicated they had been having a lot of issues with medication not being administered by agency nurses on the night shift. In an interview on 08/13/15 at 11:40 AM LVN A stated that she reported Resident #4's missed doses of Eliquis to the DON and completed an incident report as ordered by FNP A. She stated this was also documented in the nurses' notes for 06/28/15. LVN A stated that the FNP A also instructed her to notify the family about the missed medication. LVN A stated around June 28, 2015 the Eliquis was moved to the controlled medication box and a control sheet was initiated to help address the missed doses. (A controlled medication box was a locked box inside the medication cart where medication whose administration must be tracked was kept. When these medications are administered the staff administering the medication would sign out each dose on the control sheet. The control sheet would indicate the number of tablets administered and the number of tablets remaining after each time the medication was administered) Record review of Nursing Documentation Record for Resident #4 revealed an entry dated 06/28/15 at 1300 (1:00 PM). The entry indicated FNP A was in the facility and gave a new order for an incident report. The entry indicated the family and the DON were notified. This entry was signed by LVN A. Record review of the MAR, dated 07/01/15, for Resident #4 revealed an order for [REDACTED]. The order was dated 06/15/15 and was open ended. The MAR was initialed on 07/01/15, indicating the medication was administered as ordered at 9:00 AM and 9:00 PM. Record review of Individual Resident Narcotics Record for Resident #4's Eliquis revealed no entry for 07/01/15. The count on 06/30/15 after the 8:00 PM dose was administered was 5. There was no tablets signed out on the control sheet on 07/01/15. The next count on 07/02/15 after the 8:00 AM dose was administered was 4. The last count of 2 was on 07/03/15 after the 8:00 AM dose was administered. The resident was discharged from the facility after the 8:00 AM dose on 07/03/15. An additional, undated, Individual Resident Narcotics Record for Resident #4's Eliquis indicated a beginning count of 28 with no doses signed out. Record review of the Medications Taken Out of Home Consent Form for Resident #4, dated 06/03/15, (mistakenly dated with 06/03/15 instead of 07/03/15) revealed the resident was discharged with 30 Eliquis 5 mg tablets. Resident #9 Record review of Resident #9's Face Sheet, undatedrevealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #9's Start Up Orders (initial physician's orders), undated, revealed he was prescribed [MEDICATION NAME] 200 milligram (mg) po (by mouth) QD (once a day) at 8:00 PM. According to the Mayo Clinic [MEDICATION NAME] was used to treat life-threatening heart rhythm problems called ventricular arrhythmias. This medicine was used in patients who have already been treated with other medicines that did not work. http://www.mayoclinic.org/drugs-supplements/[MEDICATION NAME]-oral-route/description/drg- 854 Record review of Resident#9's MARs for 07/28/15-07/31/15 revealed facility staff failed to document administration of the medication at any time during the residents stay at the facility. Resident #9 missed his daily dose of the medication on 07/28/15, 07/29/15, and 07/30/15. In an interview on 08/11/15 at 3:25 PM the ADON stated the medications from the start up orders are sent to the facility's pharmacy provider. The ADON stated she would check to see if the [MEDICATION NAME] for Resident #9 was ordered. In an interview on 08/12/15 at 12:00 PM the ADON stated the [MEDICATION NAME] for Resident #9 was never ordered. In an interview on 08/07/15 at 4:10 PM FNP A stated she began reviews her patients' MARs and identified an ongoing issue with residents not receiving their medication, including blood thinners, blood sugar checks, [MEDICAL CONDITION] medication, and [MEDICAL CONDITION] medication. FNP A stated that she identified the issue with Resident #4's Eliquis and [MEDICATION NAME], and Resident #9's [MEDICATION NAME]. FNP A indicated Resident #4 had been admitted to the facility because of a [MEDICAL CONDITION] Embolism and her missing doses of the medication used to prevent further blood clots was beyond dangerous. FNP A stated it was especially important for the resident to receive the medication as ordered because there was no lab work that can be conducted to determine levels of the medication in a patient's system. FNP A stated she moved Resident #9 to another facility because she felt this facility was not able to meet his needs. FNP A stated she was concerned about admitting any other residents to the facility while they continue to have such issues with medication administration. In an interview on 08/07/15 at 4:50 PM the ADON stated she could not locate any incident reports regarding medication errors involving Resident #4 or #9. Record review of the facility policy entitled Medication-Administration, effective 01/2008 and revised 06/2012, revealed the policy of the facility is that medications will be administered and documented as ordered by the physician and in accordance with state regulations. The procedure indicated the resident's MAR is . initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Record review of the facility's policy entitled Medication-Unusual Occurrences, effective 01/2008 and revised 03/2012, revealed the policy of the facility is to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. The policy indicated a medication error occurs when a medication is administered in any manner that is consistent with the physician's order for that medication. The policy identified the following procedures: 1. Unusual occurrences may be medication errors .Medication errors . shall be immediately report to the resident's physician and the Director of Nursing. 2. An entry of the incident shall be made in the resident's medical record and a report shall be completed and filed in the administrative files. 4. Licensed nurses who observe such unusual occurrences are to. b. Report the incident immediately to the Director of Nursing. c. Make the appropriate records and notifications required above. Immediate Jeopardy (IJ) was identified on 08/11/15 at 4:06 PM and the Administrator, interim DON, ADON, and Regional Nurse Consultant were notified. The seventh version of the Plan of Removal was accepted on 08/13/15 at 5:57 PM. The plan was as follows: Problem: Failed to administer and document medication administration Failed to report change of condition to physician. Plan: · (identified staff) have been in-serviced on medication administration documentation and notification of changes of condition to physician prior to retuning to work. These in-services had been completed by the regional nurse consultant or corporate RN. Included in the services, will be proper medication administration including right patient, right dose, right medication, right route, and right time. Requirement to document administration of medication as ordered by M.D., and initialing a medication administration record as required legally and by Board of Nursing examples of change of condition and requirement to promptly notify M.D. of change to allow prompt intervention based on identified change of condition. DON/ADON monitoring dailies with the use of 24-hour report (reviewing change of condition, admissions, and discharges) and incident reports followed by review of the clinic record to validate proper documentation has been done. Completion Date: 08/12/15 · (Resident #9) CBG 06:00 was 91, taken by (staff identified), was discharged to hospital swing bed 09:00, 07/31/15. (Resident #4) was discharged home with home health to follow 07/03/15. Vital signs: 130/66, 60, 18, 99.1, 94 O2 sat on 07/03/15 by (staff identified). Completion Date: 08/11/15-ongoing. · All residents ' medication administration records have been accessed beginning 08/11/15 by reviewing for holes in the medication administration record and medication availability and then every other day to validate compliance by the DON/designee (regional nurse consultant, corporate RNs) to ensure they are complete and medications administered were per M.D. orders; 24-hour report will be checked to assure errors were transcribed by charge nurse. Completion Date: 08/12/15 · Any resident ' s medication administration record identified (where) medications have not been dispensed as ordered will result in the DON/ADON notifying the medical director and as well as the resident ' s primary care physician by phone. DON/ADON will assess residents to ensure no negative effects have occurred, with staff counseling and determination as indicated. Completion Date: 08/12/15 · All licensed staff/agency staff have been in-serviced by DON/designee. Currently working and staff not present will be in-serviced before starting shift to include: Completion Date: 08/12/15-ongoing. . Proper administration of medication documentation on medication administration record. Proper notification of medication errors are to be reported to DON, administrator, physician, and family. . Proper protocol on reviewing admission and readmission orders [REDACTED] Newly hired licensed nurses and med aides have been trained regarding proper medication administration and documentation, physician notification of changes of condition. Before the beginning of their shift, agency staff will receive an in-service on proper medication administration and do documentation notification of physician of all changes of condition prior to the beginning of their assigned shift. Completion Date: 08/11/5 and ongoing. · New admission, readmission, discharge charts have been reviewed by DON/designee/administrator in morning meeting to evaluate for any identified concerns where further training or disciplinary action is needed to validate the medication administration system notification of condition changes is accurate and completed. This process will be ongoing to monitor for any changes of conditions. Completion Date: 08/11/15 and ongoing. · RNC will do audits of minimum of every month on medication administration records for completeness and accuracy during routine visits. Any identified issues/concerns have been immediately addressed through training or counseling as needed. · DON/ADON will monitor to assure medication availability in facility on an ongoing basis. Completion Date: 08/12/15 and ongoing. · Results of audit have been brought to QA and will be ongoing monthly x3 months. QA will make recommendations based on finding of audits. Completion Date: 08/12/15 through 11/12/15. · Medical Director Dr. McEachrin, M.D., was notified on 08/11/15, at 9:41 p.m., of IJ status. Administrator had QA conference held by telephone. · Regional nurse consultant (RNC) has done random chart/medication administration record audits to determine if any changes of condition or other concerns related to medication administration are present. These random audits done by the RNC will continue during visits to the facility for the next 90 days. · Pharmacy consultant will conduct random audits on scheduled monthly visits x3 months to validate medication administration record for accuracy and documentation completion. In-service training will be provided for inaccuracy is identified each visit for q. month x3 then quarterly thereafter. · Pharmacy consultant will monitor at least one licensed nurse per visit q. month x3 months for medication administration accuracy and documentation completion. Any inaccuracy or unacceptable medication administration error rates will be reported to the DON/administrator. Pharmacy consultant will provide in-service and training as needed. · DON/ADON had begun audits of the medication administration records during their morning routine. Weekend RN will review and report findings to ADM/DON. · A med error report will be written and DR and RP notified. Completion Date: 08/13/15 · DON/ADON have monitored a med pass to ensure accuracy and completion of medication administration documentation. Nurses found to have inaccuracies with med pass have received training/in-services on proper medication administration and documentation completion, with counseling and termination as indicated. Completion Date: 08/13/15 through ongoing. · Med pass observation by DON/ADON will continue two times a week for four weeks. Nurses found to have inaccuracies with med pass have received training/in-services on proper medication administration and documentation completion. Completion Date: 08/13/15 through 09/13/15. Plan of removal was verified through the following observations, interviews, and record reviews conducted by the surveyors on 08/12/15 through 08/17/15: Interviews with eight nurses from various shifts, including the weekend, revealed staff had been inserviced on multiple areas, including medication administration, change of condition, notification of physician, and insulin. The interviewed staff were able to discuss the facility's policies and procedures for the identified areas, including the changes being made by the facility. The staff were able to confirm new procedures, such as reviewed the MARs after each shift and blood sugar checks and insulin administration being done by the same nurse, were being put into practice. Record review of the facility's 24 hour reports for 08/14/15, 08/15/15, and 08/16/15 revealed changes in condition were identified and documented on the 24 hours report. Record review of all the residents' MARs for 8/11/15-08/17/15 through revealed no concerns related to medications not being administered as ordered or blood sugar checks not being performed. Any blanks in the MAR were accounted for by staff. Record review of Inservice Training Report revealed the following trainings were conducted by the facility and attended by the facility's nursing staff: Weekend RN/24 hours report (08/12/15); CBG's (capillary blood glucose) (08/12/15); Meal Intake (related to) Diabetic Residents (08/12/15); Changes of Condition (08/12/15) The following inservices were also conducted on 8/11/15 and 8/12/15 instructing staff to review the attached policies related to the subject: Change in condition-observing, reporting and recording (8/11/15); Charge nurse duties (8/11/15); Medication Administration (08/11/15); Accu-Checks and Insulin Administration (8/12/15). Inservice sign in sheets were compared with list of employees and all LVNs and RNs were inserviced on the areas of concerns identified above. This was confirmed with in an interview with the interm DON. On 08/17/15 at 1:08 p.m. the Administrator was informed the IJ was removed effective 8/13/15. The facility remained out of compliance at a level of no actual harm at a pattern due to the facility needed to monitor their plan for effectiveness. Record review of Physician's Orders by Category, dated 08/10/15 and provided by the ADON on 08/10/15, revealed 13 residents were prescribed anticoagulants and 28 residents were prescribed antiarrhythmic medication.

Based on observation, interview and record review, the facility failed to acquire and administer medications in accordance with the physician's orders, and facility policy for 2 (Resident #4 and Resident #9) out of 14 residents whose medication regiments were reviewed. The facility failed to: a. Administer Resident # 4's Eliquis (an anticoagulant administered to reduce the risk of blood clots and stroke), as ordered, on 06/16/15, 06/20/15, 06/21/15, 06/25/15, 06/26/15, and 06/30/15. b. Order and ensure delivery of Resident #9's Amiodarone (used to treat life-threatening heart rhythm problems) resulting in missed doses on 07/28/15, 07/29/15, and 07/30/15. An Immediate Jeopardy (IJ) was identified on 08/11/15. While the IJ was removed on 08/13/15, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern, due to the facility monitoring the implementation of the Plan of Removal. These failures had the potential to place 41 residents at risk for not receiving their medications and /or not receiving their medications timely as prescribed by their physician. The findings include: a. Resident # 4 Record review of Resident #4's Medication Administration Record (MAR), dated 07/01/15-07/31/15, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of a Consultation Report from a local medical center, dated 06/11/15, revealed Resident #4 was admitted to the medical center on 06/11/15 and was found to have a thrombus consistent with pulmonary embolus. The U.S. National Library of Medicine defined a pulmonary embolus as a sudden blockage in a lung artery. The cause is usually a blood clot in the leg called a deep vein thrombosis that breaks loose and travels through the bloodstream to the lung . If a clot is large, or if there are many clots, pulmonary embolism can cause death. <https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=pulmonary+embolism> Record review of Resident #4's Start Up Orders (initial physician's orders), dated 06/15/15, revealed she was prescribed Eliquis 5 milligram (mg) tablets po (by mouth) bid (twice a day) at 8:00 AM and 8:00 PM The Food and Drug Administration (FDA) identified Eliquis as a prescription medicine used to reduce the risk of stroke and blood clots in people who have [DIAGNOSES REDACTED]. treat blood clots in the . lungs (pulmonary embolism), and reduce the risk of them occurring again. The FDA indicated stopping Eliquis could cause an increased risk of forming a clot, and instructed people taking Eliquis not to change your dose or stop taking ELIQUIS unless your doctor tells you to. <http://www.fda.gov/downloads/Drugs/DrugSafety/UCM 1.pdf> Record review of Resident #4's MARs for 06/15/15-06/30/15 revealed facility staff failed to document administration of the 8:00 PM dose of Eliquis on the following six dates: 06/16/15, 06/20/15, 06/21/15, 06/25/15, 06/26/15, and 06/30/15. On each of the identified dates the square on the MAR where staff initial the medication has been administered was blank, and each blank square was circled (indicating nothing was documented on the MAR that the medication was administered). Further review of the MAR revealed no documentation indicating why the doses were missed, such as refusal or the medication not being available. Record review of the Nursing Documentation Record for Resident #4 on 8/7/15 revealed no documentation on the dates the Eliquis was not administered to indicate the medication was administered or why it was not administered. Record review of the 24 hour report for the dates the Eliquis was not administered revealed no documentation related to the missed doses of medication. In an interview on 08/07/15 at 2:40 PM LVN A confirmed she had been the nurse for resident #4 for part of her stay in the facility. LVN A stated she was the nurse who had circled the missing doses of Eliquis on the MAR and the issue had also been brought to her attention by FNP A. LVN A indicated they had been having a lot of issues with medication not being administered by agency nurses on the night shift. In an interview on 08/13/15 at 11:40 AM LVN A stated that she reported Resident #4's missed doses of Eliquis to the DON and completed an incident report as ordered by FNP A. She stated this was also documented in the nurses' notes for 06/28/15. LVN A stated that the FNP A also instructed her to notify the family about the missed medication. LVN A stated around June 28, 2015 the Eliquis was moved to the controlled medication box and a control sheet was initiated to help address the missed doses. (A controlled medication box was a locked box inside the medication cart where medication whose administration must be tracked was kept. When these medications are administered the staff administering the medication would sign out each dose on the control sheet. The control sheet would indicate the number of tablets administered and the number of tablets remaining after each time the medication was administered) Record review of the MAR, dated 07/01/15, for Resident #4 revealed an order for [REDACTED]. The order was dated 06/15/15 and was open ended. The MAR was initialed on 07/01/15, indicating the medication was administered as ordered at 9:00 AM and 9:00 PM. Record review of Individual Resident Narcotics Record for Resident #4's Eliquis revealed no entry for 07/01/15. The count on 06/30/15 after the 8:00 PM dose was administered was 5. There was no tablets signed out on the control sheet on 07/01/15. The next count on 07/02/15 after the 8:00 AM dose was administered was 4.The last count of 2 was on 07/03/15 after the 8:00 AM dose was administered. The resident was discharged from the facility after the 8:00 AM dose on 07/03/15. An additional, undated, Individual Resident Narcotics Record for Resident #4's Eliquis indicated a beginning count of 28 with no doses signed out. Record review of the Medications Taken Out of Home Consent Form for Resident #4, dated 06/03/15, (mistakenly dated with 06/03/15 instead of 07/03/15) revealed the resident was discharged with 30 Eliquis 5 mg tablets. b. Resident #9 Record review of Resident #9's Face Sheet, undated revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #9's Start Up Orders (initial physician's orders), undated, revealed he was prescribed Amiodarone 200 milligram (mg) po (by mouth) QD (once a day) at 8:00 PM. According to the Mayo Clinic Amiodarone was used to treat life-threatening heart rhythm problems called ventricular arrhythmias. This medicine was used in patients who have already been treated with other medicines that did not work. http://www.mayoclinic.org/drugs-supplements/amiodarone-oral-route/description/drg- 854 Record review of Resident #9's MARs for 07/28/15-07/31/15 revealed facility staff failed to document administration of the medication at any time during the residents stay at the facility. Resident #9 missed his daily dose of the medication on 07/28/15, 07/29/15, and 07/30/15. In an interview on 08/11/15 at 3:25 PM the ADON stated the medications from the start up orders are sent to the facility's pharmacy provider. The ADON stated she would check to see if the Amiodarone for Resident #9 was ordered. In an interview on 08/12/15 at 12:00 PM the ADON stated the Amiodarone for Resident #9 was never ordered. In an interview on 08/07/15 at 4:10 PM FNP A stated she began reviews her patients' MARs and identified an ongoing issue with residents not receiving their medication, including blood thinners, blood sugar checks, [DIAGNOSES REDACTED]medication, and thyroid medication. FNP A stated that she identified the issue with Resident #4's Eliquis and Resident #9's Amiodarone. FNP A indicated Resident #4 had been admitted to the facility because of a Pulmonary Embolism and her missing doses of the medication used to prevent further blood clots was beyond dangerous. FNP A stated it was especially important for the resident to receive the medication as ordered because there was no lab work that can be conducted to determine levels of the medication in a patient's system. FNP A stated she moved Resident #9 to another facility because she felt this facility was not able to meet his needs. FNP A stated she was concerned about admitting any other residents to the facility while they continue to have such issues with medication administration. Record review of the facility policy entitled Medication-Administration, effective 01/2008 and revised 06/2012, revealed the policy of the facility is that medications will be administered and documented as ordered by the physician and in accordance with state regulations. The procedure indicated the resident's MAR is . initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration. Record review of the facility's policy entitled Medication-Unusual Occurrences, effective 01/2008 and revised 03/2012, revealed the policy of the facility is to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. The policy indicated a medication error occurs when a medication is administered in any manner that is not consistent with the physician's order for that medication. The policy identified the following procedures: 1. Unusual occurrences may be medication errors . Medication errors . shall be immediately report to the resident's physician and the Director of Nursing. 2. An entry of the incident shall be made in the resident's medical record and a report shall be completed and filed in the administrative files . 4. Licensed nurses who observe such unusual occurrences are to . b. Report the incident immediately to the Director of Nursing. c. Make the appropriate records and notifications required above . Immediate Jeopardy (IJ) was identified on 08/11/15 at 4:06 PM and the Administrator, interim DON, ADON, and Regional Nurse Consultant were notified. The seventh version of the Plan of Removal was accepted on 08/13/15 at 5:57 PM. The plan included: Problem: Failed to administer and document medication administration Plan: 3. All residents medication administration records have been accessed beginning 08/11/15 by reviewing for holes in the medication administration record and medication availability and then every other day to validate compliance by the DON/designee (regional nurse consultant, corporate RNs) to ensure they are complete and medications administered were per M.D. orders; 24-hour report will be checked to assure errors were transcribed by charge nurse.Completion Date: 08/12/15 4. Any resident's medication administration record identified (where) medications have not been dispensed as ordered will result in the DON/ADON notifying the medical director and as well as the resident's primary care physician by phone. DON/ADON will assess residents to ensure no negative effects have occurred, with staff counseling and determination as indicated. Completion Date: 08/12/15 5. All licensed staff/agency staff have been in-serviced by DON/designee. Currently working and staff not present will be in-serviced before starting shift. Completion Date: 08/12/15-ongoing. 6.Proper administration of medication documentation on medication administration record. Proper notification of medication errors are to be reported to DON, administrator, physician, and family. .Proper protocol on reviewing admission and readmission orders [REDACTED] Newly hired licensed nurses and med aides have been trained regarding proper medication administration and documentation, physician notification of changes of condition. Before the beginning of their shift, agency staff will receive an in-service on proper medication administration and do documentation notification of physician of all changes of condition prior to the beginning of their assigned shift . Completion Date: 08/11/5 and ongoing. 7. New admission, readmission, discharge charts have been reviewed by DON/designee/administrator in morning meeting to evaluate for any identified concerns where further training or disciplinary action is needed to validate the medication administration system notification of condition changes is accurate and completed. This process will be ongoing to monitor for any changes of conditions. Completion Date: 08/11/15 and ongoing. 8. RNC will do audits of minimum of every month on medication administration records for completeness and accuracy during routine visits. Any identified issues/concerns have been immediately addressed through training or counseling as needed. DON/ADON will monitor to assure medication availability in facility on an ongoing basis. Completion Date: 08/12/15 and ongoing. 9. Results of audit have been brought to QA and will be ongoing monthly x3 months. QA will make recommendations based on finding of audits. Completion Date: 08/12/15 through 11/12/15. 10. Medical Director was notified on 08/11/15, at 9:41 p.m., of IJ status. Administrator had QA conference held by telephone . Regional nurse consultant (RNC) has done random chart/medication administration record audits to determine if any changes of condition or other concerns related to medication administration are present. These random audits done by the RNC will continue during visits to the facility for the next 90 days. Pharmacy consultant will conduct random audits on scheduled monthly visits x3 months to validate medication administration record for accuracy and documentation completion. In-service training will be provided for inaccuracy is identified each visit for every month for three months and quarterly thereafter. Pharmacy consultant will monitor at least one licensed nurse per visit every month for three months for medication administration accuracy and documentation completion. Any inaccuracy or unacceptable medication administration error rates will be reported to the DON/administrator. Pharmacy consultant will provide in-service and training as needed. DON/ADON had begun audits of the medication administration records during their morning routine. Weekend RN will review and report findings to ADM/DON. A med error report will be written and DR and RP notified. Completion Date: 08/13/15 11. DON/ADON have monitored a med pass to ensure accuracy and completion of medication administration documentation. Nurses found to have inaccuracies with med pass have received training/in-services on proper medication administration and documentation completion, with counseling and termination as indicated. Completion Date: 08/13/15 through ongoing. 12. Med pass observation by DON/ADON will continue two times a week for four weeks. Nurses found to have inaccuracies with med pass have received training/in-services on proper medication administration and documentation completion. Completion Date: 08/13/15 through 09/13/15. Plan of removal was verified through the following observations, interviews, and record reviews conducted by the surveyors on 08/12/15 through 08/17/15: Interviews with eight nurses from various shifts, including the weekend, revealed staff had been inserviced on multiple areas, including medication administration, change of condition, notification of physician, and insulin. The interviewed staff were able to discuss the facility's policies and procedures for the identified areas, including the changes being made by the facility. The staff were able to confirm new procedures, such as reviewed the MARs after each shift and blood sugar checks and insulin administration being done by the same nurse, were being put into practice. Record review of the facility's 24 hour reports for 08/14/15, 08/15/15, and 08/16/15 revealed changes in condition were identified and documented on the 24 hours report. Record review of all the residents' MARs for 8/11/15-08/17/15 through revealed no concerns related to medications not being administered as ordered or blood sugar checks not being performed. Any blanks in the MAR were accounted for by staff. Record review of Inservice Training Report revealed the following trainings were conducted by the facility and attended by the facility's nursing staff: Weekend RN/24 hours report (08/12/15); CBG's (capillary blood glucose) (08/12/15); Meal Intake (related to) Diabetic Residents (08/12/15); Changes of Condition (08/12/15) The following inservices were also conducted on 8/11/15 and 8/12/15 instructing staff to review the attached policies related to the subject: Change in condition-observing, reporting and recording (8/11/15); Charge nurse duties (8/11/15); Medication Administration (08/11/15); Accu-Checks and Insulin Administration (8/12/15). Inservice sign in sheets were compared with list of employees and all LVNs and RNs were inserviced on the areas of concerns identified above. This was confirmed with in an interview with the interm DON. On 08/17/15 at 1:08 p.m. the Administrator was informed the IJ was removed effective 8/13/15. The facility remained out of compliance at a level of no actual harm at a pattern due to the facility needed to monitor their plan for effectiveness. Record review of Physician's Orders by Category, dated 08/10/15 and provided by the ADON on 08/10/15, revealed 13 residents were prescribed anticoagulants and 28 residents were prescribed antiarrhythmic medication.

Based on observation, interview, and record review, the facility failed to ensure that three residents (Residents #1, 2, and 3) of four reviewed for high fall risk received adequate supervision and assistance devices to prevent accidents as evidenced by: a) failure to ensure fall prevention measures of a sensor alarm and low bed were in place as ordered by the physician from 10/7/14 through 10/11/14 and failure of CNA (certified nurse's aide) B to provide supervision to Resident # 2 when she left her hall and was sitting in the sitting room when Resident #2 fell on [DATE] at approximately 5:55 a.m. and sustained a fractured hip requiring surgical repair. CNA B reported Resident #2 had been trying to get out of bed unassisted throughout the night; b) failure to ensure that staff were implementing fall prevention measures for Resident #2 including the sensor pad alarm, a matt by her bed, and constant supervision in the restroom. Resident #2 had six falls that included two trips to the emergency room , injury to her coccyx and two falls from the toilet when staff were reportedly in the room to supervise her, occurring between 9/2/14 and 10/8/14; c) failure to ensure fall prevention measures were implemented for Resident #3. Observation on 10/23/14 revealed her sensor alarm was off while she was sitting in her wheelchair and needed items were out of her reach. These failures resulted in Resident #1's fall and broken hip that resulted in lasting pain and the need for surgical repair. These failures could result in increased falls for the 23 residents at high risk for falls and result in pain, decreased functional abilities, serious injury or death. Findings included: Resident #1 1. An undated Resident Admission Record for Resident #1 documented he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A fall risk assessment form dated 10/7/14 documented that Resident #1 scored "17". A score of 10 or more indicated a high risk for falls. An Admission Care Plan for Resident #1 dated 10/7/14 documented that Resident #1 had cognitive loss and intermittent confusion. The care plan documented he needed the assistance of two staff for ambulation, transferring, toilet use and bathing. He required the assistance of one staff for grooming, dressing, and eating. Resident #1 had a catheter. He required oxygen continuously and took breathing treatments as needed. The care plan documented that Resident #1 was a fall risk and interventions included a sensor pad alarm. Physician's start up orders for Resident #1 dated 10/7/14 documented a fall alarm to bed and wheelchair due to fall risk. 2. A Provider Investigation Report dated 10/17/14 documented that CNA A found Resident #1 on the floor of his room on 10/11/14 at 5:55 a.m. The report documented that Resident #1 was moaning and complaining of pain, so he was sent to the hospital by ambulance for a suspected hip fracture, which was confirmed at the hospital. The report documented that Resident #1 was determined to be at high risk for falls when he was admitted , thus fall interventions of a bed alarm and low bed were ordered by the physician, but were not implemented. The Provider Investigation report included statements from three nurses that indicated that the sensor alarm was not implemented on admission as the nurses could not locate an alarm in the building. The report included a statement from CNA A, stating that she was going down hall #2 (where Resident #1 resided) to take out trash and heard Resident #1 moaning. She said she found him on the floor, sitting in an upright position with his hand on his right hip, groaning in pain. She said there was no fall mat or sensor alarm in place. She said Resident #1 told her he rolled from the bed to the floor. The report concluded that administrative staff had counseled the nursing staff regarding failure to implement the alarm, implemented the fall alarm and measures to monitor all fall alarms in the building, and in-serviced staff accordingly. 3. During an interview on 10/22/14 at 10:10 a.m., Resident #1 was in his room with two of his daughters (Daughter A and B). Resident #1 and his sisters were spanish speaking only, so Housekeeper A interpreted the interview. Resident #1 was observed to be lying on his bed with oxygen in place. Daughter A said that they visit him multiple times a day at the facility. She said that the family had been having concerns about the staff's supervision of Resident #1, and their english speaking sister had spoken with the Administrator or Director of Nurses about it several times, but it did not seem to improve. Daughter A said that Resident #1 used his call light for help, but they had noticed it took a long time for staff to answer the call light, and sometimes they had to go look for staff after waiting too long. She said that when she arrived to see Resident #1 yesterday, He was trying to get up and the alarm was sounding, but, "Nobody ever came." She said that she put him back in bed. She said that Resident #1 had surgery on his hip at the hospital but he was not totally oriented and would forget he had surgery and still try to get up. She said that he did not have an alarm until he came back from the hospital after surgery. Daughter A said that when she spoke with Resident #1 after the fall, he told her that he turned on his call light and no one ever came. He told her he then started yelling for help. She was not sure if he meant that he activated the call light before falling or after falling. Daughter A said that Resident #1 had been in the hospital immediately prior to his admission to this facility, and had fallen at the hospital and sustained a hematoma to his forehead. An attempt was made to interview Resident #1. He could not recall the details of his fall. He stated, "I just fell ." 4. During an interview on 10/22/14 at 10:30 a.m., CNA A said that she was the person who found Resident #1 on the floor of his room on 10/11/14. She was not the nurse aide assigned to Resident #1's hall that night, as Resident #1 resided on hall two and she was assigned to hall three. She said that CNA B was assigned to Resident #1. CNA A said it was nearing the end of her shift and she was taking out the trash. She said that as she walked past the foyer that separates hall two and three, she saw CNA B sitting on the couch. She said she heard loud moaning before she ever reached hall two and followed the sound to Resident #1's room. She said that she found him on the floor in pain and informed the nurse. CNA A said that the bed was not in a low position, there was no fall matt in the room, and there was no sensor alarm in place. CNA A said that she had worked on Resident #1's hall after he came in to the facility. She said that she remembered walking in and finding him there, but no one had informed her she had a new resident on her hall or that he was a fall risk. She said sometimes the only way the CNA's knew a new resident was a fall risk the first time they met them was if they observed an alarm or a mat beside the bed. She said that prior to his fall, Resident #1 did very well and only required one staff to assist him as he could bear some weight and followed instructions well. She said that although he had a catheter, Resident #1 was continent of bowel and they assisted him to the restroom when needed. 5. During a telephone interview on 10/22/14 at 12:10 p.m., CNA B said that she was on duty from 10:00 p.m. to 6:00 a.m. and assigned to Resident #1's hall on 10/11/14. When discussing her monitoring of Resident #1 that night, she said that she was in his room many times that night because he was "constantly putting his legs down over the side of the bed trying to get up." She said she just put him back to bed each time. She said she did not know what he wanted because she could not understand spanish. When discussing whether she could get assistance from a peer to talk to the resident, she said that she asked a spanish speaking peer to find out what he needed and they talked but she never asked the peer what Resident #1 had said. When discussing when she last saw Resident #1, she said that she started her last rounds of the night about 4:00 a.m. and ended them between 5:00 a.m. and 5:30 a.m. She said she saw him some time during that window, and that she was standing at the nurse's station when he fell . She said she was with CNA A. 6. An observation of the facility 10/22/14 at 2:00 p.m. revealed the nurse's station was situated in a large area in the center of the building with halls one, two, three, and four splitting off of that main area in a "wagon wheel" like fashion. Halls two and three split off the back side of the room. Between halls two and three was a sitting area for residents with a television, couches, and chairs. (This was the area that CNA A described as where she had seen CNA B sitting when Resident #1 was found on the floor). Behind the sitting area was the dining room. Observation of the sitting area revealed that none of the hallways were visible from any location in the sitting area. Call lights on the doorways of the rooms could not be seen from the sitting area. Observation revealed that in order to be on hall two and see what was going on in hall two, one would be required to leave the sitting area and turn a corner to the left to be on hall two. 7. During an interview on 10/22/14 at 3:45 p.m., CNA C said she did not have direct knowledge about Resident #1's fall, but she had worked with him prior to, and since his fall. She said that prior to the fractured hip, Resident #1 could assist in his transfer. She said that he could sit up and put his legs over the side of the bed and stand up with assistance. She said that now when he tried to do that, he yelled out in pain and would just lie back down. CNA C said Resident #1 was not the type of resident that was so confused that he just tried to get out of bed for no reason. She said she believed he only tried to get out of bed when he wanted something, and most of the time that was to go to the restroom, and otherwise, "He doesn't budge." She said that prior to the fall, Resident #1 was good to use his call light when he needed help, but if staff did not respond to the light in a relatively short time, he would always try to get himself up. She said that Resident #1 was not the type of resident that you could ask to wait. 8. During an interview on 10/23/14 at 10:10 a.m., CNA D said she came to work the morning of 10/11/14 at 5:50 a.m. She said that it could have been 5:45 a.m. but it was no later than 5:50 a.m. She said that she parked her car outside hall two, and had to travel down hall two to get to her work station. She said that she walked by Resident #1's room and noticed he was not in. She said she asked someone where he was and was told that he had already left the facility in an ambulance after a fall. 9. During an interview on 10/23/14 at 2:30 p.m., the Director of Nurses (DON) said that the charge nurse generally gathered information regarding how a fall occurred at the time of the incident. She said that since there was an injury involved in Resident #1's case the Administrator conducted an investigation regarding the fall. When discussing that the facility's documentation regarding this incident did not include identifying or addressing that CNA B was not providing supervision to Resident #1 when his accident occurred, the DON said that she was only aware of the issues related to the fall precautions not being in place and the corrective measures taken to address them. 10. During an interview on 10/23/14 at 2:45 p.m., the Administrator said that the only person that she talked to that was on duty when Resident #1 fell was the charge nurse. She said she did not ask where CNA B was at the time Resident #1 fell . She said she guess she could have talked to more people. Resident #2 11. An undated admission record documented Resident #2 was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment for Resident #2 dated 8/25/14 documented that she required extensive assistance of one staff for transfers, dressing, bed mobility, and toilet use. She had impaired range of motion to one side of her upper extremity and both lower extremities. She used a wheelchair for mobility. She was occasionally incontinent of bowel and bladder. A fall risk assessment dated [DATE] documented a score of 16. A score of 10 or more indicated high risk for falls. 12. Incident reports for Resident #2 revealed the following: 10/8/14 at 6:10 p.m.: Resident on toilet- lost balance. (There were no statements or description of how Resident #2 fell off the toilet). Resident #2 was sent to the emergency room due to pain and bruising on her hand. Discharge instructions from the hospital that were attached to the incident report documented, "left hand/elbow contusions." Under, "what measures were put in place or what systemic changes were made?" the facility documented, "Will continue to check sensor pad at least bid (twice daily) and low bed with mat at bedside." 10/4/14 at 12:15 p.m.: Lowered to floor in restroom while on toilet, skin tear to top left wrist. Cause documented as "Res on commode and staring leaning-lost balance." A brief summary documented that the CNA (CNA F) turned her back briefly to move an object in the resident's room and when the resident started leaning the CNA lowered her to the floor. Immediate action taken was in-service with staff not to leave resident alone or unattended while on commode. Attached to the incident was a statement by CNA G confirming CNA F's report. An attached in-service signed by staff and dated 10/4/14 documented, "Do not leave resident on commode alone/unassisted.) 9/23/14 at 7:00 p.m.: Resident went to restroom after evening meal with assist from CNA. Assist off and back into wheelchair from toilet. Resident in room, did not put brakes on wheelchair and attempted to ambulate independently without assistance. Sat on floor. The report documented that visitor and CNA reported that the alarm sounded for greater than one minute. The facility's documented interventions/measures put in place were, "Given call light/ BR (bathroom) q (every) 2 hours, repositioned every 2 hours with assistance. Offered water/ice with rounds. CNA to frequently assist and ensure call light in place and in reach of resident and personal alarm in place and responded to. An attached witness statement to this incident included the following statement: "My name is ( ). I'm a witness. I was taking my mom to her room last night when (resident name) called me to her room to tell me she needed help. I asked her what kind of help she needed and she said Resident #2 had fell . (resident name) said she went to the nurse's station to ask for some help and that the three nurses that were standing there did not pay attention to her. I then see a staff member coming out of a room from picking up trays and we picked her up and put her on her bed. I stayed with her til (staff member, CNA E) got back then finally after about 20 minutes the nurse finally showed up and I left." 9/14/14 at 12:40 p.m.: Resident with sensor alarm on and in place said she lost her balance on side of the bed and let herself down on the floor. The facility documented interventions that Resident #1 was not to be left alone in room and she had wheeled herself from the hallway into her room. 9/6/14 at 9:55 a.m.: CNA reports alarm sounded and noted resident on the floor when entering room. Resident #2 was complaining of tailbone pain and sent to the emergency room . The incident report documented that Resident #2 had been in her wheelchair and attempted to transfer herself. The disposition documented a fractured coccyx. The facility documented that interventions included that resident was to be out of her room when not in bed unless supervised. 9/2/14 at 9:20 a.m.: Another resident reported Resident #2 was sitting on the floor in her room. Resident #2 was reportedly sitting in her wheelchair and attempted to transfer herself out of the wheelchair when she fell . The facility documented interventions as: In-service (that alarm was to be on in bed and wheelchair and a matt at bedside when in bed), reviewed safety measures with resident, and physical therapy screening. 13. During an interview on 10/22/14 at 9:55 a.m., Resident #2's daughter said that she was told that Resident #2 fell in the bathroom because the staff member left her on the toilet and went to retrieve an item from the room. Resident #2's daughter said she had observed that it took a long time for staff to answer her mother's call light. She also stated the staff did not consistently implement fall prevention measures as sometimes her mat was by her bed and sometimes it was not. She said that she has observed the sensor pad alarm not even turned on and she has to turn it on. She said that Resident #2 gets tired of waiting on the staff to come and help her and she will always try to get up and go to the bathroom or try to get in bed from her wheelchair. Resident #2's daughter said that she and her sister have made complaints to the DON. She said they always say they will take care of it, but there had not been improvement. 14. During an interview on 10/22/14 at 3:45 p.m., CNA C said that she worked with Resident #2 but was not involved in the incidents when Resident #2 fell in the restroom. CNA C said that Resident #2 was known to get up and try to transfer herself when not supervised closely. She said that most of the time, Resident #2 tried to do this when she wanted to go to the restroom or if she wanted to get back in bed from her wheelchair. She said Resident #2 did not just randomly try to get out of bed for no reason. She said that Resident #2 must be closely supervised on the toilet because as soon as she is finished she will stand and try to pull her pants up. She said Resident #2 had only one good arm, so this would always throw her off balance. CNA C said Resident #2 did use her call light. 15. During an interview on 10/23/14 at 9:40 a.m., CNA H said she worked with Resident #2 but was not involved in either of the incidents that occurred in the restroom recently. She said that when taking Resident #2 to the restroom, she assists the caregiver and follows instructions. CNA H said, "She's not hard to assist or monitor." She said that Resident #2 would hold on to the rail in the bathroom and would stand while the CNA lowered her pants. Then Resident #2 would sit on the toilet. CNA H stated she stands right next to Resident #2 and assists her off the toilet. CNA H said Resident #2 had not been observed leaning to the side while on the toilet when she had worked with her. CNA H stated she believed that the CNAs had to have left Resident #2 in the restroom alone, because there was "no way" Resident #2 could fall off the toilet if the CNA was beside her. CNA H said, "Somebody's lying, I'm sorry..." 16. During an interview on 10/23/14 at 10:35 a.m., CNA I said she had lowered Resident #2 to the floor in the restroom on 10/4/14. She said she had placed Resident #2 on the toilet and turned her back to move a fall matt that had been propped against the wall because it was in her way. She said that while turned around, Resident #2 began leaning on the toilet, and could not be kept from falling so CNA I had lowered her to the floor. An observation in Resident #2's room (accompanied by CNA I) on 10/23/14 at 10:45 a.m. revealed Resident #2's restroom was very spacious, with room for a chair situated next to the toilet. The resident's fall mat was beside her bed and it was a very large thick mat. CNA I acknowledged this mat would not have fit in the restroom against the wall and she said it must have been one of the gray mats that was in the bathroom at that time. CNA I pointed out where she was standing and turned around to move the mat. Based on this observation, CNA I would have remained within arms' length distance to the resident when she turned from facing the resident. 17. During an interview 10/23/14 at 2:30 p.m., the Director of Nursing said that they had just in-serviced the staff to be sure and stay with the resident in the restroom, and continued previous interventions of fall alarm, mat, low bed, and not leaving the resident in her room unless she was put to bed. She did not identify how the facility addressed the problem that Resident #2 continued to fall despite these interventions and the in-service. Resident #3 18. An undated admission record documented Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with intracranial hemmorhage, depression, hypertention, aphasia, dysphagia, anxiety, [DIAGNOSES REDACTED] dominant side, history of stroke, diabetes, and abnormal gait. A physician's note dated 1/14/14 also documented [DIAGNOSES REDACTED]. A care plan problem dated 9/4/14 documented that Resident #3 had cognitive deficits with poor safety awareness, unsteady gait, attempts to stand unassisted, history of previous falls, impulsiveness, and right [DIAGNOSES REDACTED]. Interventions included a sensor pad alarm in her chair and bed, fall mats while in bed, and to keep commonly used items within her reach. A fall risk assessment dated [DATE] documented a score of "19" which indicated Resident #3 was at high risk of falls. 19. an incident report dated 10/8/14 documented that Resident #3 was found laying on the floor directly next to her bed and she fell while leaning for something on her bedside table. 20. During an observation and interview with Resident #3 in her room on 10/23/14 at 2:10 p.m., she was observed sitting in her wheelchair next to her bed. Her light was not on and the room was very dim. Resident #3 spoke in short sentences and when asked if she was okay, she said, "nope." When asked what she needed, she said she needed a drink and pointed to an over-bed table that was just out of her reach. A plastic water bottle was sitting on the table. There was a sensor pad alarm attached to her wheelchair and observation revealed the green light was not blinking and the alarm did not appear to be activated. Resident #3's call light was turned on. Ten minutes later, CNA J entered the room. He gave Resident #3 the water bottle. His attention was called to the sensor alarm. He looked at it and said it was turned off. He turned a switch on the alarm and the alarm showed a green blinking light. CNA J said that he had just come on duty for the 2:00 to 10:00 p.m. shift, and the off-going CNA must have left the alarm off. 21. A policy and procedure titled "Falls-Evaluation and Prevention" effective 1/2008 and revised 3/2012 which was provided by the DON 10/23/14 at 1:15 p.m. included the following: A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. Following a fall....Review the plan of care and update the interventions as appropriate. Intervention suggestions for fall prevention ...evaluate and implement toileting program if indicated ...provide adequate lighting... ...Ensure personal items and water is within easy reacy 22. The DON provided a list of residents at high risk for falls on 10/22/14 at 2:00 p.m. The list contained 23 residents.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible for one of four residents reviewed for accidents (Resident ID #3). The facility failed to: A) prevent Resident ID #3 from being hit from behind by a facility food cart while it was being pushed by a CNA on 03/13/14. Resident #3 suffered a 7 cm. laceration to the left lower leg. The wound subsequently became infected requiring hospitalization for treatment on 04/03/14 B) properly inservice staff on the proper use and handling of the facility food carts on 03/14/14. This failure could have affected any of the 80 residents currently in the facility, placing them at risk of avoidable injuries. The findings included: 1. On 03/27/14 at 6:50 p.m., CNA "B" was observed to be pushing a facility food cart (used to serve hall trays) down halls 1&2 of the facility during the supper meal service. It was observed tht CNA "B" was not able to see over the top of the cart or around the sides of the cart so she could see who was in front of her while rolling the cart down the halls. The CNA was also noted to park the cart in the middle of the hall while trays were being served down the halls. In an interview with CNA "B" during this same date and time, it was revealed that she had never run into anyone with the food cart due to her vision being diminished, but she had "almost" done it. The CNA was not able to share any additional information concerning the time it had "almost" happened. 2. Review of the current clinical record for Resident #3 revealed she had been admitted to the facility on [DATE] and was currently [AGE] years of age. The resident's current [DIAGNOSES REDACTED]. In an interview with the facility Administrator in person on 04/08/14 at 10:10 a.m., it was revealed that Resident #3 was currently in the hospital being treated for [REDACTED]. Review of nurses notes in Resident #3's record and an incident report for Resident #3 (both dated 03/13/14 at time 6:30 p.m.) revealed the resident was walking out of the dining room with her walker and stopped to talk. A CNA (identified as CNA "A") was pushing a hall food cart out of the dining area and did not see that the resident had stopped in front of her. The CNA ran into the back of Resident #3 with the food cart which resulted in a 7 cm. skin tear on the back of the resident's left ankle. CNA "A" was interviewed in person in the facility on 04/08/14 at 1:45 p.m. CNA "A" stated that on the night of 03/13/14, she had looked around both sides of the food cart and saw no one in front of her. She stated that she had not realized that Resident #3 had stopped in front of her and she ran into the back of the resident with the hall food cart. She stated it caused the resident to have a skin tear to the back of her left ankle. She stated that when she looked at the skin tear it was gapping open, the skin was peeled off and bleeding "alot". She stated that Resident #3 said to her "watch where you are going". 3. Further review of Resident #3's current clinical record revealed a hospital "history and physical examination [REDACTED]. The patient cannot express this problem." The document goes on to document: "This all started about three weeks agao when a worker at the nursing home ran over the patient's leg with a food cart. This developed a skin tear. They have been caring for it at the nursing home. However, over the last five days, the wound had become more purulent. Over the last couple of days she had developed significant [DIAGNOSES REDACTED] around the wound." "However, because of the worsening of the character of the wound and the developing redness, her daughters brought her into the clinic today. After examining the leg and wound I felt the patient needed hospitalization for further management of this." This document also revealed "The skin review is positive for the skin tear with a subsequent wound infection and cellulitis." "SKIN: The examination reveals that on the left leg she had an obvious wound present that measures about 4 cm. x 8 cm. It is purulent. Around that the patient has surrounding [DIAGNOSES REDACTED]. This is tender." The resident was admitted to the hospital with [REDACTED]. The wound is extremely purulent." Other admission [DIAGNOSES REDACTED]. ([DIAGNOSES REDACTED] means redness and purulent means infected drainage). In an interview with the facility ADON on 04/08/14 in person at 11:40 a.m., it was verfied that the injury received from the food cart on 03/13/14 and the skin area currently being treated for [REDACTED]. 4. Review of a facility "Inservice Training Report" dated 03/14/14 revealed that the facility ADON had inserviced the staff on "Hall Cart Meal Pass". In an interview with the facility ADON in person on 04/08/14 at 11:40 a.m., she stated that the inservice of 03/14/14 mainly addressed that when the hall food cart was being pushed to be careful where you were going and not really how to use the cart in a way where one could see clearly who was in front of them during use (this could explain why CNA "B" was observed to be pushing the cart from behind during the supper meal service with a diminished view on 03/27/14). 5. In an interview with the facility ADON in person on 04/08/14 at 11:40 a.m., it was revealed that no other resident (or person) had been injured by the use of the facility hall food cart except for Resident #3. 6. In an interview with the facility Administrator on 04/08/14 at 10:10 a.m., it was revealed that the resident facility census upon entrance to the facility on [DATE] at 6:45 p.m. was 80.