Every finding on record at Sunnybrook Rehabilitation Center

Based on observation, record review, and interviews with staff, Emergency Medical Services (EMS) staff, Nurse Practitioner, and Medical Director, the facility failed to ensure basic lifesaving support was provided effectively when there was a delay in initiating Cardio Pulmonary Resuscitation (CPR) to a resident who had no signs of life and was a full code (an official directive to perform all necessary life-sustaining measures, including CPR and defibrillation, if a person stops breathing or their heart stops). Additionally, the facility failed to do the following: 1) ensure staff knew how to announce a code blue to obtain assistance when a resident was without signs of life, 2) ensure all emergency equipment, which included an AMBU bag (an AMBU bag is used to ventilate a resident who has stopped breathing so that with each chest compression oxygenated blood will circulate while resuscitation efforts are being conducted) and an Automatic External Defibrillator (AED, a device used to deliver a shock to the heart) was in a place which would not delay effective resuscitation efforts, and 3) immediately notify emergency medical services (EMS) when no signs of life were identified and the code status was confirmed to be a full code. Resident #89's resuscitation efforts were stopped and Resident #89 was pronounced deceased on [DATE] at 2:15 am by EMS. This affected 1 of 1 residents reviewed for CPR (Resident #89). Immediate jeopardy began on [DATE] when staff failed to immediately initiate their CPR protocol to Resident #89 who was a full code and found warm and without breaths or a pulse. Immediate Jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. The findings included:The facility's policy titled CPR-Cardiopulmonary Resuscitation last revised on [DATE] revealed the center shall provide basic life support, including CPR- Cardiopulmonary Resuscitation when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order, and resident choice indicated in the resident's advance directives. The policy further noted the procedure as follows:1. In the event of cardiac or respiratory arrest, identify code status. If no DNR (Do Not Resuscitate) order exists, or if resident has no obvious clinical signs of irreversible death, initiate CPR. 2. Activate emergency response system by clearly paging over the PA (public address) system, code blue and the area/room number. 3. Use an Automatic External Defibrillator (AED, a device used to deliver a shock to the heart) per manufacturer indications of use as soon as possible when the device is ready for use. Follow the voice and onscreen instructions. 4. Continue CPR until the resident responds, healthcare practitioner arrives and takes over or EMS arrives and takes over. Review of CPR certification records revealed Nurse #8 and Nurse #3 had current CPR training for basic life support (BLS) provider for CPR and AED based on the American Heart Association (AHA) guidelines. The 2025 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (CPR & ECC) revealed recognition of cardiac arrest by the healthcare professional for an adult who was unconscious or unresponsive with absent or abnormal breathing was to check for a pulse no longer than 10 seconds and if no definite pulse is felt, should assume person is in cardiac arrest. The AHA stated that the first link in the chain of survival for cardiac arrest included prompt activation of the emergency response system which allows dispatch of the designated EMS agency. The AHA guidelines stated that early provision of high-quality CPR and prompt defibrillation are the key interventions to improve outcomes from adult cardiac arrest. The guidelines further recommended that the use of breaths with chest compressions and to perform CPR until a defibrillator or AED is applied and readied for use. The AHA guidelines further note that delivery of chest compressions without assisted ventilation for prolonged periods could be less effective than conventional CPR (compressions and ventilation) because arterial oxygen content decreases as the CPR duration increases. The American Red Cross revealed that when cardiac arrest occurred the heart stops beating or beats too ineffectively to circulate blood to the brain and other vital organs. The American Red Cross noted that the human brain can typically only survive 3-4 minutes without oxygen before sustaining irreversible injury and that CPR was vital for preventing brain death during a cardiac arrest by manually pumping blood to deliver oxygen to the brain. The American Red Cross further noted that every minute without intervention, the chance of survival drops for the person experiencing sudden cardiac arrest and that CPR significantly reduces the risk of permanent brain damage until emergency medical professionals arrive. The Cleveland Clinic revealed that sudden cardiac arrest causes the brain to be totally deprived of oxygen. The Cleveland Clinic noted that oxygen loss to the brain is a medical emergency that leads to a rapid timeline of cell damage. The Cleveland Clinic further noted that with loss of oxygen to the brain consciousness is lost within 10 to 15 seconds, permanent brain cell death begins within 4 to 6 minutes, and if oxygen is not restored irreversible brain damage or brain death occurs shortly after. Resident #89 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, diabetes, and unspecified dementia. Resident #89 had a physician order dated [DATE] for full code. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #89 had severe cognitive impairment and unclear speech. Resident #89 had a care plan which was last reviewed on [DATE] for advance directive to include full code.The nursing progress note dated [DATE] at 3:35 am written by Nurse #8 who was assigned to Resident #89 revealed that during a routine check at approximately 1:25 am Resident #89 was observed to have no visible chest rise and fall, no palpable radial pulse noted and the resident was unresponsive. Nurse #8 noted that she reviewed Resident #89's medical chart and confirmed the resident was a full code and proceeded to locate additional nursing staff. Nurse #8 further noted that she was able to locate Nurse #3 and notified Nurse #3 of the situation and need for assistance for Resident #89. The nursing progress note stated that the crash cart (an emergency cart that holds life-saving equipment) was brought to the bedside but the cart did not have an AMBU bag (a bag is used to ventilate a resident who has stopped breathing so that with each chest compression oxygenated blood will circulate while resuscitation efforts are being conducted) available and was retrieved after CPR had begun. Nurse #8 wrote that CPR continued until EMS arrived and assumed resuscitation efforts for Resident #89. Nurse #8 noted that Resident #89 remained without pulse or respirations and was pronounced by EMS with the time of death at 2:15 am. The EMS record dated [DATE] revealed an emergency call was received from the facility at 1:37 am for a cardiac arrest and EMS was at the resident bedside at 1:45 am and assumed resuscitation efforts. The EMS record noted that at the time of arrival facility staff were performing CPR and staff reported that they were not sure what time the resident was last seen but when they checked on him at 1:30 am he was found unresponsive with absent pulses and CPR was initiated. Upon EMS arrival the resident was pale and warm, unresponsive with absent carotid pulses and apnea (temporary cessation of breathing). EMS applied the AED and shocks were delivered at 1:47 am and 2:00 am, an artificial airway was placed, vascular access was obtained, emergency medications were administered, and resuscitation efforts including compressions and ventilation was performed by EMS for 26 minutes without improvement. The EMS record noted that resuscitation efforts were discontinued and resident was pronounced as deceased on [DATE] at 2:15 am. Review of Nurse #8's statement hand-written and signed by the Administrator dated [DATE] revealed that the Administrator met with Nurse #8 and the nurse informed the facility that she checked on Resident #89 at the beginning of her shift and he was stable at that time. Nurse #8 reported that she went back to check on the resident after midnight to get vital signs and she did not see his chest rise or fall and vital signs were unable to be obtained. The statement further read that Nurse #8 left the room to get nurse assistance and checked his code status, once the code status was confirmed that the resident was a full code she proceeded to the other nurses station to find the other nurse. Nurse #8's statement noted that when the other nurse was found, Nurse #8 asked for assistance with Resident #89 and they grabbed the crash cart. Nurse #8's statement concluded that they were able to position Resident #89 properly for chest compressions and performed CPR until EMS arrived shortly thereafter. Nurse #8 did not sign the written statement. A telephone interview was conducted with Nurse #8 on [DATE] at 11:53 am. Nurse #8 stated that during her medication pass sometime after 1:00 am she was near the doorway of Resident #89's room and was unable to see a rise and fall of his chest. Nurse #8 stated she entered the room immediately and attempted to obtain a blood pressure and pulse but that was unsuccessful. She stated Resident #89's was not cold to the touch and she was unable to feel or see his chest rise or feel a pulse on his wrist. Nurse #8 stated she had to leave Resident #89's room to confirm the code status at the computer that was outside the room. She reported that once she confirmed Resident #89 was a full code and she needed to do CPR she stated she attempted to make an announcement of code blue over the intercom system but she was unable to work the system so she stated she yelled out code blue in the hall but no one was near Resident #89's room and no one responded. Nurse #8 stated at that time she ran to nursing station #1 which was on the other side of the facility and there were two Nurse Aides (NAs) sitting at the nursing station but there was not a nurse so she ran to nursing station #2 which was down the hall from Resident #89's room. Nurse #8 stated that there were two NAs at the nursing station #2 and when she asked where Nurse #3 was the staff reported they were not sure. Nurse #8 stated that Nurse #3 exited a resident room and she went to Nurse #3 and told her Resident #89 was not breathing and she needed help. Nurse #8 stated she then ran back to Resident #89's room while another staff member brought the crash cart to the room and CPR was started. She stated that the crash cart did not have an AMBU bag so she was unable to give rescue breaths so she just continued to do compressions until a second crash cart was brought to the room that had the AMBU bag. Nurse #8 stated she thought it took her about 3 minutes to find Nurse #3 and return to Resident #89 to start CPR but she was not certain. Nurse #8 stated EMS arrived at the facility and took over the CPR but Resident #89 expired at 2:15 am at the facility. A follow-up telephone interview was conducted with Nurse #8 on [DATE] at 1:03 pm. Nurse #8 stated that the AED was not brought to the room during Resident #89's code blue and she did not think to ask anyone to get it because she was busy doing compressions. Nurse #8 stated when EMS arrived they put their AED on Resident #89 and the resident did receive one or two shocks but it was not successful.Review of Nurse #3's statement hand-written and signed by the Administrator, not dated, revealed the Administrator met with Nurse #3 who worked with Nurse #8 on [DATE]. Nurse #3 indicated that Nurse #8 reported that she needed assistance for a code so she immediately followed Nurse #8 to the resident room and that both nurses validated the resident was unresponsive. Nurse #3 stated she immediately went to nursing station to call 911 and then returned to the room to assist Nurse #8 with CPR. Nurse #3 reported that not much time had elapsed during the entire incident. Nurse #3 did not sign the written statement.A telephone interview was conducted with Nurse #3 on [DATE] at 2:24 pm. Nurse #3 stated that on [DATE] she was told by Nurse #8 that she thought Resident #89 was dead because she was unable to get any vital signs. Nurse #3 stated she immediately went to Resident #89's room with Nurse #8 and did not observe him breathing or responding. Nurse #3 stated she found out the resident was a full code from Nurse #8 and she told Nurse #8 that they needed to start CPR. Nurse #3 stated she made the code blue call over the system and she notified the NAs at the nursing station that they had a code blue and the NAs stated that Nurse #8 never told them about the code blue. Nurse #3 stated she brought the crash cart from the emergency closet next to Resident #89's room and began getting the supplies to Nurse #8 who was doing CPR. Nurse #3 stated at this time they realized the crash cart did not have an AMBU bag available and an NA went to get the other crash cart while she went to call 911. Nurse #3 stated she was not sure what time she made the call to 911 or how long Nurse #8 was looking for her before she was told about Resident #89. Nurse #3 stated she returned to assist with CPR once 911 was called until EMS arrived. Nurse #3 stated the AED was not present at the time of Resident #89's code blue. Nurse #3 stated she thought the AED was stored in the crash cart and did not know that it was mounted to the wall in the emergency closet. A telephone interview was conducted on [DATE] at 10:05 am with NA #1 who was assigned to Resident #89 during the hours when the code blue occurred. NA #1 stated she provided care to Resident #89 around 12:30 am and she stated he was at what she knew to be his baseline at the time she left the room. She stated Resident #89 did not normally speak but she stated he did open his eyes when she provided care and he was breathing normally when she was with the resident. NA #1 stated that around 1:20 am Nurse #8 approached her and NA #4 at the nursing station and asked where Nurse #3 was. She stated she and NA #4 told Nurse #8 that they were not sure where Nurse #3 was but NA #4 offered to call Nurse #3 on her phone. NA #1 stated that she and NA #4 had asked Nurse #8 if she needed help with something but Nurse #8 did not say anything was needed and never mentioned Resident #89 was not breathing. She stated that Nurse #8 told her that she walked around the facility a few times looking for Nurse #3 and could not find her. NA #1 stated soon after the conversation with Nurse #8, Nurse #3 came out of a room and met with Nurse #8 and both nurses went to Resident #89's room. NA #1 stated she did not know what the nurses talked about and no one said anything about a code blue at that time. NA #1 stated that Nurse #3 returned to the nursing station and told them that Resident #89 was a code blue and they ran to the room. NA #1 stated that at no time did Nurse #8 announce a code blue over the intercom, report a code blue while she was at the nursing station, and she did not hear her yell out for help or code blue for Resident #89. NA #1 stated she and NA #4 were sitting at nursing station #2 that was closest to Resident #89's room and they would have heard Nurse #8 yell because it was quiet in the facility at night and they were very close to Resident #89's room. NA #1 stated had Nurse #8 announced the code blue for Resident #89 staff would have followed the facility protocol for code blue and would have come to the room immediately but Nurse #8 did not tell anyone there was an emergency with Resident #89. Review of NA #4's statement hand written by the Administrator, not dated, revealed NA #4 reported being at the nursing station when Nurse #8 approached the desk and asked for Nurse #3. NA #4 reported she did not know where Nurse #3 was and asked Nurse #8 what she needed and received no response from Nurse #8. NA #4 further noted that Nurse #3 appeared and Nurse #8 asked for help with Resident #89. NA #4 stated she went to get the crash cart on the hall and it did not have the AMBU bag on it so she then went to the other cart to get the AMBU bag and bring it to the room. After she brought the other cart to Resident #89's room she left the area. NA #4 did not sign the written statement.A telephone interview was conducted on [DATE] at 10:40 am with NA #4. NA #4 stated she was sitting at the nursing station on [DATE] which was just a few rooms down from Resident #89's room with NA #1 when Nurse #8 came to the nursing station and asked where Nurse #3 was. She stated that Nurse #8 had no sense of urgency and it was like pulling teeth to get her to say what she needed. NA #4 stated she tried to ask Nurse #8 what she needed but she did not say anything and never said anything about a code blue for Resident #89. NA #4 stated she never heard Nurse #8 make an announcement over the intercom or yell out for a code blue. NA #4 stated she was not sure how long Nurse #8 walked around looking for Nurse #3 but had she yelled code blue right away staff would have come to the room and she would not have wasted time walking around the building. NA #4 stated they were not aware Resident #89 was a code blue until Nurse #3 returned to the nursing station and told them. She stated at that point she ran towards Resident #89's room and believed that she got the crash cart from the emergency cart room and took it to the residents room. NA #6 was interviewed via telephone on [DATE] at 11:19 am who revealed on [DATE] she recalled hearing commotion in the hall and going to see what happened but she did not hear anyone announce a code blue over the speaker or yell it out in the hall. NA #6 stated she went to the room and Nurse #8 was doing CPR and other staff were there so she went back to her work assignment. During an interview on [DATE] at 11:37 am with NA #7 she revealed she was at the nursing station #2 on [DATE], which was close to Resident #89's room when Nurse #8 came and asked for the supervisor on duty. NA #7 stated Nurse #8 appeared very calm and did not report any medical emergency or code blue. NA #7 stated that another NA at the nursing station told her Nurse #3 may be on break and would try to call her on her phone. NA #7 stated she later heard commotion down the hall, she went to the area and saw a code blue and went to get the second crash cart when told the AMBU bag was not on the first cart. NA #7 stated she did not get the AED from the wall when she got the second crash cart. A telephone interview was conducted with NA #2 on [DATE] at 1:55 pm who revealed that on [DATE] she was sitting at the nursing station that was on the other side of the facility sometime after midnight and Nurse #3 ran down the hall and told us there was a code blue. She stated she had not worked with Nurse #8 before and she reported Nurse #8 did not make any announcement over the intercom system about a code blue and she never heard anyone yell code blue until Nurse #3 told her. NA #2 stated she went to the room but by the time she arrived both crash carts were there and Nurse #8 was doing CPR.A telephone interview was conducted on [DATE] at 9:18 am with the EMS Shift Commander who revealed that any delay in initiation of basic life support including notification of 911, placement of the AED, and initiation of quality CPR reduces the chance of survival from a cardiac arrest. The EMS Shift Commander noted that the first intervention when identification of a person that does not have a pulse is to active the 911 notification so the EMS professionals can be dispatched. He stated that the recommendation if there are two people present at the scene is that one person calls 911 and the other person puts on the AED to determine if a shock is required. He stated the AED was a crucial part of the process and should be placed on the person so the heart rhythm could be analyzed as quickly as possible. The EMS Shift Commander stated once the AED determines if a shock was needed the machine directs everyone to stand clear while shock is administered then will direct to continue CPR if needed. The EMS Shift Commander stated that if 911 was called and determined no longer needed the facility could always call back or just let the EMS squad know when they arrive but the delay in notification of 911 slows the arrival of EMS and Paramedics who are able to provide advanced life support measures in the field.An observation of the two facility crash carts and emergency closets where the crash carts and AED were stored was completed on [DATE] at 10:05 am with the Director of Nursing. The two crash carts had all required equipment and the AED was noted to be mounted to the wall in each emergency closet. The typed attestation statement dated [DATE] and signed by the Administrator revealed the facility reviewed the facility cameras to visualize the time lapse of the code blue for Resident #89 in the morning of [DATE]. The Administrator noted that around the hour of 1:00 am Nurse #8 was observed to leave Resident #89's room abruptly to get assistance at the nursing station. The first station she approached did not have anyone available and she quickly proceeded to the second nursing station where she was able to exchange words with NAs that were present. The Administrator further noted that Nurse #3 appeared from down the hall and shortly after both staff members arrived at Resident #89's room. A crash cart was obtained and brought to the room and a staff member had to then retrieve the second crash cart. The Administrator concluded the time lapse was no more than 7 minutes from the start of the event to staff at Resident #89's room. The typed attestation statement, not dated, provided by the Administrator on [DATE] revealed the facility cameras were reviewed and noted that Resident #89 was checked on by NA #1 around 12:45 am. The Administrator stated after discussion with staff regarding this incident further it was determined that Nurse #8 had entered Resident #89's room periodically after 1:00 am. At 1:25 am Nurse #8 approached the nurses station for help, quickly found Nurse #3 and both rushed to Resident #89's room immediately to initiate CPR. The Administrator noted that EMS arrived shortly after CPR began. The Nurse Practitioner (NP) was interviewed via telephone on [DATE] at 2:31 pm. The NP stated that when performing CPR, it was incredibly important for the crash cart to have all the required emergency equipment available and without all the necessary equipment it was not possible to run and effective code blue. The NP stated the AED was to be used as soon as possible in the event that a shock is required. The NP further stated that immediate notification of EMS was important to expedite advanced life support (ALS; life-saving medical protocols used to treat emergencies like cardiac arrest using advanced airway management, vascular access and emergency medications and typically administered by paramedics) by EMS because when ALS is initiated quickly there is a greater chance of a successful resuscitation. A telephone interview was conducted with the Medical Director on [DATE] at 9:05 am. The Medical Director stated he was made aware of the incident with Resident #89 by the facility. The Medical Director stated that when CPR was initiated compressions were most important so not having the AMBU bag present at the beginning of CPR was less problematic than not having the AED. The Medical Director stated that when a resident was found without a pulse you should apply the AED as quickly as possible to determine if a shock is needed. The AED would direct staff of the need for a shock or to continue with CPR until the next reading to determine if a shock was needed. He stated if no shock was needed staff would continue CPR until EMS arrived. The Medical Director stated he did not believe the outcome for Resident #89 would have been different if the staff had used the AED and AMBU bag when they performed CPR because the resident was a very sick man.A telephone interview was conducted on [DATE] at 11:10 am with the Previous Director of Nursing (DON) #1, who revealed she did not recall being notified of Resident #89's code blue or concerns with the crash cart not being stocked at the time it occurred. The Previous DON #1 stated she met with Nurse #8 along with the Administrator on [DATE] to obtain her statement about the events of the code blue for Resident #89. She stated Nurse #8 reported she left Resident #89's room to check the code status and find Nurse #3 before starting CPR. The Previous DON #1 stated Nurse #8 had reported the crash cart did not have the AMBU bag present on the first crash cart but that it was obtained quickly. The Previous DON #1 was unable to recall if any other concerns were identified related to the Resident #89's code blue but she stated an investigation was conducted and education was provided to staff. The Previous DON #1 stated she did not believe the delay of obtaining the AMBU bag from the second crash cart negatively impacted the CPR that was provided to Resident #89 although she was unable to state exactly how long it took for the CPR to be started when Resident #89 was found unresponsive. An interview was conducted with the Administrator on [DATE] at 1:42 pm. The Administrator stated that the code blue was discussed during the morning clinical meeting on [DATE] and they contacted Nurse #8 to return to the facility so they could conduct an interview. The Administrator stated that Nurse #8 did not report any issue with the overhead paging system in her statement but she did state the AMBU bag was missing from the first crash cart. The Administrator stated that she was able to review the facility camera after the code blue but when she attempted to save the video she was unsuccessful. The Administrator stated that from watching the video she was able to see that the NA #1 was in Resident #89's room around 12:45 am but she was unable to state how long. She stated that Nurse #8 was seen to enter Resident #89's room sometime after 1:00 am and again around 1:25 am when she exited the room and began looking for Nurse #3. The Administrator stated the video did not have any sound so she was unable to hear what was said during this time. She stated that what she was able to see in the video was that Nurse #8 went to the nursing stations and back to the room quickly and that staff were running around and responding. The Administrator stated Nurse #8 and Nurse #3 entered the room quickly and began CPR but she confirmed she was unable to state exactly when CPR was started because the resident rooms did not have cameras. The Administrator reported that 911 should have been called as soon as possible. She stated that she had not been notified by Nurse #8 or Nurse #3 that the AED was not brought to Resident #89's room during the code blue and she was not sure if the AED was required to be brought to the room during a code blue she would have to review the policy. The Administrator stated based on the video of the incident on [DATE] it was less than 7 minutes from the time Nurse #8 was seen exiting Resident #89's room and when all staff were back to the room to provide CPR. The Administrator stated that she felt the time frame from when Nurse #8 left Resident #89's room to find Nurse #3 until she returned was not a very long time and she stated that staff reported they were timely in response and most of the staff overheard and acted quickly when they heard the commotion. The Administrator stated she felt the staff managed Resident #89's code blue appropriately. The Administrator was notified of immediate jeopardy on [DATE] at 4:24 pm.The facility provided the following credible allegation of immediate jeopardy removal:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:During morning Clinical Interdisciplinary Team [IDT] meeting on [DATE], upon review of 24-hour report reflecting nursing notes, the Director of Nursing identified that there was an initial delay in obtaining the Ambu bag and activating EMS, during a Code Blue situation. An investigation was initiated, including staff interviews. The facility failed to ensure basic life support was provided effectively when there was a delay in initiating Cardiopulmonary Resuscitation to Resident # 89. During the early morning hours of [DATE], Resident #89 was evaluated by Nurse #8 and noted without palpable radial pulses, respirations or blood pressure, as per staff interview and medical record review on [DATE]. Nurse #8 left the resident room and checked the Code status of the resident, identifying they were a full code status. Nurse #8 then attempted to call Code Blue overhead, although was unsuccessful, so she yelled out 'Code Blue, HELP!'. When no one immediately responded, Nurse #8 ran to the other nursing station to obtain help from Nurse #3. Nurse #8 asked nurse aides where Nurse #3 was, stating she needed assistance. Nurse #3 appeared at nursing station, Nurse #8 stated, I have a Code!Nurse #8 and Nurse #3 ran back to the residents' room at 1:25am (approximately 2-3 minutes), confirmed pulselessness and lack of respirations, as described in nursing note dated [DATE], as exhibited by no visible rise and fall of chest and initiated chest compressions, as resident was a Full Code status. A nurse aide ran and brought the crash cart to the room as directed. It was identified that an Ambu bag was not noted on the crash cart, and the nurse aide was directed to obtain the second crash cart, which contained an Ambu bag, and was then utilized. Nurse #3 called 911 to activate the EMS system at 1:37am, then returned to the resident's room to again assist with CPR. CPR was in progress by licensed nurses until EMS arrived and took over CPR at 1:45am. CPR continued by EMS staff, until the event was called at 2:15am by EMS, at which time EMS staff stopped CPR. During initial investigation by the Director of Nursing, on [DATE], the only missing item mentioned was the Ambu bag. Upon reinterviews on [DATE], Nurse #8 disclosed to the surveyor that the AED was not brought into Resident #89's room.After being interviewed by the Administrator and Director of Nursing, on [DATE], regarding the Code Blue occurrence, the Administrator informed Nurse #8 that she was being suspended pending the outcome of an investigation into occurrence. Upon being informed of the suspension, Nurse #8 stood up and stated, then I'm not coming back. I quit as of right now.Both crash carts were checked and stocked with all required equipment needed to conduct effective Cardiopulmonary Resuscitation, immediately after Code Blue on [DATE], by the Nurse Manager. On [DATE], the nurse aide who brought the crash cart to the resident room was reeducated to assure their understanding, that when delegated to obtain a crash cart, that always includes the AED. Nurse #3 was reeducated on [DATE] on CPR- Cardiopulmonary policy and procedure, including timely notification/ activation of EMS-911 system. Nurse #8 was reported on [DATE] to the North Carolina Board of Nursing by the facility Administrator.The Director of Clinical Services completed a full-house audit on [DATE], for any CODE Blue events that occurred during the 30 days prior to [DATE], to identify any other potential areas of concern. Audit conducted included active and discharged residents with a 'full code' status, during the stated time period, and included review of MD orders and progress notes. No concerns noted.Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete:The Director of Nursing, who is a Registered Nurse, with a current CPR certification through the American Heart Association, conducted a Code Blue drill on [DATE], with 7a-3p licensed nurses, using a mannequin as the 'resident'. The drill did not identify any concerns.T[TRUNCATED]

Based on observations and staff interviews, the facility failed to ensure narcotic lock boxes were permanently affixed to the medication refrigerators in 2 of 2 medication rooms observed for medication storage (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]). The findings included:a. On 5/19/26 at 12:38 PM an observation was conducted of Medication room [ROOM NUMBER] with Nurse #1. The observation revealed two black lock boxes in the medication refrigerator. Nurse #1 was observed as she picked up the lock box labeled #2. Lock box #2 was not permanently affixed to the medication refrigerator. Nurse #1 unlocked and opened lock box #2. Lock box #2 contained one card of Marinol (a cannabinoid drug that us used to treat appetite loss, nausea and vomiting) 5 milligrams(mg) with 14 tablets. Further observation revealed the lock box labeled #3 was permanently affixed to the refrigerator. Nurse #1 confirmed that medication lock box #2 should have been permanently affixed to the refrigerator.b. On 5/19/26 at 12:54 PM an observation was conducted of Medication room [ROOM NUMBER] with Nurse #2. The observation revealed two black lock boxes in the medication refrigerator. Nurse #2 was observed as she picked up the lock box labeled #1. Lock box #1 was not permanently affixed to the medication refrigerator. Nurse #2 unlocked and opened lock box #1. Lock box #1 contained one card of Marinol 5 mg with 5 tablets and Marinol 10 mg with 9 tablets, and three vials of Ativan 2 milligrams per milliliter (2mg/ml). Nurse #2 confirmed that the medication lock box should have been permanently affixed to the refrigerator. Nurse #2 stated the facility had recently replaced the refrigerators due to needing more storage space. Nurse #2 stated she did not have the key to lock box #4 but demonstrated the lock box was not permanently affixed to the refrigerator.An interview was conducted with the Director of Nursing (DON) on 05/21/2026 at 3:04 PM. She stated the facility should have immediately bolted the narcotic boxes to the medication refrigerator when they were exchanged. The DON stated the medication refrigerators had been exchanged a couple of weeks ago and she was not aware that narcotic lock boxes were not bolted to the inside of the refrigerator. An interview was conducted on 05/21/2026 at 3:04 PM with the Administrator. She indicated she expected that the narcotic boxes would have been immediately affixed to the medication refrigerator. The Administrator stated she was not aware that the narcotic lock boxes had not been affixed to the medication refrigerator.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for PASRR (Resident #3).The findings included:Resident #3 was admitted to the facility on [DATE] with diagnoses which included unspecified bipolar disorder and major depressive disorder recurrent. Review of Resident #3's electronic medical record revealed a Level II PASRR Determination Notification dated 4/04/22 which noted Resident #3's nursing home placement was appropriate. The Minimum Data Set (MDS) annual assessment dated [DATE] noted Resident #3 was not currently considered by the state Level II PASRR process to have a serious mental illness. An interview was conducted with MDS Nurse #1 on 5/20/26 at 2:29 p.m. MDS Nurse #1 confirmed that Resident #3 had a Level II PASRR Determination Notification located in the electronic health record and the resident should have been coded for the Level II PASRR on the assessment. MDS Nurse #1 stated she must have missed the document in Resident #3's electronic health record when she completed the annual MDS assessment. During an interview with the Administrator on 5/21/26 at 2:09 p.m. she revealed MDS Nurse #1 was responsible for accurately coding Resident #3's MDS assessment related to the Level II PASRR. The Administrator stated MDS Nurse #1 should have coded Resident #3 for a Level II PASRR based on the documentation that was in the health record.

Based on record review and staff interviews, the facility failed to develop a person-centered care plan in the area of a Level II Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident reviewed for PASRR (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses which included unspecified bipolar disorder and major depressive disorder recurrent. Review of Resident #3's electronic medical record revealed a Level II PASRR Determination Notification dated 4/04/22 which noted Resident #3's nursing home placement was appropriate.The Minimum Data Set (MDS) annual assessment dated [DATE] noted Resident #3 was not currently considered by the state Level II PASRR process to have a serious mental illness. Resident #3's care plan which was last reviewed on 4/17/26 revealed no care plan related to the Level II PASRR Determination. An interview was conducted with MDS Nurse #1 on 5/20/26 at 2:29 p.m. MDS Nurse #1 confirmed that Resident #3 had a Level II PASRR determination and that it was required to have a care plan. MDS Nurse #1 stated Resident #3 had a previous care plan in place for the Level II PASRR, but it was resolved on 12/05/24. MDS Nurse #1 stated she could not say why the previous care plan may have been resolved but assumed it was accidentally checked to resolve it at that time. MDS Nurse #1 stated she did not have a care plan in place for Resident #3's Level II PASRR because she did not see the Level II PASRR Determination Notification in the resident's health record when she completed the 1/15/26 MDS assessment. During an interview with the Administrator on 5/21/26 at 2:09 p.m. she revealed MDS Nurse #1 was responsible to ensure that Resident #3's care plan was in place to reflect the Level II PASRR status.

Based on record review and staff interviews, the facility failed to revise the person-centered care plan in the area of elopement risk and use of a wander/elopement alarm bracelet for 1 of 25 residents whose care plans were reviewed (Resident #54).The findings included:Resident #54 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder bipolar type and Alzheimer's Disease. Resident #54 was hospitalized on [DATE] and returned to the facility on [DATE]. The elopement risk assessment dated [DATE] revealed Resident #54 was at risk for elopement. Resident #54 had an active physician order for an alerting bracelet (elopement alarm bracelet) located on the left ankle, check functionality every day shift, check placement every shift. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #54 had severe cognitive impairment and was coded for inattention and disorganized thoughts that were continuously present. Resident #54 was coded for wandering which occurred daily and the use of a wander/elopement alarm daily. The care plan which was last reviewed on 3/11/26 revealed there was no care plan or interventions in place for Resident #54's risk for elopement or use of the wander/elopement alarm bracelet. An interview was conducted with MDS Nurse #1 on 5/21/26 at 1:14 p.m. who revealed she was responsible for Resident #54's comprehensive care plan. MDS Nurse #1 reported she should have initiated the care plan for the elopement risk and use of the wander/elopement alarm bracelet when the care plan was last reviewed but she just missed it. The Director of Nursing (DON) was interviewed on 5/21/26 at 1:58 pm. The DON stated that MDS Nurse #1 was responsible for Resident #54's comprehensive care plan and should have started the care plan for the wander/elopement alarm bracelet and risk for elopement when the care plan was reviewed. During an interview on 5/21/26 at 2:08 pm the Administrator stated that MDS Nurse #1 was responsible for resident care plans and the care plan should reflect the current resident status.

Based on record review, family member and staff interviews, the facility failed to ensure a resident was transported for a scheduled orthopedic appointment and instead transported a different resident to the appointment for 1 of 1 resident reviewed (Resident #95). Findings: Resident #95 was admitted on [DATE] with diagnoses that included heart failure and difficulty walking.The admission Minimum Data Assessment (MDS) dated [DATE] revealed Resident #95 was moderately cognitively impaired.Resident #95 was discharged from the facility on 2/26/26.During an interview with the Medical Records Staff #1 on 5/20/26 at 3:26 p.m. she stated that she prepared Resident #95 for his appointment on 2/25/26 and sat him by the reception area to wait for his driver. Medical Records Staff #1 stated that later in the day she learned that a mix up had occurred and Resident #95 did not go for his appointment. She stated that Driver #1 went to Resident #95's room and picked up Resident #45 who was Resident #95's roommate and took him to the appointment. Medical Records Staff #1 further stated that Resident #45 was sent back by the doctor's office because he was not Resident #95. During a telephone interview on 5/19/26 at 9:15 a.m. Resident #95's Family Member stated that on 2/25/26 at 2:00 p.m. Resident #95 had an orthopedic appointment and that she arrived for this appointment ahead of time and waited for Resident #95 to arrive. The Family Member stated that Resident #95 never arrived and instead Resident #95's roommate (Resident #45) showed up for the appointment and did not have an appointment and was sent back to the facility after the doctor's office discovered it was not Resident #95 at the appointment. She stated she attempted to speak with the Scheduler at the facility without success. During an interview with Resident #45 on 5/19/26 at 2:29 p.m. he revealed that he went for an appointment early this year that was not his, but the driver brought him back. He stated that it was a short ride to the doctor's office.During an interview with Driver #1 from the transportation company on 5/21/26 at 3:11 p.m. he revealed that he arrived at the facility on 2/25/26 at 1:00 p.m. to take Resident #95 for his appointment. He stated that he did not know Resident #95 and stated that the facility gave him the wrong resident, and he only discovered he had the wrong resident when he arrived at the appointment. Driver #1 revealed that when he arrived at the facility he went to the nursing station and could not remember who gave him paperwork for the appointment for Resident #95 and he proceeded to Resident #95's room and found Resident #45 seated by the door to Resident #95's room. Driver #1 stated that he called out Resident #95's name, and Resident #45 responded and he asked Resident #45 if he was ready to go to his appointment and the resident responded yes. Driver #1 stated that the resident did not have footrests on his wheelchair and the nurses located the footrests and continued talking among themselves and did not notice he had left with Resident #45 instead of Resident #95. Driver #1 stated that when they arrived at the appointment Resident #45 stated his name and that's when they discovered he had brought the wrong resident to the appointment and not Resident #95. Driver #1 revealed that he returned Resident #45 to the facility and reported an error to nursing staff and to his manager. During an interview with the Manager of the transportation company on 5/20/26 at 3:55 p.m. he revealed that a mistake happened on 2/25/26 and Resident #95 missed his appointment because Driver #1 took the wrong resident for the appointment. The Manager stated Driver #1 arrived at the facility and received the paperwork for the appointment and proceeded to Resident #95's room to pick him up but instead picked up Resident #45 and took him to the appointment. The Manager stated that they have now changed company policy, and that a driver must first review appointment paperwork with nursing staff and make sure they have the right resident before leaving for an appointment. Record review of an email from the Manager of the transportation company dated 5/20/26 at 4:31 p.m. revealed that the transportation company had conducted client verification training for its drivers and changed their resident pick-up process to make sure clients were confirmed before leaving the building for appointments. During an interview with previous Administrator on 5/21/26 at 8:39 a.m. she stated that the transportation driver made a mistake and took the wrong resident to an appointment. She stated that the driver went to the resident's room and took the wrong resident. The Administrator stated that they did an investigation and discussed the incident with the transport company and nursing staff to make sure the mix up does not occur again. An interview was conducted on 5/21/26 at 1:52 p.m. with the Administrator and she stated that the facility had new policy where nursing staff were expected to validate residents before being sent out for appointments to ensure the driver has the correct resident for the correct appointment.

Based on record review and staff interviews, the facility failed to post accurate licensed and non-licensed nurse staffing data for 14 of 30 days reviewed for sufficient staffing (4/20/26, 4/24/26, 4/25/26, 4/26/26, 4/27/26, 4/28/26, 4/30/26, 5/01/26, 5/02/26, 5/03/26, 5/04/26, 5/11/26, 5/12/26, and 5/17/26). The findings included:1. A review of the posted daily staffing data sheets and the daily nursing staff schedule from 4/18/26 through 5/17/26 revealed the following for licensed nursing staff:a. A review of the posted daily staffing data sheets for the 6:45 am to 3:15 pm shift revealed the licensed nursing staff was not recorded accurately for the following days:4/25/26- the posted daily staffing data sheet noted one (1) Registered Nurse (RN) and 3 Licensed Practical Nurses (LPNs); the daily staff schedule recorded no RN and 2 LPNs.4/30/26- the posted daily staffing data sheet noted 5 LPNs; the daily staff schedule recorded 4 LPNs.5/01/26- the posted daily staffing data sheet noted 5 LPNs; the daily staff schedule recorded 4 LPNs.5/03/26- the posted daily staffing data sheet noted 5 LPNs; the daily staff schedule recorded 4 LPNs.5/12/26- the posted daily staffing data sheet noted one (1) RN and 4 LPNs; the daily staff schedule recorded no RN and 4 LPNs.b. A review of the posted daily staffing data sheets for the 2:45 pm to 11:15 pm shift revealed the licensed nursing staff was not recorded accurately for the following days:4/27/26- the posted daily staffing data sheet noted 5 LPNs; the daily staff schedule recorded 4 LPNs.c. A review of the posted daily staffing data sheets for the 10:45 pm to 7:15 am shift revealed the licensed nursing staff was not recorded accurately for the following days:4/24/26- the posted daily staffing data sheet noted 3 LPNs; the daily staff schedule recorded 2 LPNs.5/11/26- the posted daily staffing data sheet noted 3 LPNs; the daily staff schedule recorded 2 LPNs.5/12/26- the posted daily staffing data sheet noted 4 LPNs; the daily staff schedule recorded 3 LPNs.5/17/26- the posted daily staffing data sheet noted 3 LPNs; the daily staff schedule recorded 2 LPNs.2. A review of the posted daily staffing data sheets and the daily nursing staff schedule from 4/18/26 through 5/17/26 revealed the following for non-licensed nursing staff:a. A review of the posted daily staffing data sheets for the 7:00 am to 3:00 pm shift revealed the non-licensed nursing staff was not recorded accurately for the following days:4/25/26- the posted daily staffing data sheet noted 8 Nurse Aides (NAs); the daily staff schedule recorded 7 NAs.5/02/26- the posted daily staffing data sheet noted 9 NAs; the daily staff schedule recorded 8 NAs.5/03/26- the posted daily staffing data sheet noted 10 NAs; the daily staff schedule recorded 8 NAs.5/04/26- the posted daily staffing data sheet noted 11 NAs; the daily staff schedule recorded 10 NAs.b. A review of the posted daily staffing data sheets for the 3:00 pm to11:00 pm shift revealed the non-licensed nursing staff was not recorded accurately for the following days:4/24/26-the posted daily staffing data sheet noted 8 NAs; the daily staff schedule recorded 7 NAs.4/25/26- the posted daily staffing data sheet noted 8 NAs; the daily staff schedule recorded 6 NAs.4/26/26- the posted daily staffing data sheet noted 8 NAs; the daily staff schedule recorded 6 NAs. 4/28/26- the posted daily staffing data sheet noted 9 NAs; the daily staff schedule recorded 8 NAs.5/03/26- the posted daily staffing data sheet noted 10 NAs; the daily staff schedule recorded 8 NAs.5/04/26- the posted daily staffing data sheet noted 10 NAs; the daily staff schedule recorded 9 NAs. 5/11/26- the posted daily staffing data sheet noted 9 NAs; the daily staff schedule recorded 7 NAs.5/12/26- the posted daily staffing data sheet noted 8 NAs; the daily staff schedule recorded 7 NAs.c. A review of the posted daily staffing data sheets for the 11:00 pm to 7:00 am shift revealed the non-licensed nursing staff was not recorded accurately for the following days:4/20/26 the posted daily staffing data sheet noted 6 NAs; the daily staff schedule recorded 5 NAs. 4/24/26 the posted daily staffing data sheet noted 6 NAs; the daily staff schedule recorded 4 NAs.4/25/26- the posted daily staffing data sheet noted 6 NAs; the daily staff schedule recorded 4 NAs.4/26/26- the posted daily staffing data sheet noted 6 NAs; the daily staff schedule recorded 5 NAs.5/11/26- the posted daily staffing data sheet noted 7 NAs; the daily staff schedule recorded 6 NAs.A telephone interview was conducted on 5/20/26 at 3:39 pm with the previous Scheduler, who was responsible for the facility staff posting and scheduling until a week prior to the survey. She reported that she no longer worked at the facility and would not answer any questions related to the staffing sheets. An interview was conducted with the Director of Nursing (DON) on 5/21/26 at 1:54 pm. The DON stated she had just begun managing the staff posting and scheduling within the last week since the previous Scheduler had left the position at that time. The DON stated the previous Scheduler had not been adjusting the staff posting when changes were needed. The Administrator was interviewed on 5/21/26 at 2:02 pm and revealed the DON had taken over the scheduling responsibilities during the previous week since the previous Scheduler's employment was ended with the facility a week ago. The Administrator explained the previous Scheduler was employed by the facility up to the week prior to the survey and would have been responsible for the staff posting during her employment. The Administrator stated she was not sure why the previous Scheduler did not correct the staff posting when the changes occurred.

Based on record review and staff and Pharmacy Consultant interviews, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) assessment for 1 of 5 residents (Resident #28) reviewed for unnecessary medications who received psychotropic medications. The findings included: Resident #28 was admitted to the facility on [DATE] with diagnoses that included manic depression (bipolar disorder) and depression. A review of Resident #28's electronic medical record revealed an AIMS was completed on 5/17/24. A review of Resident #28's Physician's orders revealed an order dated 10/18/24 for Geodon (antipsychotic medication) oral capsule 40 milligrams 1 capsule by mouth daily each morning for bipolar disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 was cognitively intact and was coded as receiving an antipsychotic during the lookback period. A review of the Pharmacist Consultation Report dated 12/6/24 revealed an AIMS assessment had not been completed in the previous 6 months and the completion of one was recommended due to Resident #28 receiving an antipsychotic medication. The AIMS assessment was utilized to detect Tardive Dyskinesia (involuntary repetitive movements which occur following treatment with medication) in residents prescribed antipsychotic medications. The Consultation Report stated this antipsychotic medication had the potential to cause involuntary movements, including Tardive Dyskinesia. A review of Resident #28's electronic medical record revealed an AIMS was completed on 1/20/25. A review of Resident #28's electronic medical record revealed no psychotropic medication side effect monitoring tool in the medication administration report (MAR). A telephone interview was completed on 2/18/25 at 3:33 pm with the Pharmacy Consultant. The Pharmacy Consultant stated an AIMS or other involuntary movement monitoring tool should have been completed on Resident #28 every 6 months to monitor Resident #28 for any involuntary repetitive movements or side effects related to the prescribed antipsychotic medication. A telephone interview was completed on 2/20/25 at 11:34 am with the Director of Nursing (DON). The DON stated an AIMS should have been completed on Resident #28 every 6 months to monitor for any involuntary repetitive movements. The DON stated the assessment triggered in a resident's electronic record when it was due, prompting nursing staff to complete it. The DON was unsure why it was not completed. A telephone interview was completed on 2/20/25 at 12:09 pm with the Administrator. The Administrator stated it was her expectation the AIMS assessment was completed per the facility's protocol and as the Pharmacy Consultant recommended them.

Based on record review, and staff and Ombudsman interviews, the facility failed to notify the Ombudsman in writing of a resident transfer for 2 of 3 residents reviewed for hospitalization (Resident #1 and Resident #18). The findings included: 1. Resident #1 was admitted to the facility on [DATE]. The nursing progress note dated 1/20/2025 at 7:17 AM revealed Resident #1 was transferred to the hospital for evaluation after a fall. Resident #1 was discharged from the facility on 1/20/25 and returned to the facility on [DATE]. Record review of the Ombudsman Discharge and Transfer report for January 2025 did not reveal documentation the Ombudsman was notified when Resident #1's was transferred to the hospital on 1/20/25. In an interview on 2/18/25 at 12:55 PM the Social Worker revealed he started working at the facility in October 2024. He reported he did not notify the Ombudsman of residents discharged to the hospital but did notify when residents were discharged home. A telephone interview was conducted on 2/19/25 at 3:29 PM with the Ombudsman who revealed she had not received written notification of hospitalization discharges for the last 2 months. In an interview on 2/18/25 at 1:15 PM the Administrator stated the Social Worker should send a monthly notice to the Ombudsman of all residents sent out. 2. Resident #18 was admitted to the facility on [DATE]. The nursing progress note dated 11/15/24 at 9:55 PM revealed Resident #18 was transferred to the hospital for evaluation of chest pain and cough. Resident #18 was discharged from the facility on 11/15/24 and returned to the facility on [DATE]. Record review of the Ombudsman Discharge and Transfer report for November and December 2024 provided by the facility did not reveal documentation the Ombudsman was notified when Resident #18's was transferred to the hospital on 11/15/24. In an interview on 2/18/25 at 12:55 PM the Social Worker revealed he started working at the facility in October 2024. He reported he did not notify the Ombudsman of residents discharged to the hospital but did notify when residents were discharged home. A telephone interview was conducted on 2/19/25 at 3:29 PM with the Ombudsman who revealed she had not received written notification of hospitalization discharges for the last 2 months. In an interview on 2/18/25 at 1:15 PM the Administrator stated the Social Worker should send a monthly notice to the Ombudsman of all residents sent out.

Based on record review, and Responsible Party (RP) and staff interviews, the facility failed to notify the resident or Responsible Party of the facility bed hold policy for 2 of 3 residents reviewed for hospitalization (Resident #1 and Resident #2). The findings included: 1. Resident #1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. a. The Change in Condition report dated 9/19/24 revealed Resident #1 was transferred to the hospital for further evaluation of elevated temperature. Resident #1 was discharged from the facility on 9/19/24. Record review of Resident #1's electronic medical record revealed there was no documentation that Resident #1 or the Responsible Party (RP) received the bed hold policy for the 9/19/24 discharge. The nursing progress note dated 9/22/24 revealed Resident #1 was readmitted to the facility. b. The Change in Condition report dated 9/26/24 revealed Resident #1 was transferred to the hospital for further evaluation of temperature and hand swelling. Resident #1 was discharged from the facility on 9/26/24. Record review of Resident #1's electronic medical record revealed there was no documentation that the bed hold notice was completed for Resident #1 or that Resident #1's RP was provided with the bed hold notice for the 9/26/24 discharge from the facility. A telephone interview was conducted with Resident #1's RP on 10/07/24 at 3:36 pm who revealed she was not contacted by the Admission Director to discuss the process of the bed hold policy for the 9/19/24 or 9/26/24 discharges. The RP stated when Resident #1 returned to the facility on [DATE] from the 9/19/24 discharge, Resident #1 returned to the same room and all her personal belongings were still in the room. Resident #1's RP stated when she went to the facility on [DATE] to pick up Resident #1's clothing to wash, another resident was in the room and Resident #1's personal belongings were packed up and put in a storage closet. The RP stated she was not notified by the facility or the Admission Director that she was required to hold the room while Resident #1 was hospitalized and that Resident #1's personal belongings would be removed if she did not hold the room. An interview was conducted on 10/07/24 at 2:30 pm with Nurse #4 who confirmed she was assigned to Resident #1 on 9/19/24 and 9/26/24 when Resident #1 was discharged to the hospital. Nurse #4 stated when a resident was sent to the hospital she would send the resident face sheet (resident information sheet) and the medication summary report. Nurse #4 stated she was not sure about the bed hold notice being sent to the hospital, but she stated she did not discuss holding a bed with residents before going to the hospital. Nurse #4 stated she did not know if she completed and sent a bed hold notice with Resident #1 when she discharged to the hospital on 9/19/24 or 9/24/24. During an interview on 10/07/24 at 3:46 pm the Business Office Manager stated she was not responsible to notify the resident or the RP regarding the bed hold policy. The Business Office Manager stated the Admissions Director was responsible to contact the resident or RP to ask if they wanted to hold the bed while the resident was in the hospital and if the resident or RP decided to hold the bed then she would then reach out to discuss the costs. The Business Office Manager stated she was not asked to contact Resident #1's RP to discuss the costs for bed hold for either discharge. An interview was conducted on 10/07/24 at 3:52 pm with the Admission Director who revealed she was responsible to contact the resident or RP regarding the bed hold policy. The Admission Director stated typically she would call the first listed RP the next morning after discharge to the hospital to see if they wanted to hold the bed while the resident was in the hospital, but she stated it was hit or miss that she called. The Admission Director stated she tried to call Resident #1's RP the day after the discharges but she did not speak to the RP, and she reported she did not make any further attempts to contact Resident #1's RP to discuss the bed hold policy. During an interview with the Director of Nursing (DON) on 10/08/24 at 2:05 pm she revealed Nurse #4 was responsible to complete the bed hold notice in the electronic record and send with Resident #1 to the hospital, but she did not know the process once the resident was at the hospital. The DON stated all nurses were educated on the bed hold notice process, but it was not something she monitored when the discharges to hospital were reviewed. An interview was conducted with the Administrator on 10/08/24 at 10:00 am who reported the nurse that sent the resident to the hospital was responsible to complete the bed hold notice in the electronic record and send the document to the hospital with the resident information to be given to the RP when they arrived at the hospital. The Administrator stated she did not know who was expected to give the bed hold notice to the RP at the hospital or how the facility was sure the bed hold notice was given to the RP, but stated the bed hold notice was sent with the resident paperwork at time of transfer. The Administrator stated the Admission Director was responsible to follow-up with the resident or RP when discharged to hospital to determine if the bed hold was wanted or not. The Administrator stated she was unable to locate any documentation that the bed hold notice was completed and sent with Resident #1 or that Admission Director contacted Resident #1's RP for the 9/19/24 or 9/26/24 discharges to discuss the bed hold process or if the RP wanted to hold the bed for Resident #1. 2. Resident #2 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #2 had severe cognitive impairment. Review of the Change in Condition report dated 9/27/24 completed by Nurse #2, revealed Resident #2 was transferred to the hospital for further evaluation of injury to the right lower leg. Resident #2 was discharged from the facility on 9/27/24. An attempt to interview Resident #2's Responsible Party (RP) on 10/08/24 at 12:30 pm was unsuccessful. Record review of Resident #2's electronic medical record revealed there was no documentation that the bed hold notice was completed or that Resident #2's RP received the bed hold notice for the 9/27/24 discharge from the facility. An attempt to interview Nurse #2 on 10/7/24 at 2:00 pm and 3:15 pm were unsuccessful. An interview was conducted on 10/08/24 at 10:52 am with the Admission Director who revealed she was not aware she needed to discuss the bed hold notice for long term care residents when they discharged to the hospital, and it was not something she had done in the past for long term care residents in the facility. The Admission Director stated she did not contact Resident #2's RP regarding the bed hold notice and desire to hold the room because she knew Resident #2 would be returning to the facility and a bed would be available at the facility when Resident #2 was ready to return. An interview was conducted with the Administrator on 10/08/24 at 10:00 am who reported the nurse that sent the resident to the hospital was responsible to complete the bed hold notice in the electronic record and send the document to the hospital with the resident information to be given to the RP when they arrived at the hospital. The Administrator stated the Admission Director was responsible to follow-up with the RP when Resident #2 was discharged to hospital to determine if the bed hold was wanted or not. The Administrator stated she was unable to locate any documentation that the bed hold notice was completed for Resident #2 or that Admission Director contacted Resident #2's RP for the 9/27/24 discharge to discuss if a bed hold was wanted.

Based on record review, resident interview, staff interview, and pharmacy manager interview the facility failed to obtain and administer narcotic pain medication as ordered for moderate to severe pain for one (Resident #3) of one resident reviewed for pain control. The findings included: Resident #3 was admitted to the facility on [DATE] with multiple diagnoses some of which included a healing hip fracture, anxiety disorder, and depression. Documentation on the hospital medication administration record (MAR) revealed Resident #3 was administered one tablet of Acetaminophen 650 milligrams (mg) and one tablet of Oxycodone 5 mg immediate release on 6/14/2024 at 5:18 PM. Acetaminophen and Oxycodone are pain medications. Resident #3 had a physician's order initiated on 6/14/2024 for one tablet of Norco (Hydrocodone-Acetaminophen) 7.5-325 mg to be administered by mouth every six hours as needed for moderate to severe pain for 175 days. Norco is a narcotic pain medication. There were no other physician orders upon admission for pain medication for Resident #3 in the electronic medical record. Documentation in an admission note dated 6/15/2024 at 12:29 AM stated, [Resident #3] arrived at [7:00 PM] this evening 06/14/2024 via stretcher from [hospital name]. [Vital Signs Stable] [complained of] right hip [relative to] fracture. Tylenol given effective. Alert and oriented times 3. An interview was conducted with Resident #3 on 6/19/2024 at 9:48 AM. Resident #3 explained when she was admitted to the facility it was a fiasco. Resident #3 elaborated providing the following information. Resident #3 stated her medications were not at the facility when she arrived like she assumed they would be. Resident #3 stated the very worst thing that happened was she was in extreme pain and became hysterical. Resident #3 explained that her pain medication did not arrive until late at night on 6/15/2024 and the facility was not able to give her anything that was strong enough to stop the pain until her medication arrived. An interview was conducted with Nurse Aide (NA #7) on 6/20/2024 at 10:51 PM. NA #7 confirmed she was the nurse aide for Resident #3 on 6/14/2024 for the 3:00 PM to 11:00 PM shift. NA #7 stated Resident #3 was crying and in pain on the night she was admitted . NA #7 confirmed she did notify the nurse and they both tried to calm her down. NA #7 stated she had to explain to Resident #3 she was not able to get out of bed to go to the bathroom and Resident #3 had to use a bed pan. NA #7 stated she had changed all the bedding for Resident #3 a couple of times requiring Resident #3 to roll from side to side causing the resident pain. An interview was conducted with Nurse #6 on 6/20/2024 at 2:49 PM. Nurse #6 confirmed she had been the nurse for Resident #3 on the night of her admission on 6/14/2024 and again on 6/15/2024 for the 3:00 PM to 11:00 PM shift. Nurse #6 conveyed the following information. Resident #3 arrived and was assessed to be alert and oriented with a surgically repaired hip fracture. Nurse #6 explained to Resident #3 she was not allowed out of bed until therapy assessed her and she would have to use a bed pan. Nurse #6 revealed she also explained to Resident #3 she was going to have to use the mechanical sling lift to obtain her weight because the facility could not give any medication to Resident #3 without obtaining her weight. Nurse #6 said Resident #3 was extremely anxious about being put in the mechanical sling lift but with the assistance of two nurse aides she was able to obtain the weight of Resident #3 in the mechanical sling lift. Nurse #6 further explained Resident #3 had never used a bed pan before and a couple different times during the night the nurse aide had to change all the bedding for Resident #3 due to the bed pan spilling. Nurse #6 said Resident #3 had to do a lot of moving around in the bed with the changing of the bed linens and being put in the mechanical sling lift. Nurse #6 said Resident #3 was screaming in pain and hitting the walls. Nurse #6 stated she tried to calm her down and she gave Resident #3 Tylenol per standing orders, but it was not working. Nurse #6 revealed she faxed the pharmacy the medication orders for Resident #3 as soon as she arrived, but the orders were put in too late for the pharmacy to deliver the medications on the evening of 6/14/2023 and they would have to be delivered on the morning delivery. Nurse #6 explained she called the pharmacy and was not able to get a STAT (urgent) order due to there not being a driver. Nurse #6 revealed she was not able to get narcotic pain medication out of the automated medication dispensing cabinet because the Assistant Director of Nursing was working on getting her access. Additionally, Nurse #6 did not think any of the nurses on the 3:00 PM to 11:00 PM shift had access to the automated medication dispensing cabinet because there were no administrative staff working past 5:00 PM at the facility. Nurse #6 reiterated Resident #3 was in pain, and she did her best to comfort her on 6/14/2024 but thought perhaps Resident #3 was more anxious than in pain. Documentation on the MAR by Nurse #6 revealed Resident #3 had a pain level of 3 for the evening shift on 6/14/2024. The pain scale was 0 being no pain, 5 being moderate pain, and 10 being worst possible pain. There was no documentation on the Medication Administration Record of Resident #3 receiving any Tylenol on the evening of 6/14/2024. Nurse #7 was interviewed on 6/20/2024 at 3:26 PM. Nurse #7 revealed she was the nurse for Resident #3 for the 7:00 AM to 3:00 PM shift on 6/15/2024. Nurse #7 explained a family member of Resident #3 approached her at the nursing medication cart requesting to review the medications Resident #3 was receiving. Nurse #7 indicated she opened the drawer with Resident #3's family member present and discovered Resident #3 did not have any medication. Nurse #7 stated she called the pharmacy and was told the pharmacy was still working on the medications for Resident #3. Nurse #7 stated Resident #3 never expressed she was in any pain on her shift on 6/15/2024. Documentation on the MAR revealed Resident #3 had a pain level of 0 for the night shift on 6/14/2024 and a pain level of 0 for the day shift on 6/15/2024. An interview was conducted with Nurse #6 on 6/20/2024 at 2:49 PM. Nurse #6 revealed when she arrived the next day, 6/15/2024, for her shift on 3:00 PM to 11:00 PM, she found out in report that the medications for Resident #3 had not arrived. Nurse #6 stated Resident #3 was again in pain and requesting her pain medication. Nurse #6 indicated she gave Resident #3 Tylenol per a standing order, and this helped a little but not enough to relieve Resident #3's pain. Nurse #6 stated Resident #3 was no longer screaming in pain on 6/15/2024 but was visibly upset when I told her she was going to have to wait for her pain medication to come to the facility. Nurse #6 revealed Nurse #8 (Infection Preventionist) came to her during the shift on 6/15/2024 and asked her how her new admissions were doing. Nurse #6 explained to Nurse #8 that Resident #3 was in pain and her narcotic pain medication had not arrived at the facility yet. Nurse #6 revealed Nurse #8 looked in the automated medication dispensing cabinet and the narcotic pain medication needed by Resident #3 was not in there. Nurse #6 confirmed the ordered Norco arrived at the facility at around 11:00 PM on 6/15/2024, which was immediately administered to Resident #3 who was still awake. Nurse #3 explained Resident #3 was much calmer and understanding after receiving her pain medication on 6/15/2024. Nurse #8 was also interviewed on 6/20/2024 at 3:26 PM and 4:26 PM. Nurse #8 stated she went to the facility on [DATE] arriving at the facility at 9:30 PM. Nurse #8 stated at around 10:15 PM or 10:30 PM on 6/15/2024 she approached Nurse #6 who told her Resident #3 did not have her pain medication. Nurse #8 said Nurse #6 explained to her Resident #3 came in late on 6/14/2024, the pharmacy didn't have a driver, and Resident #3 was upset about her pain medication not coming in from the pharmacy. Nurse #8 stated she called the pharmacy and was told the medications for Resident #3 were in route to the facility. Nurse #8 stated she then went to check the automated medication dispensing cabinet and found the narcotic pain medication ordered for Resident #3, but it was not the same dosage ordered for Resident #3. Nurse #8 revealed she then went to Resident #3 and asked her if she wanted the dosage of narcotic pain medication from the automated medication dispensing cabinet or to wait for her dosage of narcotic pain medication to arrive from the pharmacy in route to the facility. Nurse #8 stated Resident #3 opted to wait for her pain medication to come to the facility. There was no documentation on the Medication Administration Record of Resident #3 receiving any Tylenol on the evening of 6/15/2024. Documentation on the MAR by Nurse #6 revealed Resident #3 was administered the physician ordered dose of Norco on 6/15/2024 at 11:03 PM for a pain level of 9. The Director of Nursing (DON) was interviewed on 6/20/2024 at 4:00 PM and 6:00 PM. The DON provided the following information. The DON was not at the building when Resident #3 arrived on 6/14/2024 and she was not notified by Nurse #6 of Resident #3 being in pain or the lack of access to the automated medication dispensing cabinet. The DON could have remotely obtained access to the automated medication dispensing cabinet for Nurse #6, or a unit manager could have come to the facility. The automated medication cabinet would have had the narcotic pain medication ordered for Resident #3, but not in the specific dose ordered for Resident #3. The DON stated Nurse #6 should have called her and should have utilized the automated medication dispensing cabinet for pain medication for Resident #3. The DON confirmed the facility had standing orders for the administration of Tylenol for residents in pain. An interview was conducted with the pharmacy manager of the pharmacy the facility utilizes on 6/21/2024 at 8:51 AM. The pharmacy manager revealed the cut off time for medication orders to be received at the pharmacy for the evening delivery was 7:00 PM on 6/14/2024. The pharmacy manager stated the medication orders for Resident #3 were entered into the electronic system earlier in the day on 6/14/2024 but they could not be filled until after the resident arrived at the facility. The pharmacy manager stated the pharmacy was notified Resident #3 had arrived at the facility at 9:31 PM on 6/14/2024. The pharmacy manager confirmed the facility had all the medications ordered for Resident #3 in the automated medication dispensing cabinet on 6/14/2024 and 6/15/2024. The pharmacy manager further explained the dose of Norco in the automated medication dispensing cabinet did not match the ordered dose for Resident #3, but a one-time order could have been obtained from a physician. The pharmacy manager stated a STAT order for medications for Resident #3 would have required the facility to call the pharmacy with this request, a pharmacist would fill it, and an on-call driver would have delivered the medications. The pharmacy manager explained the pharmacy always had an on-call pharmacist and driver for a STAT delivery, but there was no record of the facility calling the pharmacy requesting a STAT delivery. The pharmacy manager revealed the facility only received one medication delivery on 6/15/2024 and the driver left the pharmacy at approximately 6:30 PM, delivering the medications for Resident #3 at 10:54 PM to the facility.

Based on record review, resident interview, staff interview, consultant pharmacist interview, and pharmacy manager interview the facility failed to dispense medications from an approved pharmacy source for one (Resident #3) of one resident reviewed for pharmaceutical services. Findings included: Resident #3 was admitted to the facility on Friday, 6/14/2024 with multiple diagnoses some of which included a healing hip fracture, anxiety disorder, acute embolism and thrombosis of the right femoral vein (blood clots), and depression. The electronic record listed the physician orders initiated on 6/14/2024 for Resident #3 as the following: 60 milligrams (mg) Cymbalta delayed release particles to be given as two capsules by mouth at bedtime for depression; Vitamin D3 to be given as one capsule by mouth one time a day for supplement; 150 mg Trazadone HCL to be given as one tablet by mouth at bedtime for depression; 17 grams Polyethylene Glycol Powder to be given by mouth as needed for constipation once daily; 1 mg Lorazepam to be given as one tablet by mouth every six hours as needed for anxiety for 14 days; 300 mg Gabapentin to be administered as two capsules by mouth at bedtime for neuropathy; 10 mg Ezetimibe to be given as one tablet by mouth one time a day for Hyperlipidemia; 5 mg Apixaban to be given as two tablets by mouth two times a day for deep vein thrombosis for seven days; and 7.5-325 mg Norco to be given as one tablet by mouth every six hours as needed for moderate to severe pain for 175 days. An interview was conducted with Resident #3 on 6/19/2024 at 9:48 AM. Resident #3 explained when she was admitted to the facility it was a fiasco. Resident #3 stated her medications were not at the facility when she arrived like she assumed they would be. Documentation on the Medication Administration Record (MAR) revealed Resident #3 was administered per physician orders the medications Trazadone HCL, Apixaban, Cymbalta, and Gabapentin by Nurse #6 prior to bedtime on the evening of 6/14/2024. An interview was conducted with Nurse #6 on 6/20/2024 at 2:49 PM. Nurse #6 confirmed she had been the nurse for Resident #3 on the night of her admission on 6/14/2024 and again on 6/15/2024 for the 3:00 PM to 11:00 PM shift. Nurse #6 conveyed the following information. Resident #3 arrived and was assessed to be alert and oriented with a surgically repaired hip fracture. Nurse #6 revealed she faxed the pharmacy the medication orders for Resident #3 as soon as she arrived, but the orders were put in too late for the pharmacy to deliver the medications on the evening of 6/14/2023 and they would have to be delivered on the morning delivery. Nurse #6 explained she called the pharmacy and was not able to get a STAT (urgent) order due to there not being a driver. Nurse #6 revealed she was not able to get medication out of the automated medication dispensing cabinet because the Assistant Director of Nursing was working on getting her access. Additionally, Nurse #6 did not think any of the nurses on the 3:00 PM to 11:00 PM shift had access to the automated medication dispensing cabinet because there were no administrative staff working past 5:00 PM at the facility. Documentation on the MAR revealed Resident #3 was administered per physician orders Vitamin D3, Apixaban, and Ezetimibe by Nurse #7 on 7/15/2024 upon rising for the day. Nurse #7 was interviewed on 6/20/2024 at 3:26 PM. Nurse #7 revealed she was the nurse for Resident #3 for the 7:00 AM to 3:00 PM shift on 6/15/2024. Nurse #7 explained a family member of Resident #3 approached her at the nursing medication cart requesting to review the medications Resident #3 was receiving. Nurse #7 indicated she opened the drawer with Resident #3's family member present and discovered Resident #3 did not have any medication. Nurse #7 stated she called the pharmacy and was told the pharmacy was still working on the medications for Resident #3. Nurse #7 explained she did not have access to the automated medication dispensing cabinet. Nurse #7 further explained she took medication from other resident's medication cards to give to Resident #3 except for the Vitamin D3, which was available from house stock. Nurse #7 confirmed the medications she took from other residents to give to Resident #3 were Apixaban and Ezetimibe. Documentation on the MAR revealed Resident #3 was administered per physician orders the medications Trazadone HCL, Apixaban, Cymbalta, and Gabapentin by Nurse #6 prior to bedtime on the evening of 6/15/2024. An interview was conducted with Nurse #6 on 6/20/2024 at 2:49 PM. Nurse #6 revealed when she arrived the next day, 6/15/2024, for her shift on 3:00 PM to 11:00 PM she found out in report that the medications for Resident #3 had not arrived. Documentation on the MAR revealed Resident #3 was administered per physician orders Lorazepam and Norco by Nurse #6 at 11:03 PM on 6/15/2024. Nurse #6 was reinterviewed on 6/20/2024 at 4:31 PM. Nurse #6 stated she had borrowed medications from other residents to give to Resident #3 on the evening of 6/14/2024 and 6/15/2024 because it was important that she take the medications ordered for her. Nurse #6 confirmed the medications she borrowed were the Trazadone HCL, Apixaban, Cymbalta, and Gabapentin. Nurse #6 added she knew she was not supposed to borrow medications from other residents and confirmed she did not borrow the Lorazepam or the Norco from other residents to give to Resident #3. An interview was conducted with the Director of Nursing (DON) on 6/20/2024 at 4:00 PM. The DON stated there was always someone on every shift who had access to the automated medication dispensing cabinet. The DON further stated if she had been called, she could have obtained access to the automated medication dispensing cabinet remotely for the nurses. The DON explained after thirty days the nurse's access to the automated medication dispensing cabinet will expire if the automated medication dispensing cabinet was not used by the nurse. The DON stated in addition the unit manager lives nearby and could have come to the facility to obtain medications from the automated medication dispensing cabinet for Resident #3. The DON explained the pharmacy has only one delivery on Saturday, but the pharmacy could have been called to deliver a STAT delivery if they had been called. The DON confirmed the nursing staff should call the DON or Administration for access to the automated medication dispensing cabinet, call in a STAT order to the pharmacy, or obtain hold orders from the physician. The DON stated the nurses should not borrow medications from other residents for a new admission. An interview was conducted with the facility consultant Pharmacist on 6/21/2024 at 8:21 AM. The Pharmacist confirmed there was a cut off time for delivery of medications in the evening after which medications will have to be obtained from the automated medication dispensing cabinet or a STAT order from the pharmacy. The Pharmacist stated she would have instructed the nurses to not borrow from other residents as this was not a pharmacy recommendation for dispensing medication. The Pharmacist conveyed she thought someone in the facility should have access to the automated medication dispensing cabinet at all times. An interview was conducted with the pharmacy manager of the pharmacy the facility utilizes on 6/21/2024 at 8:51 AM. The pharmacy manager revealed the cut off time for medication orders to be received at the pharmacy for the evening delivery was 7:00 PM on 6/14/2024. The pharmacy manager stated the medication orders for Resident #3 were entered into the electronic system earlier in the day on 6/14/2024 but they could not be filled until after the resident arrived at the facility. The pharmacy manager stated the pharmacy was notified Resident #3 had arrived at the facility at 9:31 PM on 6/14/2024. The pharmacy manager confirmed all the medications ordered for Resident #3 were available in the facility automated medication delivery cabinet except for the Norco and Lorazepam, which were available in alternate strengths. The pharmacy manager noted the facility did not remove any medications for Resident #3 from the automated medication dispensing cabinet on 6/14/2025 or 6/15/2024. The pharmacy manager stated a STAT order for medications for Resident #3 would have required the facility to call the pharmacy with this request, a pharmacist would fill it, and an on-call driver would have delivered the medications. The pharmacy manager explained the pharmacy always has an on-call pharmacist and driver for a STAT delivery, but there was no record of the facility calling the pharmacy requesting a STAT delivery. The pharmacy manager revealed the facility only received one medication delivery on 6/15/2024 and the driver left the pharmacy at approximately 6:30 PM, delivering the medications for Resident #3 at 10:54 PM to the facility.

Based on record review, family interview, and staff interview the facility failed to notify a responsible party after a resident fell , sustained a head injury, and was transferred to the hospital for one (Resident #1) of one resident reviewed for notification of change in condition. Findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses some of which included dementia and a chronic progressive neurological disorder. Documentation in a nursing progress note by Nurse #1 dated 6/5/2024 but crossed out as created in error revealed Resident #1 fell at an exit door hitting his forehead and was sent to the hospital. The documentation also revealed the power of attorney for Resident #1 was notified. Documentation on a hospital emergency department visit for Resident #1 dated 6/5/2024 revealed Resident #1 arrived in the emergency room at 4:12 AM from the nursing home with no identifying information. Nurse #1 was interviewed on 6/19/2024 at 1:19 PM. Nurse #1 explained she called 911 and when she went to look at the laptop on her medication cart to print out information to send Resident #1 to the hospital, she realized the electronic medical record was not available. Nurse #1 explained she did not have anything to send with Resident #1 when Emergency Medical Services (EMS) arrived. Nurse #1 stated she explained to EMS that she did not have access to any electronic medical records, but she did tell them the name of Resident #1. Nurse #1 also requested EMS take Resident #1 to the hospital he was admitted from as they would have his prior medical information on file. Nurse #1 stated after Resident #1 left with EMS to the hospital, a family member called the facility to check on the status of Resident #1. Nurse #1 revealed she told the family member about Resident #1 falling at the facility and being sent to the hospital with a head injury because prior to that she did not have access to emergency contact information from the electronic medical record. A family member of Resident #1 was interviewed on 6/19/2024 at 2:56 PM. The family member stated on 6/5/2024 at approximately 5:00 AM in the morning the hospital called her and told her they thought Resident #1 was in their emergency room with a head injury. The family member said she was doubtful because she did not receive any phone call from the facility, but as the emergency room physician described Resident #1 there was no doubt in her mind it was Resident #1. The family member called the facility to inquire about Resident #1 after which she was notified the facility computer system was down and they did not have access to her phone number to notify her prior to sending Resident #1 to the hospital. An interview was conducted with the [NAME] President of Operations on 6/20/2024 at 2:24 PM. The [NAME] President of Operations explained the facility nursing staff had access on the desk top computers to all the medical information required to send a resident to the hospital on a backup electronic medication administration record. The [NAME] President of Operations stated he would have to check on where and how the nursing staff would access the contact information for a responsible party if the electronic medical record could not be accessed, as this information was not located on the backup electronic medication administration record.

Based on record review, family interview, staff interviews, and hospital admission records the facility failed to send written documentation with identifying information, medication list, physician contact information, and responsible party contact information in an emergency transfer to the hospital for one (Resident #1) of one resident reviewed for hospital transfers. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses some of which included dementia and a chronic progressive neurological disorder. Documentation in nursing progress note by Nurse #1 dated 6/5/2024 but crossed out as created in error revealed Resident #1 fell at an exit door hitting his forehead and was sent to the hospital. Nurse #1 was interviewed on 6/19/2024 at 1:19 PM. Nurse #1 explained she called 911 and when she went to look at the laptop on her medication cart to print out information to send Resident #1 to the hospital, she realized the electronic medical record was not available. Nurse #1 explained she did not have anything to send with Resident #1 when Emergency Medical Services (EMS) arrived. Nurse #1 stated she explained to EMS that she did not have access to any electronic medical records, but she did tell them the name of Resident #1. Nurse #1 also requested EMS take Resident #1 to the hospital he was admitted from as they would have his prior medical information on file. Nurse #1 stated after Resident #1 left with EMS to the hospital, a family member called the facility to check on the status of Resident #1. Nurse #1 revealed she told the family member about Resident #1 falling at the facility and being sent to the hospital with a head injury because prior to that she did not have access to emergency contact information from the electronic medical record. Nurse #3 was interviewed on 6/19/2024 at 3:38 PM. Nurse #3 explained she was working as a nurse on another hallway in the facility on 6/5/2024 when Resident #1 fell . Nurse #3 stated she became aware of the electronic medical record system being down after Nurse #1 told her. Nurse #3 explained when EMS arrived, they were told EMS the name of Resident #1, and requested to take him back to the hospital he was admitted to the facility from. Nurse #3 stated Nurse #1 went to the medication cart and quickly looked through the medication cards to give confirmation to EMS that Resident #1 was not on any anticoagulants. Nurse #3 stated the hospital was called after EMS left the facility with Resident #1 to verbally confirm who the facility sent to the hospital. Documentation on an emergency department to hospital admission for Resident #1 dated 6/5/2024 revealed Resident #1 arrived in the emergency room with a head injury from the facility with no identifying information. Documentation in the hospital record under history of his present illness revealed Resident #1 was found by EMS to not open his eyes, to not respond to commands, and with garbled intelligible speech. The hospital record documented in the admission information, they had no confirmation of what medications Resident #1 was ordered to have and no referring provider information. A family member of Resident #1 was interviewed on 6/19/2024 at 2:56 PM. The family member stated on 6/5/2024 at approximately 5:00 AM in the morning the hospital called her and told her they thought Resident #1 was in their emergency room with a head injury. The family member said she was doubtful because she did not receive any phone call from the facility, but as the emergency room physician described Resident #1 there was no doubt in her mind it was Resident #1. The family member called the facility to inquire about Resident #1 after which she was notified the facility computer system was down and they did not have access to her phone number to notify her prior to sending Resident #1 to the hospital. An interview was conducted with the Director of Nursing (DON) on 6/19/2024 at 2:21 PM. The DON stated she received a phone call in the early morning hours notifying her of the fall sustained by Resident #1 and the electronic medical record system was down. The DON stated the Assistant DON came directly to the facility to resolve the issues with the electronic medical record system. The DON stated it was her expectation that the nursing staff notify her immediately so any issues with the electronic medical record system could be resolved. An interview was conducted with the [NAME] President of Operations on 6/20/2024 at 2:24 PM. The [NAME] President of Operations stated the facility already had a backup system in place when the electronic medical record system was down, but more training of the licensed nursing staff had been put into place on how to access the backup system after the 6/5/2024 hospital transfer for Resident #1. The [NAME] President of Operations revealed the following information as the back up plan for when the electronic medical record system was down for longer than 5 minutes. The licensed nursing staff will call nursing administration at the phone numbers posted at each nursing station. Information technology assistance will be contacted. The licensed nursing staff will access the backup electronic medication record on the desk top computers located at each nursing station. The [NAME] President of Operations provided an example of an electronic medication record to demonstrate diagnoses, medication orders, code status, and physician name will be available for each resident on the back up electronic medication administration record. The [NAME] President of Operations stated the phone numbers for the resident's physician was posted at each nursing station for easy availability. The facility provided a performance improvement plan initiated on 6/6/2024. The issue identified by the facility was the nursing staff did not access the Southern Healthcare Management (SHCM) electronic medication administration record (e MAR) back up system for Resident #1 prior to sending him to the hospital for evaluation after a fall. All residents have the potential to be affected by this deficient practice. The Director of Nursing and/or designee will complete audits of each SHCM e MAR back up system to ensure each computer was accessible to e MAR and had the availability to print. The e MAR in the backup system contains the medication orders, diagnoses, physician name, resident name, and code status. The licensed nurses were provided re-education by the DON or designee on 6/6/2024 regarding how to contact nursing administration, call information technology support, and access the e MAR back up system. Specific directions on what to do if there was an interruption of internet service or the electronic medical record system was down for more than 5 minutes was posted at each nursing station on 6/6/2024. The licensed nursing staff were educated on the following already existing process for an interruption of the electronic medical record system. In the event of an internet service interruption and/or [Electronic Medical Record System name] downtime, MAR and TAR (treatment administration record) PDF (portable document format) files can be accessed from the eMAR Back up desktops located at the nursing stations and labeled with the machine name and number. These devices should be connected to a local printer supported by generator power for printing purposes. The files can also be saved to a thumb drive/USB (universal serial bus) and inserted directly into a printer supported by generator power if needed. New or agency licensed nurses will be provided the education during orientation. As of 6/6/2024, this education will be completed by the Director of Nursing or designee. Effective 6/8/2024, the DON and/or designee will review e MAR backup computers weekly. The DON will report the results of the audits to the Quality Assurance Improvement Committee for 2 months. The Committee will review the results to determine if further action is needed. Alleged date of compliance: 6/7/2024 The plan was validated for the alleged date of compliance of 6/7/2024 on 6/20/2024. Interviews were conducted with licensed nursing staff to confirm education was provided on what steps to take if the electronic medical record system goes down, how to access the e MAR back up system on the desktop computers, and the knowledge was retained. Observations were made of the instructions posted at each nursing station detailing the steps to take if the electronic medical record system was not available for access. Documentation of in-service records dated 6/6/2024 and audits to ensure the backup computers were working properly functioning dated 6/6/2024, 6/13/2024, and 6/17/2024 were reviewed.

Based on record review, staff interviews, Physician Assistant interview, and Responsible Party (RP) interview, the facility failed to notify the RP when an antidepressant medication was discontinued for 1 of 1 resident reviewed for notification of change (Resident #12). The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. A physician order dated 8/18/23 for Resident #12 indicated sertraline (an antidepressant medication) 12.5 milligrams (mg) one time a day for depression. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #12 had severe cognitive impairment and was not coded for behaviors. Resident #12 was coded for depression and use of an antidepressant medication. A Physician Assistant (PA) visit progress note dated 11/29/23 revealed Resident #12's sertraline (antidepressant medication) would be discontinued because her mood was stable. There was no documentation regarding Resident #12's RP notification of the discontinuation of the antidepressant medication by the PA. A physician order dated 11/29/23 indicated Resident #12's sertraline 12.5 mg was discontinued. A PA progress note dated 1/1/24 revealed staff and family reported Resident #12 had agitation following discontinuation of the antidepressant medication (sertraline). The PA reported the antidepressant would resume at previous dose. A physician order dated 1/01/24 for Resident #12 indicated sertraline 12.5 mg daily for depression. A PA progress note dated 1/02/24 revealed Resident #12's RP was called to discuss reported concerns. The PA noted that Resident #12's RP reported she did not want the antidepressant medication to be discontinued in the future and the PA noted she would not recommend dose reduction of the antidepressant in the future. An interview was conducted on 01/10/24 11:29 am with the Physician Assistant, who revealed based off her clinical judgement and the reduce medication burden, she discontinued Resident #12's antidepressant medication. The PA stated she observed Resident #12 to be stable and she did not get any feedback from staff that she was experiencing any depressive symptoms. Therefore, she discontinued the antidepressant medication on a trial basis. The PA stated she did not notify Resident #12's RP of the decision to discontinue the antidepressant medication and she believed it was the nurses' responsibility to notify the RP of medication changes. Record review of the nursing progress notes from 11/29/23 through 1/1/23 revealed no documentation that Resident #12's RP was notified the antidepressant medication was discontinued. A telephone interview was conducted on 1/09/24 at 10:21 am with Resident #12's RP who revealed the facility stopped Resident #12's antidepressant medication that she had taken for the past [AGE] years, and the facility did not notify her of the change. Resident #12's RP stated she visited with Resident #12 six days a week and had not been notified of the discontinuation of the antidepressant medication during any of her in person visits or via phone by any staff at the facility. The RP stated Resident #12 experienced increased anxiety and behaviors after the medication was stopped. The RP further stated had the facility contacted her prior to stopping the medication or when the medication was stopped, she would have told them not to stop the medication. An interview was conducted on 1/10/24 at 1:25 pm with Nurse #1 who revealed the Unit Manager (UM) normally notified the RP of any medication changes. Nurse #1 stated that the normal process was when the UM was notified of a medication change by either a conversation with the PA or when the order was entered/verified in the medical record, they would notify the RP. During an interview on 1/10/24 at 1:27 pm with Nurse #2 she revealed she had worked at the facility for approximately 1 year and she stated the Unit Manager was the person that should have notified Resident #12's RP of medication changes. An interview was conducted with the current Unit Manager on 1/10/24 at 1:30 pm who revealed she was new to the facility and did not work at the facility when Resident #12's antidepressant medication was discontinued. The Unit Manager was unable to state why Resident #12's RP was not notified of the discontinuation of the antidepressant medication. An attempt to conduct a telephone interview with the previous Unit Manager on 1/10/24 at 9:00 am was unsuccessful. An attempt to interview the previous Director of Nursing on 1/10/24 at 9:03 am was unsuccessful. A telephone interview was conducted on 1/11/24 at 11:34 am with the Administrator who revealed Resident #12's RP should have been notified of the discontinuation of the antidepressant medication either by phone or in person and a note should have been entered in the medical record that the notification was completed. The Administrator stated during the morning clinical meeting medication changes were reviewed and progress notes were checked to make sure notification was made, but she was unable to state why Resident #12's RP was not notified of the discontinuation of the antidepressant medication.

Based on record review and interviews with staff the facility failed to include documentation in the resident's medical record to reflect education was provided regarding the benefits and potential side effects associated with vaccines for 2 of 5 residents reviewed for COVID-19 vaccination status (Resident #58 and #59). The findings included: Review of the facility's policy titled, COVID-19 Vaccine revised on 10/2/23 read in part: Residents and their representatives have the right to refuse the COVID-19 vaccine in accordance with Resident Rights requirements .The resident's medical record will include documentation that indicates, at a minimum, that the resident or resident representative was provided education regarding the benefits and potential side effects of the COVID-19 vaccine, and that the resident (or representative) either accepted and received the COVID-19 vaccine or did not receive the vaccine due to medical contraindications, prior vaccination, or refusal. 1a. Resident #58 was originally admitted to the facility on [DATE] with diagnoses that include autism, white matter disease, and developmental disorder of speech and language. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58's cognition was severely impaired. Review of Resident #58's medical records revealed no immunization documentation was included to reflect the Responsible Party (RP) or resident were provided education on the benefits and potential side effects of administering the COVID-19 vaccines or if the vaccine was contraindicated, administered, or refused. 1b. Resident #59 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include stroke, congestive heart failure, and hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59's cognition was intact. Review of Resident #59's medical records revealed no immunization documentation was included to reflect the Responsible Party (RP) or resident were provided education on the benefits and potential side effects of administering the COVID-19 vaccines or if the vaccine was contraindicated, administered, or refused. During an interview with the [NAME] President of Operations on 1/10/24 at 2:37 PM, he revealed that the current Director of Nursing (DON) provided the COVID-19 vaccination education information to Residents #58 and #59 in January 2023. However, there was not any documentation in their medical records to reflect this. An interview was conducted with the Infection Preventionist (IP) on 1/10/24 at 3:43 PM. She revealed that for all new admissions, admitting nurse was expected to offer all vaccination consents/refusals, and the IP would follow-up with the resident within 24 hours. The previous IP could not administer vaccinations because he was not a nurse. The IP indicated that all vaccination refusals with education provided should have been documented in the medical record. The Administrator was interviewed on 1/11/24 at 11:31 AM, and she revealed that there was a designee for new admissions (IP or Nurse) to gain the COVID-19 vaccine consent/declination form. If the resident was not alert and oriented, then the responsible party (RP) would be contacted. The Nurse would administer the COVID vaccine if consented. If the vaccine was declined, education would be provided to the resident/RP about the risks/benefits and sign the declination form. A witness would also have signed, and the document would be uploaded to the resident's medical record. The COVID vaccines were offered to Residents #58 and #59 by Nurse #1, who said that there were a lot of vaccine forms being offered at one time, and some of the papers were mistakenly lost. The declination forms for Residents #58 and #59 could not be found.

Based on record review and staff interviews, the facility failed to notify the Ombudsman in writing of the residents transfer to the hospital for 6 of 6 residents reviewed for hospitalization (Resident #67, Resident #71, Resident #16, Resident #65, Resident #61, and Resident #41). a. Resident # 67 was admitted to the facility on [DATE]. The nursing progress noted dated 11/10/23 at 3:42 pm revealed Resident # 67 was transferred to the hospital and returned to the facility on [DATE]. Review of Resident #67's progress notes revealed there was no notification the Ombudsman was notified of the transfer to the hospital on 11/10/23. b. Resident #71 was admitted to the facility on [DATE]. The nursing progress noted dated 10/27/23 at 3:42 pm revealed Resident # 71 was transferred to the hospital and did not return. Review of Resident #71's progress notes revealed there was no notification the Ombudsman was notified of the transfer to the hospital on 10/27/23. c. Resident # 16 was admitted to the facility on [DATE]. The nursing progress noted dated 11/30/23 at 3:42 pm revealed Resident # 16 was transferred to the hospital and returned to the facility on [DATE]. Review of Resident #16's progress notes revealed there was no notification the Ombudsman was notified of the transfer to the hospital on 11/30/23. d. Resident # 65 was admitted to the facility on [DATE]. The nursing progress noted dated 12/23/23 at 9:52 am revealed Resident # 65 was transferred to the hospital and returned to the facility on [DATE]. Review of Resident #65's progress notes revealed there was no notification the Ombudsman was notified of the transfer to the hospital on 12/23/23. 45045 e. Resident #61 was admitted to the facility on [DATE]. The nursing progress note dated 6/12/23 at 12:48 am revealed Resident #61 was transferred to the hospital. Resident #61 was transferred to the hospital during the previous shift on 6/11/23 and returned to the facility on [DATE]. The nursing progress note dated 7/09/23 at 3:00 pm revealed Resident #61 was transferred to the hospital. Resident #61 was transferred to the hospital on 7/09/23 and returned to the facility on [DATE]. The nursing progress note dated 9/19/23 at 10:32 pm revealed Resident #61 was transferred to the hospital. Resident #61 was transferred to the hospital on 9/19/23 and returned to the facility on [DATE]. Review of Resident #61's progress notes revealed there was no documentation that the Ombudsman was notified of the transfers to the hospital on 6/11/23, 7/09/23, and 9/19/23. 43222 f. Resident #41 was readmitted to the facility on [DATE]. The nursing progress note dated 12/15/23 at 1:11 PM revealed Resident #41 was transferred to the hospital from an outpatient appointment. Resident #41 was transferred to the hospital on 12/15/23 and returned to the facility on [DATE]. Review of Resident #41's progress notes revealed there was no documentation that the Ombudsman was notified of the transfers to the hospital on 12/15/23. The [NAME] President (VP) of Operations was interviewed on 1/10/24 at 4:30 PM, and he revealed that the written notification to the Ombudsman upon transfer to the hospital was not able to found for Resident #67, Resident #71, Resident #16, Resident #65, Resident #61, and Resident #41. During a follow-up interview with the VP of Operations on 1/11/24 at 9:09 AM, he revealed that the Social Services Manager would email a copy of the discharge list to the Ombudsman at least monthly. He stated that the expectation was for the SSM to keep a copy of those notices. The VP of Operations indicated that he had contacted the Ombudsman directly, and they notified him that they had not received any documentation of discharges since July 2023. Attempts were made to contact the Social Services Manager, but she was unavailable during the investigation. The Administrator was interviewed on 1/11/24 at 11:36 AM, and she revealed that the Social Services Manager was supposed to notify the Ombudsman via fax or email of discharges/transfer notices monthly. That documentation should be kept in a record in the Social Services Manager's office. A copy of the transfer notification was usually sent with the resident upon transfer, or mailed if the resident was not present in the facility, which would also have been documented by the Social Services Manager.

Based on record review, staff, friend, Nurse Practitioner, Physician Assistant and Medical Director interviews, the facility failed to monitor 1 of 1 resident (Resident #1) when her blood sugar was dangerously high, 544 milligrams per deciliter (normal blood sugar levels are considered to be between 70mg/dL (milligrams per deciliter) to 100mg/dL). Fast-acting insulin (Humalog insulin 12 units) was administered to Resident #1 by Nurse #1 on 8/5/23 at 5:47 PM. On 8/5/23 at 9:00 PM Nurse #1 found Resident #1 unresponsive, and her blood sugar was 33mg/dL, critically low. Resident #1 was transferred to the Emergency Department unresponsive and was intubated and admitted to the Intensive Care Unit (ICU). Immediate Jeopardy began on 8/5/2023 when Nurse #1 failed to monitor Resident #1 after she had a dangerously high blood sugar. Immediate Jeopardy was removed on 8/10/2023 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D to ensure education is completed and monitoring systems put in place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, and Type 2 diabetes. On 7/7/2023 an order for Insulin Glargine Subcutaneous Solution 100 unit/milliliter (a long-acting insulin with effects generally beginning an hour after injection and lasts 24-36 hours) to inject 12 units subcutaneously one time a day at 6:00 AM for Diabetes Mellitus hold if blood sugar less than 100. On 7/10/2023 an order for Insulin Lispro Injection Solution 100 unit/milliliter, (a fast-acting insulin that starts to work about 15 minutes after injection) was received with the following guidelines: Inject per sliding scale if blood glucose 150-200 = 2 units, 201-250 = 4 units, 251-300 = 6 units, 301-350 = 8 units, 351 - 400 = 10 units subcutaneously before meals and at bedtime. Call Physician if blood sugar less than 70 or greater than 400. Resident #1 had an order for blood glucose checks to be performed before meals and at bedtime. Resident #1's care plan revised on 7/10/2023 was reviewed and contained the following information: Resident #1 had an altered endocrine system status related to diabetes with a goal to maintain blood glucose values within normal limits for the resident. The interventions included: labs/diagnostics as ordered, medications/treatments as ordered, monitor for signs and symptoms of hyperglycemia: increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing, acetone (fruity) breath, stupor, coma. Monitor for signs and symptoms of hypoglycemia: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. The Admission Minimum Data Set, dated dated dated [DATE] indicated that Resident # 1 was cognitively intact, and Resident #1 had received insulin injections 6 days out of the last 7 days and was receiving renal dialysis. A review of the Medication Administration Record revealed: - On 8/3/2023 Resident #1's blood glucose at 5:21 AM was 215mg/dL and she received 4 units of Lispro insulin, her blood sugar was rechecked at 8:27 AM and noted to be 98 mg/dL. At 11:52 AM Resident #1 blood glucose was 248 mg/dL and received 4 units of Lispro insulin and at 4:36 PM noted blood glucose to be 131 mg/dL and no insulin was given and at 8:31 PM her blood glucose was 152 mg/dL and received 2 units of Lispro insulin. - On 8/4/2023 Resident #1's blood glucose level at 5:10 AM was 242 mg/dL and Resident #1 received Lispro insulin 4 units. At 9:38 AM her blood glucose level was rechecked and was 207 she received no insulin, her blood glucose level was rechecked again at 10:09 AM and was 207 mg/dL, she received 4 units of Lispro insulin. At dinner time Resident #1 was out of the facility, at 9:20 PM Resident #1's blood glucose level was 201 mg/dL and she received 4 units of Lispro insulin. - On 8/5/2023 included at 6:16 AM the blood glucose was 133 mg/dL Resident #1 refused her morning Glargine insulin and received no Lispro insulin, at 12:12 PM blood glucose was 233 mg/dL and Resident #1 received 4 units of Lispro insulin, at 5:35 PM blood glucose was 544 mg/dL and Resident #1 received 12 units of Lispro insulin and at 9:00PM the blood glucose was 33 mg/dL. Nursing progress note dated 8/5/2023 at 5:35 PM written by Nurse #1 read in part, Resident #1's blood glucose level was 544mg/dL. Nurse #1 did not document any signs of hyperglycemia at that time. According to the note, Nurse #1 called telehealth Physician and received an order for a one-time dose of Humalog insulin 12 units to be given subcutaneously. A review of the Physician orders noted an order dated 8/5/2023 for Lispro insulin 12 units subcutaneously for one dose. A nursing progress note dated 8/5/2023 at 9:42 PM revealed that at 9:00 PM Nurse #1 went into Resident #1's room to administer Resident #1's medication and check her blood glucose as ordered and noted Resident #1 was unresponsive Nurse #1 checked Resident #1's blood glucose level and noted it to be 33 mg/dL. Nurse #1 then gave Resident #1 Glucagon (a hormone made by the pancreas that raises blood glucose levels. A manmade version is used to treat very low blood glucose levels in people with diabetes) IM (intramuscular) twice and called Emergency Medical Services. Resident #1 was then transferred to the hospital. A record review of Physician progress notes noted an addendum to the Telehealth Physicians progress note dated 8/5/2023 included the order to recheck the blood glucose level of Resident #1 in one hour and changed the insulin to be given from Novolog to Humalog. A review of the hospital records dated 8/5/2023 revealed the Resident #1 presented for concern for unresponsiveness and hypoglycemia. Shortly after arrival Resident #1 went from sonorous respirations (a production of loud, harsh, or vibrating sounds during breathing typically caused by the partial obstruction of the airway) to prolonged episodes of apnea (a temporary cessation of breathing). With bag-valve-mask Resident #1 did improve her spontaneous respirations however, any cessation of bag-valve-mask ventilation resulted in apnea again within 60 seconds. Resident #1 was noted to have a blood sugar of less than 10 mg/dL however after receiving 2 ampules of D50 (used to treat low blood glucose levels) the blood glucose was rechecked and noted to be 395 mg/dL. Resident #1 was euglycemic (a blood glucose less than 11 millimoles per liter) for at least several minutes with a Glasgow Coma Scale (a scale used to objectively describe the extent of impaired consciousness) never improving above 8 (considered to have suffered a severe head injury) and Resident #1 continued to episodes of apnea. Resident #1 was then intubated (a tube is inserted through the mouth down into the windpipe so air can get through) for airway protection and placed on a ventilator. Resident #1 was then admitted into the Intensive Care Unit. On 8/10/2023 Resident #1 was taken off the ventilator and her breathing tube removed but remained in the Intensive Care Unit. A telephone interview was conducted on 8/9/2023 at 10:46 AM with Resident #1's Friend revealed that she was on the phone with Resident #1 at approximately 6:00 PM on 8/5/2023 and Resident #1 had told her that she was not feeling well that she felt like her blood sugar was low. Friend #1 stated that Resident #1 had been a diabetic for a long time and could usually tell when her sugar was going low. Resident #1's Friend later revealed that Resident #1 had told her that she had turned on the call light so that staff could check her blood sugar. Friend #1 stated they talked for a while longer, approximately 20 minutes, and the staff had not been in the room before they hung up. A telephone interview was conducted with Telehealth Physician on 8/9/2023 at 3:08 PM indicated that she remembered receiving a call regarding Resident #1's blood glucose level and had ordered 12 units of Humalog. The Telehealth Physician also revealed that she had told Nurse #1 to recheck Resident #1's blood glucose level in one hour. The Director of Nursing was interviewed on 8/9/2023 at 12:30PM. The Director of Nursing indicated that she expected the blood glucose level to be checked in 1 1/2 to 2 hours after giving insulin for hyperglycemia from a physician's order. She further revealed that monitoring was needed to ensure that the medication was lowering the blood glucose level as expected and to ensure the resident was responding appropriately. An interview with Nurse Practitioner, who works daily in the facility and had stated that she had seen Resident #1 the previous week, was completed on 8/9/2023 at 1:30 PM revealed that the expectation was that a blood sugar was checked again after receiving and order to give insulin in 30 minutes to 1 hour to ensure that the blood glucose level was responding by decreasing in mg/dL. The Nurse Practitioner further stated that it is possible for a blood glucose to continue to rise even with the insulin given and it was important to recheck the blood glucose to ensure the insulin given was effective. A phone interview with Nurse #1(an agency nurse) on 8/9/2023 at 2:12 PM revealed that on 8/5/2023 at 5:35 PM when Nurse #1 checked Resident #1's blood glucose level it was 544 mg/dL, she did not verify the results by repeating the blood glucose check. Nurse #1 then called Telehealth and spoke with the Physician who gave an order for Humalog 12 units one time, she then administered the medication at 5:47 PM. At 9:00 PM she went into Resident # 1's room and noticed Resident #1 did not respond to voice or touch, her eyes were closed, and she sounded like she was snoring when breathing. Nurse #1 stated that she remembered giving the fast-acting insulin (Humalog) earlier so immediately checked Resident #1's blood glucose level and noted it was 33 mg/dL. She reported she gave Resident #1 Glucagon. Nurse #1 further stated that at the time she was just trying to make sure that Resident #1 did not die because her blood sugar was so low. Nurse #1 stated that she contacted Resident #1's Physician after Resident #1 left with Emergency Medical Services. Nurse #1 further revealed that she had not checked the blood glucose level at any time after giving the initial 12 units and checking the blood glucose at 9:00 PM. An additional phone interview with Nurse #1 on 8/10/2023 at 10:12 AM indicated that she gave Glucagon two times, without checking the blood glucose level in between injections and stated that she knew that for a low blood glucose level that Glucagon was given. Nurse #1 further revealed that she had not checked the blood glucose level at any time after giving the initial 12 units of Humalog and checking the blood glucose at 9:00 PM. Nurse #1 stated that she did not have an order to recheck Resident #1's blood glucose after administrating the 12 units of fast-acting insulin. Nurse #1 stated her normal practice was to check a blood glucose whenever it was ordered and that she did not have an order to obtain one prior to the bedtime order so she did not check Resident #1's blood glucose until then. Nurse #1 stated that she gave Glucagon twice due to Resident #1's blood glucose being so low. A phone interview conducted on 8/15/23 at 3:07 PM with Nurse #1 clarified that that Nurse #1 did not ask the assigned Nursing Assistant to tell Nurse #1 how Resident #1 ate that evening. Nurse #1 stated that she looked for the Nursing Assistant after dinner, however she did not see him and got busy and never asked him. Nurse #1 further revealed that there were no obvious signs of hyperglycemia when Resident #1 had the blood glucose level of 544 mg/dL that Resident #1 was talking to her as she normally did and had no requests or complaints while Nurse #1 was in the room. Nurse #1 stated that she did not see or look at Resident #1 after giving Resident #1 the 12 units of fast-acting insulin (5:47 PM) until shewent to Resident #1's room to do her nightly medication administration and blood glucose level monitoring at 9:00 PM. Nurse #1 revealed she checked Resident #1's blood glucose level in between administering the Glucagon and Resident #1's blood glucose level was then 32 mg/dL so Nurse #1 administered a second Glucagon injection. Nurse #1 stated she did not know why she said before that she had not checked the blood glucose in between the two Glucagon injections indicating that she was just nervous. She reported there was no documentation of the blood glucose levels being obtained in between the Glucagon injections. An interview was conducted with Nursing Assistant #1 on 8/9/2023 at 2:24 PM who stated he worked the 3:00 PM to 11:00 PM shift on 8/5/2023 and was assigned Resident #1. He stated he delivered and picked up Resident #1's dinner tray and that Resident #1 turned on her light one time that shift to be repositioned. Nursing Assistant #1 could not recall any other details about the time Resident #1 turned on her call light. Nursing Assistant #1 stated that Resident #1 did not tell him that she did not feel good at that time. He further stated that he could not remember what Resident #1 ate for her evening meal on 8/5/2023 but he had documented it. He added that he had not passed out bedtime snacks prior to Nurse #1 going into the room on 8/5/2023 at 9:00 PM. Nursing Assistant #1 further revealed that Nurse #1 had not asked him to monitor Resident #1 for any reason or give him symptoms to watch for. A review of activity of daily living documentation for 8/5/2023 revealed that Resident #1 had eaten 0-25% of her evening meal. An interview with the Physician Assistant who worked at the facility one day a week and had assessed Resident #1 previously, was completed on 8/9/2023 at 3:30 PM. The Physician Assistant indicated that a reasonable expectation was that the nurse would recheck the blood glucose after the nurse received an order to administer insulin within a time frame of 30 minutes to an hour to ensure that the intervention was effective. Physician Assistant further explained that at times a blood glucose would continue to increase even with insulin given or could decrease more rapidly than anticipated which is why monitoring the blood glucose level was important. On 8/17/2023 at 2:29 PM a phone interview was completed with the Medical Director who stated that 2 extra units of insulin would not have caused this to escalate to lower her blood sugar. He stated that he would have not given an order to re-check the blood glucose. He indicated he expected the nurse to give the insulin as ordered and then expected the nurse to recheck the blood glucose at the next scheduled time and that in this case it was bedtime. The physician also stated the Department of Health and Human Services, and the Centers for Medicare and Medicaid Services were recommending not to use the blood glucose as a monitoring system but to monitor the Hgb A1c (a test which tells the average level of blood glucose over the past two to three months) and use that for recommendations for insulin management. The facility Administrator was informed of Immediate Jeopardy on 8/15/2023 at 6:13 PM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 8/5/2023 at 5:47pm, Resident #1's blood glucose level was obtained by Nurse #1. Blood glucose level was 544. Nurse #1 contacted the medical provider. An order was received to administer 12 units of fast-acting insulin to Resident #1. Nurse #1 did not return to Resident #1's room until 9:00pm at which time she checked Resident #1's blood glucose level. At 9:00pm, Nurse #1 entered Resident #1's room to find Resident #1 unresponsive. Nurse #1 immediately checked blood glucose level, which was 33. Nurse #1 administered Glucagon. Nurse #1 (agency nurse) rechecked the blood glucose level after approximately 10 minutes, blood glucose level was 32. Nurse #1 administered glucagon again. Resident #1 remained unresponsive. Nurse #1 called 911 at approximately 9:15pm. Resident #1 was sent to the ER (emergency room ) for evaluation and treatment. Based upon review of hospital records upon arrival to the ER, Resident #1's blood glucose level was less than 10mg/dl. Resident #1 was intubated and placed on a ventilator. Resident #1 was admitted into the Intensive Care Unit for hypoglycemia and respiratory failure. All diabetic residents who require insulin are at risk for not being monitored after insulin is given for a critically high blood glucose level therefore the facility has established interventions to address this risk. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: An Ad Hoc (Quality Assurance Performance Improvement) QAPI meeting was conducted on 8/9/2023 by the QAPI Committee (Administrator, Director of Nursing (DON), Social Service Manager, Infection Prevention Control Officer, Minimum Data Set (MDS) Coordinator, Therapy Manager, Unit Manager(s), Business Office Manager, Medical Director (via phone) and Corporate - Director of Clinical Services to discuss this event and plan to address the event. Based upon record review and staff interview(s) the QAPI Committee has identified the following root cause of the event: - Nurse #1 failed to monitor a high blood glucose level after 12 units of fast-acting insulin was administered to Resident #1 on 8/5/23 at 5:47 PM. Nurse #1 states she did not obtain a recheck of the blood glucose level because she did not receive an order from the Physician when she called concerning the blood sugar level being 544. Nurse #1 states she asked the physician after obtaining the order for the 12 units of insulin was there anything further orders. Nurse #1 states the physician said no. After Nurse #1 administered the insulin at 5:47pm, she did not complete an observation of Resident #1 until 9:00pm. Root cause: Nurse #1 failed to follow professional standards when she did not recheck blood glucose level after administering 12 units of fast acting insulin. On 8/9/23, Nurse #1 was provided one to one education by the Director of Nursing on the facility policy related to monitoring of diabetic residents after administration of fast acting insulin for any critically high blood glucose level. An emphasis was placed on ensuring residents are monitored closely. Monitoring should include obtaining a re-check of the blood glucose level (1 hour after administration of fast acting insulin (per professional standards and facility protocol) or based upon the physician order). On 8/9/23, education was initiated by the Director of Nursing and Unit Managers to all Licensed Nurses (including agency/contract nurses) related to the facility policy on hyperglycemia and hypoglycemia. To include obtaining blood glucose levels as needed for signs and symptoms of hypo/hyperglycemia. If insulin is given for critically high blood glucose levels, the nurse must ensure the resident is monitored after administration by obtaining a re-check of the blood glucose level per physician order or facility protocol (1 hour after administration). Monitor/document/report to provider PRN s/s of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination and staggering gait. If fingerstick blood sugar is less than 70 and resident is symptomatic give orange juice, apple juice or instant glucose and recheck blood sugar in 15 minutes. Notify provider if fingerstick blood glucose remains less than 70 after protocol being followed. If fingerstick blood glucose level is less than 40, give IM (intramuscular) glucagon and recheck blood glucose level in 15 minutes and notify provider for further orders. Newly Hired Licensed Nurses (including agency/contract nurses) will be educated during their orientation period regarding policy and protocol on hyperglycemia/hypoglycemia and monitoring of blood glucose levels after administering any fast acting insulin. On 8/9/23, an audit of current diabetic resident's medical record was conducted for past 72hrs by the Unit Manager(s) and DON to review for any critically high blood glucose levels to ensure proper monitoring was conducted after administering any fast acting insulin. After review, no further issues were identified. An audit of current diabetic residents was conducted on 8/9/23 by the DON and Unit Managers to include the following: - Parameters for MD notification and follow-up for all diabetic residents. - Insulin hyperglycemic and hypoglycemic orders to include monitoring and when to obtain a re-check of blood glucose level per facility protocol and/or physician order: 1. Blood glucose levels as needed for signs and symptoms of hypo/hyperglycemia 2. Monitor/document/report to provider PRN s/s of hypoglycemia: sweating, tremor, increased heart rate (tachycardia), pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. 3. If fingerstick blood glucose is less than 70 and resident is symptomatic give orange juice, apple juice or instant glucose, recheck blood glucose level in 15 minutes. Notify provider if fingerstick blood sugar remains less than 70 after protocol being followed. 4. If fingerstick blood glucose level less than 40, give IM (intramuscular) glucagon and recheck blood glucose level in 15 minutes and notify provider The Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged immediate jeopardy Removal Date: 8/10/23 The credible allegation for immediate jeopardy removal was validated onsite on 8/17/23. Staff interviews and record review verified licensed nurses were educated on the facility policy on hyperglycemia and hypoglycemia. This included signs and symptoms of hypo/hyperglycemia, what to do if signs/symptoms were observed, and how to respond to a critically high blood glucose level. An audit of current residents with diabetes' medical records was verified as completed by the Unit Manager(s) and DON. This included auditing the records to ensure any critically high blood glucose levels in the past 72 hours were monitored after administering any fast-acting insulin, ensure parameters for MD notification and instructions for follow-up for all diabetic residents were present, and that insulin hyperglycemic and hypoglycemic orders included monitoring and when to obtain a re-check of blood glucose level per facility protocol and/or physician order. The immediate jeopardy removal date of 8/10/23 was validated.

Based on record review, resident and staff interviews the facility failed to provide effective oversight and leadership to correct an identified issue of a resident (Resident #4) being discharged from the facility with another resident ' s medication (Resident #8). This discharge occurred on 4/6/23 and the facility was notified of the error by Resident #4 on 4/17/23. On 5/16/23 the error occurred again when Resident #2 was discharged with medication prescribed for Resident #6. This affected 2 of 4 sampled residents reviewed for discharge and had the high likelihood for serious adverse outcomes for any resident discharged from the facility. Immediate jeopardy began on 4/17/23 when Resident #4 notified the Administrator he had been discharged with another resident ' s medications and the administration did not investigate to ensure effective systems were in place to prevent reoccurence. The immediate jeopardy was removed on 6/23/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E, a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, to ensure monitoring of systems put into place related to the discharge planning process are effective and to complete staff training. The findings included: 1.Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes, hypertension, and osteoarthritis. Review of a nursing admission note dated 3/24/23 revealed Resident #4 was admitted to the facility for diabetic foot infection and short-term rehabilitation therapy. A telephone interview conducted with Resident #4 on 6/20/23 at 11:58AM, revealed he was discharged on [DATE] and Nurse #2 provided him with medications prescribed for another resident in addition to medications prescribed for him. Resident #4 indicated he had taken medications not prescribed for him for 2 days and began to feel bad, so he called Emergency Medical Services (EMS). It was at that time Resident #4 was informed some of the medications were not prescribed for him. Resident #4 called the facility on 4/17/23 and notified the Administrator he had been given another resident ' s medication. An interview was conducted with the Director of Nursing (DON) on 6/21/23 at 10:59 AM. The DON stated she had spoken with Resident #4 on the telephone on 4/17/23. The DON stated Resident #4 informed her that he had received another resident ' s medication in his discharge medication. The DON stated Resident #4 would not disclose the name of the resident whose medication he had. The DON stated Resident #4 told her to come to his home to pick up the medication. The DON stated she did not go to Resident #4 's home because she did not feel safe. The DON stated she was unable to complete a thorough investigation because Resident #4 would not give her the name of the medications nor the other resident ' s name. An interview was conducted with the Administrator on 6/21/23 at 4:18 PM. The Administrator stated she returned a call to Resident #4 on 4/17/23 to discuss the concern with the medication. She stated Resident #4 refused to give her the name of the Resident ' s medication and a grievance was completed detailing Resident #4 ' s concerns. The Administrator further stated the facility attempted to follow up on the resident ' s concerns but had limited information to complete the investigation. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with dialysis, Parkinson ' s disease and atrial fibrillation. Review of a nursing admission note dated 4/14/23 revealed Resident #2 was admitted to the facility with a diagnosis of debility and was admitted for short term rehabilitation therapy. Review of the Interdisciplinary Discharge Summary for Resident #2 dated 5/16/23 revealed Resident #2 was discharged due to completion of the clinical pathway. She had no sensory impairment and was able to make her needs know. Resident #2 was described as ready for discharge home with family. The discharge summary revealed Resident #2 was ambulatory and required a walker and wheelchair for mobility. The discharge summary indicated prescribed medications were given to the family to take home. An interview was conducted with Family Member #1 on 6/20/23 at 2:08 PM. Family Member #1 stated she had pulled Resident #2's medication from the bubble packs received from the facility on 5/16/23 and did not look at the name on the medication cards. Family Member #1 stated she had administered baclofen medication for three doses in two days when Resident #2 had facial, and tongue swelling and became unresponsive. Family Member #1 stated she called 911 and Resident #2 was admitted to the hospital on 5/19/23. Review of the hospital discharge summary dated 6/12/23 revealed Resident #2 revealed was admitted for a primary diagnosis of altered mental status and found to have baclofen toxicity secondary to incorrect prescription. Resident #2 (who was on dialysis) took the Baclofen and had an allergic reaction requiring hospitalization . Resident #2 was admitted to the hospital on 5/19/23 where she was treated for altered mental status (change in mental function), agitation (unable to relax), hypotension (low blood pressure), rigidity (stiffness) and dysphagia (difficulty swallowing). Resident #2 was discharged from the hospital on 6/12/23 with referrals for home health, physical therapy and occupational therapy. An interview was conducted with the Director of Nursing (DON) on 6/21/23 at 10:59 AM. The DON stated she received a call on 5/20/23 from Resident #2 ' s Family Member #1 asking if resident was on Baclofen. The DON stated she reviewed Resident #2 ' s medication orders and discovered she had not been prescribed Baclofen. The DON stated Resident #2 's Caregiver indicated she had given Resident #2 Baclofen and was not paying attention to the medication cards. The DON stated Family Member #1 informed her when she reviewed the medication cards, she discovered the Baclofen had another resident ' s name on it. The DON stated Resident #2 ' s family member further stated she had taken Resident #2 to the hospital because she was not acting like herself. During the interview the DON was asked to describe the facility ' s process for medication reconciliation at discharge. The DON stated when a resident was discharged the medications were removed from the medication cart by the nurse discharging the resident. This nurse was responsible for removing the medications from the medication cart and compared the discharge medication list with those removed. The DON stated she expected the nurse discharging the resident would review the medications with the resident at the bedside and obtain a signed copy of the discharge recapitulation. The DON stated an investigation was launched upon learning about Resident #2 receiving baclofen which was not on her discharge medication list. An interview was conducted with the Administrator on 6/21/23 at 4:18 PM. The Administrator stated the facility began an investigation once being notified about Resident #2 receiving the baclofen and being hospitalized . The Administrator stated the Interdisciplinary Team reviewed the systems in place for discharge medication reconciliation and addressed any identified issues by reeducating staff. The Administrator was notified of immediate jeopardy on 6/21/23 at 1:20 PM. The facility provided the following credible allegation of immediate jeopardy removal on 6/22/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to implement an effective discharge plan when 2 residents, Resident #2 and Resident #4 were discharged to the community with medications that were prescribed for other residents. On 4/6/2023, Nurse #2 provided Resident #4 with medications prescribed for discharged Resident #8 upon discharge to home for Resident #4. Resident #4 took 3 medications not prescribed for him for 2 days resulting in calling 911 related to not feeling well and being constipated. Resident #4 called the facility on 4/17/2023 and spoke with the Administrator and Director of Nursing (DON) regarding a concern that he was discharged with another Resident ' s medications, however Resident #4 refused to identify the resident or medication that he alleged he was in possession of. Administrator initiated a grievance for Resident #4 concerns. The facility did not implement a corrective action plan to address the identified issue with Resident #2 ' s discharge medications when informed on 4/17/23. On 5/19/2023, the DON received a call from Resident #2 ' s daughter who asked if Resident #2 had ever had an order for Baclofen. The DON checked previous orders and noted that Resident #2 was never on said medication. Resident #2 ' s daughter stated that she was giving medications to Resident #2 and was not paying attention and after medication was given to Resident #2, she noticed that Resident #6 ' s medication (Baclofen) was with the other medications sent home with them. On 5/16/2023 Nurse #1 gave medications prescribed for Resident #6 to Resident #2 in error upon discharge. The medications given in error included Baclofen 10 milligram (mg) that was a scheduled medication for Resident #6. On 5/19/23, Resident #2 was noted to be in hospital with stroke like symptoms post 3-day discharge from facility. Per hospital documentation Resident #2 suffered an allergic reaction to Baclofen. Per hospital documentation Baclofen was added as an allergy for future reference as her tolerance to Baclofen has a low threshold because of her dependence on hemodialysis. All residents have the potential to be affected when the facility administration fails to implement actions to correct identified issues of non-compliance. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 6/22/2023, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator, Director of Nursing, [NAME] President of Operations, Corporate Clinical Director and Regional Director of Clinical Services to discuss root cause analysis of the facilities failure to provide effective oversight and leadership. Root cause determined that the Administrator and Director of Nursing failed to implement corrective actions for identified areas of non-compliance. On 6/22/2023, Corporate Clinical Director and [NAME] President of Operations provided education to the Administrator and Director of Nursing on the QAPI committee role in maintaining compliance with F835. Specifically, as it relates to any identified quality issues. Any identified quality issues should have interventions established to avoid further non-compliance of deficient areas identified. Administrators and Director of Nurses will receive education upon hire during orientation. On 6/22/2023, after the Corporate Clinical Director and [NAME] President of Operations in-serviced the QAPI Committee, the facility QAPI Committee will continue to identify other areas of quality concern through the quality improvement (QI) review process, for example: Transfer/Discharge process and Pre/Post medication reconciliation. The QAPI was in serviced on their role as the QAPI committee in identifying concerns and acting upon them. QAPI committee consisted of: Administrator, Director of Nursing, Unit Managers, Social Worker, Dietary Manager, Maintenance Director, Therapy Manager, Activities Director, Business Office Manager, Heath Information Coordinator, MDS Coordinator and Medical Director (by phone). Effective 6/22/2023, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. The facility alleged removal of immediate jeopardy 6/23/2023. On 6/27/23 the facility ' s immediate jeopardy removal of 6/23/23 was validated onsite and included record review and staff interviews. Interviews with the administrative staff revealed they had received recent education regarding the discharge process, medication reconciliation prior to resident discharges, and bringing to QAPI identified concerns for possible actions. Documentation review included Administrator and Director of Nursing education on 6/21/23 along with education of other members of the Interdisciplinary Team (IDT) on 6/21/23. The education topics included discussing the root cause analysis, discharge policy and procedure review, identifying quality concerns, and the QAPI role in maintaining compliance. The immediate jeopardy was removed on 6/23/2023.

Based on record review, interviews with resident, family member, pharmacist, physician, and staff the facility failed to implement an effective discharge plan when 2 residents (Resident #2 and Resident #4) were discharged to the community with medications that were prescribed for other residents. On 4/6/23 Nurse #2 provided Resident #4 with medications prescribed for Resident #8 and on 5/16/23 Nurse #1 provided Resident #2 with medications that were prescribed for Resident #6. Resident #4 reported not feeling well and was assessed by Emergency Medical Services in his home with no negative outcome or treatment required. Resident #2 suffered an allergic reaction and was hospitalized for baclofen (a muscle relaxer) toxicity. Discharging residents with medications not prescribed for them had a high likelihood of resulting in serious harm. This deficient practice was identified for 2 of 4 residents reviewed for discharge to the community. The findings included: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes, hypertension, and osteoarthritis. Review of a nursing admission note dated 3/24/23 revealed Resident #4 was admitted to the facility for diabetic foot infection and short-term rehabilitation therapy. Resident #4 ' s care plan initiated 3/24/23 had a focus that Resident #4 wished to return home. The goal was for Resident #4 to verbalize/communicate required assistance post discharge and the services required to meet needs before discharge. The Admission/Medicare 5-day Minimum Data Set assessment dated [DATE] revealed Resident #4 ' s cognition was intact. The discharge medication list dated 4/6/23 included all the medications prescribed for Resident #4. During a telephone interview with Resident #4 on 6/20/23 at 11:58AM, he stated he was discharged on [DATE] and Nurse #2 provided him with medications prescribed for another resident in addition to medications prescribed for him. Resident #4 provided Resident #8 ' s name and reported the name of each medication with its dosage. The medications included: Meloxicam, (a nonsteroidal anti-inflammatory drug [NSAIDs]), 7.5 milligrams (mg) - 1 tablet by mouth two times a day for pain. Gabapentin (used with other medications to prevent and control seizures. It is also used to relieve nerve pain) 300 mg- 2 capsules by mouth at bedtime for pain; and Tizanidine (a skeletal muscle relaxant) 4 mg - Take 2 tablets by mouth at bedtime for pain. Resident #4 stated he took three medications not prescribed for him for two days. He indicated he didn ' t feel well and was constipated so he called 911.?Resident #4 stated Emergency Medical Services reviewed the cards of medication he reported he had taken. Emergency Medical Services (EMS) instructed Resident #4 not to take those medications as they were not prescribed for him. Resident #4 indicated he had not noticed there was a different name on the medication cards. Resident #4 stated he notified the Administrator at the facility on 4/17/23 that he had been given another resident ' s medication. Resident #4 stated he had asked someone from the facility to come and pick up the medications. According to drug information, the starting dose of Meloxicam is 7.5 mg., and the maximum dose is 15 mg. Adverse effects include cardiovascular thrombotic events and gastrointestinal bleeding, ulceration, and perforation. Common side effects for Gabapentin include sleepiness and dizziness. Some common side effects of Tizanidine are drowsiness, dizziness, dry mouth, weakness, and constipation. During a telephone interview with Nurse #2 on 6/20/23 at 2:08 PM, he stated the nurse caring for the resident was responsible for gathering the resident ' s medication for discharge from the medication cart. Nurse #2 stated he was assigned to Resident #4 at discharge. Nurse #2 stated he was unable to confirm if he had sent another resident ' s medication home with Resident #4. Nurse #2 stated all of Resident #4 ' s medications were removed from the medication cart and placed in a plastic bag. Nurse #2 indicated he had reviewed Resident #4 ' s medication list with him at the time of discharge. Nurse #2 stated he did not compare the medication list with the medications he removed from the cart. Review of a signed copy of the Post Discharge Plan of Care dated 4/6/23 included an attached list of discharge medications and prescriptions. During an interview with the Director of Nursing (DON) on 6/21/23 at 10:59 AM, she stated she had spoken with Resident #4 on the telephone on 4/17/23. The DON stated Resident #4 informed her that he had received another resident ' s medication in his discharge medication. The DON stated Resident #4 would not disclose the name of the medications or resident whose medication he had. The DON stated Resident #4 told her to come to his home to pick up the medication. The DON stated she did not go to Resident #4 ' s home because she did not feel safe. Further interview with the DON revealed that she spoke with Nurse #2, and he indicated he had not sent any other medications home with Resident #4. The DON stated medications were removed from the medication cart when a resident was discharged . The DON stated the nurse discharging the resident was responsible for removing the medications from the medication cart and compared the discharge medication list with those removed. The DON stated she expected the nurse discharging the resident would review the medication with the resident at the bedside and obtain a signed copy of the discharge recapitulation. The facility did not know which medications Resident #4 took home. He called the facility and told them he had another resident ' s medication mixed in with his but did not give them the name of the resident. The facility did not produce a copy of the medication return sheets for the dates of 4/5, 4/6 and 4/7. The DON stated she was not able to complete a thorough investigation because the resident would not give her the name of the medications nor the resident ' s name. An interview was conducted with the Medical Director on 6/21/23 at 8:54 AM. The Medical Director indicated he was made aware by the Administrator. Resident #4 had indicated he had gone home with another resident ' s medication. The Medical Director stated given Resident #4 ' s history of pain and osteoarthritis the medications would help with the pain. The Medical Director stated he did not feel the resident was in any immediate danger. The Medical Director stated the facility had initiated an investigation based on the reporting of Resident #2 receiving the wrong medication. An interview was conducted with the Pharmacist on 6/21/23 at 2:10 PM. The Pharmacist stated Meloxicam was a nonsteroidal anti-inflammatory drug (NSAID) and could cause gastrointestinal upset and bleeding with long-term use. She stated that Gabapentin and Tizanidine could both cause sedation. The Pharmacist stated Tizanidine could cause some constipation, but that side effect was highly unlikely with Gabapentin. The pharmacist stated that all pre-discharge medications were to be reconciled with the post discharge medications both prescribed and over the counter. An interview was conducted with the Administrator on 6/21/23 at 4:18 PM. The Administrator stated she returned a call to Resident #4 on 4/17/23 to discuss the concern with the medication. She stated Resident #4 refused to give her the name of the Resident ' s medication. The Administrator state she completed a grievance detailing Resident #4 ' s concerns. A Grievance Report dated 4/17/23 revealed Resident #4 had left a voicemail message for the Administrator regarding his concerns after discharge. The Summary Statement of the Grievance revealed Resident #4 was concerned that no one had returned his call from the previous week regarding medication. Steps taken to investigate the grievance revealed the Administrator verified with the DON that Resident #4 had called back to the facility the previous week to discuss medication concerns. The DON stated Resident #4 gave her limited information regarding the medications he reported were sent home. Resident #4 refused to give the DON the name of the resident whose medications he had received in error. The Administrator determined that the grievance was not confirmed. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease with dialysis, Parkinson ' s disease and atrial fibrillation. Review of a nursing admission note dated 4/14/23 revealed Resident #2 was admitted to the facility with a diagnosis of debility and was admitted for short term rehabilitation therapy. Resident #2 ' s care plan initiated 4/19/23 had a focus that Resident #2 was to return home with family. The goal was for Resident #2 to verbalize/communicate an understanding of the discharge plan and describe the desired outcome by the review date of 7/25/23. The Admission/Medicare 5-day Minimum Data Set assessment dated [DATE] revealed Resident #2 ' s cognition was intact. Review of the Interdisciplinary Discharge Summary for Resident #2 dated 5/16/23 revealed Resident #2 was discharged due to completion of the clinical pathway. She had no sensory impairment and was able to make her needs know. Resident #2 was described as ready for discharge home with family. The discharge summary revealed Resident #2 was ambulatory and required a walker and wheelchair for mobility. The discharge summary indicated prescribed medications were given to the family to take home. A review of Resident #2 ' s medical record did not reveal an order for baclofen. An interview was conducted with Family Member # 1 on 6/20/23 at 2:08 PM. Family Member # 1 stated she had pulled Resident #2 ' s medication from the bubble packs received from the facility on 5/16/23. Family Member #1 stated the facility did not review Resident #2 ' s medication with her prior to the resident discharging. Family Member # 1 stated she went to administer Resident #2 ' s medications the next day and did not look at the name on the medication cards. Family Member # 1 reported she gathered the medications according to the instructions on the medication card. Family Member # 1 stated she was aware there had been some recent changes to Resident #2 ' s medication so she didn ' t think anything of the baclofen medication. Family Member # 1 stated she had administered the baclofen medication for three doses in two days when Resident #2 had facial, and tongue swelling and became unresponsive. Family Member # 1 stated she called 911 and Resident #2 was admitted to the hospital on 5/19/23. During an interview with the Director of Nursing on 6/21/23 at 11:04 AM the DON stated she was told Resident #2 was going home with family upon discharge. The DON stated she received a call on 5/20/23 from Resident #2 ' s Family Member # 1 asking if resident was on Baclofen. The DON stated she reviewed Resident #2 ' s medication orders and discovered she had not been prescribed Baclofen. The DON stated Resident #2 ' s Caregiver indicated she had given Resident #2 Baclofen and was not paying attention to the medication cards. The DON stated the Caregiver informed her when she reviewed the medication cards, she discovered the Baclofen had another resident ' s name on it. The DON stated Resident #2 ' s family member further stated she had taken Resident #2 to the hospital because she was not acting herself. The DON stated the nurse discharging the resident was responsible for removing the medications from the medication cart. and compared the discharge medication list with those removed. The DON stated she expected the nurse discharging the resident would review the medications with the resident at the bedside and obtain a signed copy of the discharge recapitulation. The DON stated an investigation was launched upon learning about Resident #2 receiving baclofen which was not on her discharge medication list. Review of Resident #6 ' s medical record revealed Resident #6 was prescribed baclofen 10 mg., one tablet by mouth three times a day for muscle spasticity. During an interview with Nurse #1 on 6/21/23 at 11:23 AM she stated she was working on Resident #2 ' s discharge when she became distracted. Nurse #1 stated she had reviewed Resident #2 ' s medications with resident the morning of her discharge. Nurse #1 stated she had given Resident #6 her scheduled medication when Resident #2 's family member approached her about discharge. Nurse #1 stated she began to remove Resident #2 ' s medication from the medication cart and must have accidentally picked up Resident #6 ' s medication card. Nurse #1 stated she had placed the medications in the room with Resident #2 when she had to step out. Nurse #1 stated she asked Family Member #2 to hold on so she could review the medications with him. Nurse #1 stated Family Member #2 did not wait for her to return so she was unable to compare the medications in the bag with the discharge medication list. Review of the hospital discharge summary dated 6/12/23 revealed Resident #2 revealed was admitted on [DATE] for a primary diagnosis of altered mental status and found to have baclofen toxicity secondary to incorrect prescription. Resident #2 (who was on dialysis) took the Baclofen and had an allergic reaction requiring hospitalization . The anticipatory guidance for the outpatient provider on the hospital discharge summary read: Please avoid prescribing baclofen in future encounters as she is very prone to baclofen toxicity. Baclofen is listed as an allergy as of this admission. Resident #2 was treated in the hospital for altered mental status, agitation, hypotension (low blood pressure), rigidity (stiffness) and dysphagia (difficulty swallowing). Resident #2 was discharged from the hospital on 6/12/23 with referrals for home health, physical therapy and occupational therapy. An interview was conducted with the Medical Director on 6/21/23 at 8:54 AM. The Medical Director revealed he had been made aware of that Resident #2 had received Resident #6 ' s medication on 5/20/23. The Medical Director indicated Resident #2 had Baclofen toxicity and exhibited hypotension (low blood pressure) and flaccid (hanging loosely) tone. The Medical Director stated he was not sure what medications Resident #2 had taken prior to being admitted to the hospital since there was no medication list to compare what she received. He stated the individual that picked up Resident #2 for discharge was in a rush and did not wait for review of the medications with the nurse. An interview was conducted with the Pharmacist on 6/21/23 at 2:10 PM. The Pharmacist stated Baclofen was not contraindicated in renal patients. She stated the medication was excreted from the body by the kidneys and the resident would have been prescribed a lower dose given her kidney issues. The Pharmacist stated she had been made aware Resident #2 received Baclofen and recommended that all residents ' medication be reviewed. An interview was conducted with the Administrator on 6/21/23 at 4:18 PM. The Administrator stated the facility began an investigation once being notified about Resident #2 receiving the baclofen and being hospitalized . The Administrator stated the facility completed a plan of correction and reviewed with the Quality Assurance and Performance Improvement committee. On 6/21/23 at 1:18 PM, the Administrator was informed of immediate jeopardy. On 6/22/23 the facility provided the following plan of correction. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. PROCESSES THAT LEAD TO THE ALLEGED DEFICIENCY CITED: On 4/17/23, Resident #4 called the facility and spoke with the Director of Nursing (DON) concerning receiving another resident ' s medication when he was discharged on [DATE]. Resident #4 refused to divulge any information related to the name of the person on the medication card. Administrator was notified and a grievance form was completed to address Resident #4 complaints. The facility investigated the complaint of receiving another resident ' s medication however was unable to validate due to lack of information. The DON interviewed Nurse #2 on 4/17/23. Nurse #2 was unable to confirm that another resident ' s medication was sent with Resident #4. The DON completed an audit of the medication cart for the hall Resident #4 resided on during his stay in the facility. All medications on this medication cart were accounted for. No residents had medication missing. The DON audited the medication room for the hall. No issues were identified. Facility did not audit residents who were recently discharged . On 5/19/2023, DON received a call from Resident #2 ' s daughter who asked if Resident #2 had ever had an order for Baclofen. DON checked previous orders and noted that Resident #2 was never on said medication. Resident #2 ' s family member stated that she was giving medications to Resident #2 and was not paying attention and after medication was given to Resident #2, she noticed that Resident #6 ' s medication (Baclofen) was with the other medications sent home with them. Resident #2 ' s family member stated she took Resident #2 to the hospital on 5/19/23 because she was more confused and not at her baseline. Investigation Findings: On 5/16/2023 Nurse #1 gave medications prescribed for Resident #6 to Resident #2 in error upon discharge. The medications given in error included Baclofen 10 milligrams (mg) that was a scheduled medication for Resident #6. Nurse #1 was preparing medications for Resident #2 for discharge and during the same time also looking for medication for Resident #6. Nurse #1 placed Resident #6 ' s medication card of Baclofen on the top of the medication cart along with Resident #2 ' s medication cards. Nurse #1 grabbed all medication cards for Resident #2 and inadvertently grabbed the medication card of Baclofen for Resident #6. On 5/19/2023 at 11:00 AM, the DON notified the facility medical provider and the corporate clinical support team (Regional Clinical Director and Corporate Clinical Director). Upon investigation of this incident by the Director of Nursing, it was determined that Nurse #1 was looking for medication for Resident #6, while pulling medications for Resident #2 for discharge. Nurse #1 pulled medication cards for Resident #2 and inadvertently pulled Resident #6 ' s medication card of Baclofen. Medications were bagged and taken into the room of Resident #2. Nurse #1 realized she did not have the discharge medication paperwork for Resident #2 with her. Nurse #1 asked Grandson to wait until she could retrieve the discharge paperwork folder from the Social Worker and review it. Prior to Nurse #1 returning to the room (less than 5 minutes later), Resident #2 and Grandson exited the facility with the medications prior to discharge medication education and paperwork being provided by Nurse #1. Resident #2 ' s medications in addition to Resident #6 ' s Baclofen medication card was within the medications sent home with Resident #2. Root cause analysis: Based upon interviews and record review, it is determined that the root cause of this incident is related to the following: Nurse #1 pulled medication for Resident #2 and subsequently got distracted during the retrieval of medications which resulted in failure of Nurse #1 to verify all medications cards which were prepared for resident to take home belonged to Resident #2. An Ad Hoc (Quality Assurance Performance Improvement) QAPI meeting was conducted on 5/22/23 by the QAPI Committee (Administrator, DON, Social Services Manager, Infection Prevention Control Officer, Minimum Data Set (MDS) Coordinator(s), Therapy Manager, Unit Manager(s), Staff Development Coordinator (SDC), Business Office Manager, Activities Director, Maintenance Director, Dietary Manager and Medical Director) to discuss this event and plan of correction. Resident #4 was discharged from the facility on 4/6/23. Resident #2 was discharged on [DATE]. On 5/19/23, Resident #2 was noted to be in a local hospital with stroke like symptoms post 3-day discharge from facility. Resident #6 ' s medication cards were reviewed by the Director of Nursing (DON) on 5/19/23 to ensure all medication cards based upon medication list are accounted for. After review, Resident #6 did not have any further medication cards missing. On 5/20/23, the Pharmacy was contacted by the Director of Nursing related to the facility replacing (at facility cost), one (1) card (30-day supply) of Baclofen 10mg for Resident #6. Per pharmacy, medication is scheduled to arrive at the facility evening of 5/20/23. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. As a precaution on 5/19/23, the DON and Social Worker called discharged residents for the past 14 days to follow up on safety and understanding of medications. No concerns were voiced by any of the residents discharged within this timeframe. An audit was also performed to ensure that discharged residents signed the Discharge Plan of Care. No issues were identified. On 5/20/23, Nurse #1 was immediately educated by the DON on medication administration, avoiding medication error specifically as it relates to distractions during resident discharge, giving discharge medications and the resident discharge process. A competency test was utilized to ensure competency of education provided. On 5/21/23, Unit Managers and Director of Nursing performed an audit comparing each current residents ' medication administration record (MAR) to the assigned medication cart to ensure discontinued medications were removed from medication cart and returned to pharmacy. Any identified issues were corrected. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; Because all residents are at risk when a Licensed Nurse gives medications at discharge and a licensed nurse can become distracted and does not follow the facility medication discharge process, the facility has implemented the following corrective action: On 5/20/23, the Corporate Clinical Director completed education with the Director of Nursing on ensuring the Interdisciplinary (IDT) Discharge Summary evaluation (which includes recapitulation of resident stay) is completed within the resident medical record for all facility discharges to home and/or another facility. On 5/22/23, the Administrator was educated by Corporate Clinical Director on the IDT Discharge Summary process to ensure this is completed prior to discharge by the IDT team. This expectation was communicated to the Interdisciplinary Team (IDT) by the Administrator during the daily stand-up meeting on 5/22/23. The following IDT members were present: DON, Unit Manager(s) Social Services Manager, Activity Director, Dietary Manager and Therapy Manager. Beginning 5/22/23, Licensed Nurses should not discharge a resident home with medications without obtaining an MD order. Previously, Licensed Nurses sent medications home without ensuring an approved transcribed MD order was within the resident medical record. Beginning 5/19/23, Licensed Nurses were provided education verbally by the SDC and DON and/or the facility electronic learning system on the following: Avoiding Common Medication Errors which included how to handle (defer) distractions during medication pass, 5 rights of medication administration, discharge processes, discharge medication education when an order to discharge home with medications has been received from the MD. Discharge Instructions and Med Review: The discharge process includes the Licensed Nurse reviewing the medication discharge instruction form with the resident/family. The PCC order summary report is to be utilized by the licensed nurse for discharge medication reconciliation. This medication discharge instruction form should be thoroughly reviewed by the Licensed Nurse with the resident/family, then signed by the resident/family acknowledging understanding of discharge medication instructions. The Licensed Nurse should sign the form. The medication discharge instruction form should be given to the resident/family. A copy should be retained by the facility and uploaded into the resident medical record. Prescriptions for medications should be given to the resident. The resident should not take any medications from the facility without an MD order. If the resident must take medications home at discharge, the Licensed Nurse must verify each medication card to ensure it belongs to the correct resident to be discharged . Additionally, when medication instructions are provided the Licensed Nurse should show each medication card to the resident/family while reviewing the medication discharge instruction form comparing to each for accuracy. A thorough discharge nurses note utilizing the electronic medical record Discharge Note template should be written to detail discharge education provided to the resident/family. If a medication is discontinued, the Licensed Nurse must remove the medication from the medication cart and return to pharmacy for destruction. Any Licensed Nurse not educated after 5/21/23 will not be allowed to work until educated. Newly hired Licensed Nurses will be trained by the facility Staff Development Coordinator or designee during their orientation period. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Beginning 5/23/23, the DON, Unit Manager or Nurse Supervisor will observe the Licensed Nurse discharge to home process with all resident discharges to ensure discharge process is conducted as per education provided. This observation will be conducted with all discharge to home residents for the next 30 days. Thereafter, observations will be conducted by the DON, Unit Manager or Nurse Supervisor twice weekly with (2) Licensed Nurses (as applicable) for 8 weeks or until a pattern of compliance is sustained. Beginning 5/23/23, education retention questionnaires will be conducted by Nursing Management with (5) Licensed Nurses to ensure retention of education provided in this plan. These questionnaires will be conducted weekly for 12 weeks or until a pattern of compliance is sustained. Beginning 5/23/23, MAR to Med Cart audits will be conducted by the Unit Managers and/or Director of Nursing weekly to ensure all discontinued medications were removed from cart and returned to pharmacy. Results of all audits will be reviewed in the facility Quality Assurance and Performance Improvement Committee meeting monthly for three (3) months. The Quality Assurance and Performance Improvement Committee will review the audits to make recommendations to ensure compliance is sustained ongoing; and determine the need for further auditing beyond the two (3) months. Effective 5/23/23, the facility Administrator and Director of Nursing will be responsible for the implementation of this plan of correction. The Administrator will ensure the facility attains and maintains substantial compliance. The facility alleged the deficiency was corrected on 5/23/23. On 6/27/23 the facility ' s corrective action plan with the date of completion of 5/23/2023 was validated onsite and included record review and licensed nursing staff interviews. Interviews with licensed nursing staff including Nurse #1 was conducted on 6/27/23. Licensed nursing staff revealed they had received recent education regarding medication administration errors. The importance of medication reconciliation, reviewing the discharge instructions with the resident or family and ensuring they understand the instructions and sign as received. A copy of the instructions was given to the resident or family and a copy was retained for the facility. Medications were only sent home with a physician order. Medications were returned to the facility pharmacy and prescriptions were given to the resident or family to be filled at their preferred pharmacy. Discharge notes were completed by the day of discharge. Documentation review included Nurse #1 ' s education on 5/20/2023, and all other licensed nursing staff education completed by 5/22/2023. Documentation included an Ad Hoc QAPI meeting 5/22/23 sign-in sheet. Review of all resident discharges with locations, follow up calls, and audits noted. Post education staff questionnaires for information retention, and medication cart audits were observed. The validation verified the corrective action plan was completed as of 5/23/23.

Based on observations, record review, and staff interviews, the facility failed to perform full body skin assessments to identify a change in skin condition which resulted in Stage 3 pressure ulcers on two toes for 1 of 3 residents reviewed for pressure ulcers (Resident #3). Findings include: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set (MDS), a 30-day assessment of 7/23/18, indicated the resident required extensive assistance of 2 or more people for bed mobility and personal hygiene, and total care of one person for bathing. The MDS indicated the resident had no pressure ulcers. During an observation of Resident #3 on 9/5/18 at 8:45am during incontinent care, the left 4th and 5th toes were noted to have a brownish crust from the base of the toes extending to the first joint of each toe. There was a dried brownish circle on the bottom of the sheet under the resident's left foot of approximately 2 centimeters (cm). A second observation was made with the Treatment Nurse on 9/5/18 at 11:30am. The nurse cleaned between the resident's left 4th and 5th toes with gauze saturated with normal saline. There was dried dark brown matter removed to separate the toes from each other, a minimal amount of fresh blood, and a moderate amount of golden residue on the gauze. The inner sides of each toe were noted to have open skin near the base of the toes. During an interview with the Treatment Nurse on 9/5/18 at 11:30am, she stated she was unaware of the open areas on the Resident's 4th and 5th toes. The nurse reported staff usually tells her about new areas or leave her a note. The Treatment Nurse provided measurements of the open areas on the fourth and fifth toes on Resident #3's left foot on 9/6/18 at 9:30am as: 4th inner toe measured 0.5cm long by 1.0cm wide by 0.5cm deep; the 5th inner toe measured 1cm long by 1cm wide by 1cm deep. The Treatment Nurse identified the areas as Stage 3 Pressure Ulcers. review of the resident's medical record revealed [REDACTED].#1 and indicated the skin check was completed on the resident with no new marks, bruises, wounds, or scars, and will continue to monitor. A Weekly Skin Check progress note dated 9/3/18 completed by Nurse #1 revealed the skin check was completed and the Resident had a skin scrape on the right knee. Review of the Resident's Care Plan of 7/25/18 revealed a problem identified as: Resident is at risk for impaired skin integrity r/t (related to) the potential for pressure, friction, and sheer. The resident is at risk for injury r/t fragile skin. Interventions included: Offload potential areas of pressure routinely and pressure reduction mattress. During an interview with Nurse #1 on 9/5/18 at 11:50am, the nurse reported she completed the Resident's skin check on 9/3/18 and 8/31/18. Nurse #1 reported she did not check between the resident's toes when she completed the skin checks and was unaware there were any problems with the resident's toes. During an interview with the Director of Nursing (DON) on 9/5/18 at 12:10pm, the DON stated she expected nurses to check between residents' toes when completing the weekly skin checks and report to the supervisor and treatment nurse when areas of concern are identified, and expected NAs cleaned between toes when providing bathing and showers.

Based on record review, observation, resident and staff interview, the facility failed to perform a comprehensive weekly skin and wound assessments of the pressure ulcers, failed to treat pressure ulcers as ordered and failed to obtain orders for the treatment of [REDACTED]. The facility also failed to turn and reposition residents and failed to properly adjust the setting of the air mattress for 3 (Residents #35, #24 & #105) of 3 sampled residents with pressure ulcers. The findings included: 1a. Resident #35 was admitted to the facility on [DATE] and readmitted [DATE] with multiple [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] indicated the resident was assessed as being cognitively intact. The MDS indicated the resident was assessed with [REDACTED]. The Plan of Care dated 2/15/16 and revised on 2/25/16 and on 5/5/16 indicated the resident was assessed with [REDACTED]. The goal for the right gluteal crease was that the wound would have signs of resolution through the next review date of 8/3/16. The interventions included to notify the physician as needed for worsening condition of a wound or the lack of improvement and to administer treatments as ordered by the physician. The Weekly Pressure Ulcer Log dated 3/4/16 indicated the resident was assessed with [REDACTED]. The ulcer measured 3.0 centimeters (cm) length x 2.0 cm width x 0.1 cm depth. The log dated 3/25/16 indicated the resident was assessed with [REDACTED]. The ulcer measured 3.0 cm length x 2.0 cm width x 0.1 cm depth. The log dated 3/30/16 indicated the resident was assessed with [REDACTED]. The ulcer measured 3.0 cm length x 2.0 cm width x 0.1 cm depth. A nurses ' note dated 4/11/16 stated the resident was sent to the emergency room for evaluation due to altered mental status, lethargy and [MEDICAL CONDITION]. The MDS dated [DATE] indicated the resident was readmitted to the facility on [DATE]. A review of the hospital discharge summary dated 4/21/16 was conducted. The right ischial pressure ulcer was not mentioned in the discharge summary. A review of the Treatment Administration Record (TAR) dated 4/1/16 to 4/30/16 was conducted. No treatment to the right ischium was ordered or documented as administered. The Weekly Pressure Ulcer Log dated 4/21/16 indicated the resident was identified with a pressure ulcer on the right ischium. The stage and the measurements of the pressure ulcer were not documented. The log dated 4/27/16 indicated the resident was assessed with [REDACTED]. The ulcer measured 7.3 cm length x 6.4 cm width. A Nurses ' Note dated 5/4/16 stated the resident was assessed by the Wound Physician and a new treatment order for the right gluteal crease for silver alginate and a dry dressing was obtained. A review of the Physician order [REDACTED]. The Weekly Pressure Ulcer Log dated 5/11/16 indicated the resident was assessed with [REDACTED]. The stage of the pressure ulcer was not documented. The ulcer measured 6.0 cm length x 6.0 cm width. A review of the Physician order [REDACTED]. A review of the Physician order [REDACTED]. Cover with calcium and secure with foam dressings at 10:00 AM. The Wound Care Specialist Evaluation dated 5/11/16 revealed an initial evaluation of an unstageable pressure ulcer of the right ischium was done by the physician. The ulcer measured 6.0 cm length x 5.5 cm width. The depth was not measurable. The assessment stated the ulcer of the right ischium was acquired during a recent hospital admission on 4/21/16. A review of the TAR dated 5/1/16 to 5/31/16 was conducted. The treatment to the right ischial wound was not administered on 5/13/16 and 5/16/16 as ordered by the physician. Nurse #1 was observed performing wound care for Resident #35 on 5/17/16 at 4:50 PM. The right ischial wound was observed to be an unstageable wound due to the presence of slough. The wound was cleaned with normal saline, Santyl was applied to the wound. The wound was covered with a calcium alginate foam dressing. An interview was conducted with Resident #35 on 5/18/16 at 12:00 PM. The resident stated the staff had performed wound treatments daily. The resident stated he had not been checked for incontinence since 5:00 AM that morning. He stated the last time incontinence care was performed for him was at 5:00 AM that morning. He stated he was not aware of when he experienced episodes of incontinence. The resident stated he laid in wet diaper on another day for approximately 12 hours. The resident stated he believed that allowing him to remain in a wet diaper had caused his wounds to become worse. The resident stated he had paid sitters in his room. The sitters had days off and were not present every day. The resident stated it was not their responsibility to check him for wetness. A clock was observed to be hanging on the wall of the resident ' s room on 5/18/16 at 12:00 PM. An interview was conducted with Nursing Assistant (NA) #1 on 5/18/16 at 12:15PM. NA #1 stated the resident was not aware of when he experienced episodes of incontinence. NA #1 stated she was expected to round on the residents every 2 hours. NA#1 stated she had not been checking the resident for wetness. She was depending on his paid sitters to let her know when he needed to have his diaper changed. She believed that the sitters were performing incontinence care on the resident. NA #1 was observed performing incontinence care for Resident #35 on 5/18/16 at 12:30 PM. The diaper taken off of the resident was observed to be saturated with urine. The draw sheet and bottom sheet were observed to be wet. The ulcer on the right ischium was not covered with a dressing. An interview was conducted with the Wound Care Physician on 5/18/16 at 1:30 PM. The Physician stated the right ischial wound was acquired at the hospital. The Physician stated that all of the resident ' s existing wounds had deteriorated while admitted to the hospital. She stated she expected the facility to administer the wound treatments as ordered. The Physician stated the resident remaining in a diaper saturated with urine from 5:00 AM to 12:30 PM could have resulted in a worsening of his wounds. An interview was conducted with NA #1 on 5/19/16 at 3:43 PM. NA #1 state she had found the resident to be in need of incontinence care three times during the shift. An interview was conducted with the Director of Nursing (DON) on 5/19/16 at 4:20 PM. The DON stated she expected the staff to check the residents for incontinence every two to three hours. The DON stated she expected the resident ' s wound treatments to be administered during the 7:00 AM to 3:00 PM shift. The DON stated to her knowledge, the resident received wet to dry dressing changes to the right ischial wound every day after his readmission from the hospital on [DATE]. She stated there was no order written for the wet to dry dressings to the right ischium and there was no documentation of the administration of the wet to dry dressings. The DON did not offer an explanation as to why an order for [REDACTED]. 1b. Resident #35 was admitted to the facility on [DATE] and readmitted [DATE] with multiple [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] indicated the resident was assessed as being cognitively intact. The MDS indicated the resident was assessed with [REDACTED]. The Plan of Care dated 2/15/16 and revised on 2/25/16 and on 5/5/16 indicated the resident was assessed with [REDACTED]. The goal for the left lateral calf pressure ulcer was that the wound would have signs of resolution through the next review date of 8/3/16. The interventions included to notify the physician as needed for worsening condition of a wound or the lack of improvement and to administer treatments as ordered by the physician. A review of the Wound Care Specialist Evaluation dated 2/24/16 indicated the left posterior shin pressure ulcer was assessed as a stage 3 and measured 3.0 cm length x 1.0 cm width x 0.3 cm depth. A review of the Physician order [REDACTED]. The Weekly Pressure Ulcer Log dated 3/30/16 indicated the resident was assessed with [REDACTED]. The ulcer measured 8.0 cm length x 4.0 cm width x 0.5 cm depth. A review of the Physician order [REDACTED]. An order dated 4/6/16 stated to clean wound to left calf with a wound cleanser, apply silver alginate dressing and secure with kerlix one time a day. A nurses ' note dated 4/11/16 stated the resident was sent to the emergency room for evaluation due to altered mental status, lethargy and [MEDICAL CONDITION]. The MDS dated [DATE] indicated the resident was readmitted to the facility on [DATE]. The hospital discharge instructions dated 4/21/16 stated the L shin wound was to be treated with normal saline moist dressings twice a day. The Weekly Pressure Ulcer Log dated 4/21/16 indicated the resident was assessed with [REDACTED]. The stage and measurements of the pressure ulcer were not documented. The Weekly Pressure Ulcer Log dated 4/27/16 indicated the resident was assessed with [REDACTED]. The ulcer measured 13.1 cm length x 13.1 cm width x 0.8 cm depth. A review of the TAR dated 4/1/16 to 4/30/16 revealed the treatments to the left calf were administered as ordered by the physician until the resident was discharged to the hospital on [DATE]. There was no documented treatment or orders for treatment to the left calf from 4/21/16 until 4/30/16. A review of the physician's order [REDACTED]. A review of the TAR dated 5/1/16 to 5/31/16 revealed there was no documented treatment or orders for treatment to the left calf from 5/1/16 until 5/4/16. The treatment order dated 5/5/16 which stated to cleanse the posterior calf to the left leg with normal saline, pat dry and apply silver alginate, cover with dry dressing and secure with paper tape once daily was not documented as administered on 5/11/16, 5/13/16 and 5/16/16. Nurse #1 was observed performing wound care for Resident #35 on 5/17/16 at 4:50 PM. The left shin wound was observed to be a stage 4 wound with granulation tissue. The wound was cleaned with normal saline, treated with silver alginate and covered with a foam dressing. An interview was conducted with Nurse #1 on 5/17/16 at 5:30 PM. Nurse #1 stated he did not administer the wound treatment as ordered until 4:50 PM because he was busy doing other dressing changes throughout the day. Nurse #1 stated he normally administered the wound treatments for Resident #35 earlier in the day. An interview was conducted with Resident #35 on 5/18/16 at 12:00 PM. The resident stated the staff had performed wound treatments daily An interview was conducted with the Director of Nursing (DON) on 5/19/16 at 4:20 PM. The DON stated to her knowledge, the resident received wet to dry dressing changes to the left calf pressure ulcer every day after his readmission from the hospital on [DATE] until 5/5/16. She stated there was no order written for the wet to dry dressings to the left calf and there was no documentation of the administration of the wet to dry dressings. The DON did not offer an explanation as to why an order for [REDACTED]. 1c. Resident #35 was admitted to the facility on [DATE] and readmitted [DATE] with multiple [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] indicated the resident was assessed as being cognitively intact. The MDS indicated the resident was assessed with [REDACTED]. The Plan of Care dated 2/15/16 and revised on 2/25/16 and on 5/5/16 indicated the resident was assessed with [REDACTED]. The goal for the left lateral calf pressure ulcer was that the wound would have signs of resolution through the next review date of 8/3/16. The interventions included to notify the physician as needed for worsening condition of a wound or the lack of improvement and to administer treatments as ordered by the physician. A nurses ' note dated 4/11/16 stated the resident was sent to the emergency room for evaluation due to altered mental status, lethargy and [MEDICAL CONDITION]. The MDS dated [DATE] indicated the resident was readmitted to the facility on [DATE]. The hospital discharge instructions stated the right heel ulcer was to be treated with a thin layer of [MEDICATION NAME] gel to maintain a moist healing environment and to reduce bioburden and to cover with Allevyn for protection. The Weekly Pressure Ulcer Log dated 4/21/16 indicated the resident was assessed with [REDACTED]. The stage and measurements of the pressure ulcer were not documented. The Weekly Pressure Ulcer Log dated 4/27/16 indicated the resident was assessed with [REDACTED]. The ulcer measured 2.5 cm length x 4.5 cm width. A review of the TAR dated 4/1/16 to 4/30/16 revealed no documented treatment or orders for treatment to the right heel from 4/21/16 until 4/30/16. The Wound Care Specialist Evaluation dated 5/4/15 revealed an initial evaluation of an unstageable pressure ulcer to the right heel. The ulcer measured 2.5 cm length x 4.5 cm width. A review of the physician's order [REDACTED]. A review of the TAR dated 5/1/16 to 5/31/16 revealed no documented treatment or orders for treatment to the right heel from 5/1/16 until 5/4/16. The treatment order dated 5/5/16 which stated to cleanse the right heel wound with normal saline, pat dry, apply silver alginate, cover with a dry dressing, secure with paper tape once daily and as needed every day shift was not documented as administered on 5/11/16, 5/13/16 and 5/16/16. Nurse #1 was observed performing wound care for Resident #35 on 5/17/16 at 4:50 PM. The right heel wound was observed to be unstageable due to the presence of eschar. The wound was cleaned with normal saline, treated with silver alginate and covered with kerlix. An interview was conducted with Nurse #1 on 5/17/16 at 5:30 PM. Nurse #1 stated he did not administer the wound treatment as ordered until 4:50 PM because he was busy doing other dressing changes throughout the day. Nurse #1 stated he normally administered the wound treatments for Resident #35 earlier in the day. An interview was conducted with Resident #35 on 5/18/16 at 12:00 PM. The resident stated the staff had performed wound treatments daily An interview was conducted with the Director of Nursing (DON) on 5/19/16 at 4:20 PM. The DON stated to her knowledge, the resident received wet to dry dressing changes to the right heel pressure ulcer every day after his readmission from the hospital on [DATE] until 5/5/16. She stated there was no order written for the wet to dry dressings to the right heel and there was no documentation of the administration of the wet to dry dressings. The DON did not offer an explanation as to why an order for [REDACTED]. 2. Resident #24 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] indicated that Resident #24 had moderate cognitive impairment and had 2 unstageable pressure ulcers that were present on admission. The assessment also indicated that the resident needed extensive assistance with bed mobility. The care plan for Resident #24 was reviewed. The original care plan dated 2/18/16 had addressed the pressure ulcers on the right and left heel. The care plan was revised on 5/2/16 to address the pressure ulcers on the right and left heel and the coccyx. One of the care plan problems was pressure ulcers on the left and right heel and coccyx and potential for impaired skin integrity. The goal was the pressure ulcers will have signs of resolution through the next review date. The approaches included notify the physician as needed for worsening condition of wound or lack of improvement from treatment, skin care and treatment per doctor ' s orders and provide extensive assistance as needed with turning and repositioning. The nursing progress notes were reviewed for weekly skin checks. The result of the weekly skin check was not documented on a weekly basis as ordered. In March 2016, there was only 1 skin check documented (3/5/16) and there was no new skin issue noted. There were 2 weekly skin checks documented in April, 2016. On April 5, there was no new skin issue noted and on April 27, a stage II ulcer was found on the buttock/sacrum measuring 14 centimeters (cm.) x (by) 11.5 cm. with drainage and was pink and purple in color. The weekly skin check dated May 9 indicated that a stage III pressure ulcer on the buttock/sacrum was found, black in color and with scant drainage noted. There was no measurement documented. The wound doctor notes were reviewed. The notes dated 5/11/16 indicated that Resident # 24 had unstageable pressure ulcer to her sacrum measuring 9.5 x 9 cm and it had 90% necrosis. The notes indicated that this was the first time the wound doctor had seen the pressure ulcer on the sacrum. On 5/16/16, there was a doctor's order to make sure Resident #24 was maintained on her side at all times to help with the healing of the sacral pressure ulcer. On 5/17/16 at 7:30 AM, Nurse #10 was interviewed. Nurse #10 stated that night shift nurse was responsible for the weekly skin checks/assessments. She added when they were short of nurse aide at night she had to help take care of residents and so she had no time to do her skin checks/assessments. On 5/17/16 at 3:15 PM, Resident #24 was observed during the dressing change. Nurse # 3 was observed to clean the pressure ulcer on the sacrum with normal saline, Santyl ([MEDICATION NAME] agent) ointment was applied and covered with Calcium Alginate (antimicrobial) dressing. On 5/18/16 at 9:15 AM, 10:10 AM and 1:25 PM Resident #24 was observed in bed on her back. The setting of the air mattress was at 120. On 5/18/16 at 1:30 PM, NA # 5 was interviewed. NA #5 stated that she was pulled from another nursing facility to help and she was assigned to Resident #24. She indicated that she forgot to turn the resident after she gave her a bath this morning. On 5/18/16 at 1:37 pm, the wound doctor was interviewed. The wound doctor indicated that the staff had informed her of the pressure ulcer on the sacrum for Resident #24 on 5/11/16. She indicated that the ulcer was big and was covered with necrosis. The wound doctor also indicated that the resident had an air mattress but the air mattress would not help with the wound healing if it was not set properly. She indicated that she had observed the air mattress of Resident #24 set at 400 lbs. and the resident weighed less than 100 lbs. She added that she had informed Nurse # 3 about the incorrect setting of the air mattress. On 5/18/16 at 3:25 PM, Nurse #1 was interviewed. Nurse #1 stated that it was his responsibility to make wound rounds with the wound doctor on a weekly basis. He confirmed that the wound doctor had brought to his attention the incorrect setting of the resident's air mattress. He indicated that he didn't inform the DON about it. Nurse #1 also stated that the maintenance person was responsible for adjusting the setting of the air mattress. Nurse #1 added that if the nurses were doing the weekly skin checks/assessments, the pressure ulcer on the sacrum of Resident #24 should have been identified earlier. On 5/18/16 at 5:30 PM, the maintenance person was interviewed. He stated that did not know that it was his responsibility to adjust the setting of the resident's air mattress. He added that the air mattress was set according to the resident's weight and he didn't even know the weights of the residents. On 5/18/16 at 5:35 PM, the air mattress of Resident #24 was observed with Nurse #6. The air mattress was set at 120. Nurse #6 was interviewed. Nurse #6 stated that she didn't check the setting of the air mattress. She added that the maintenance person was responsible in adjusting the setting of the air mattress. On 5/19/16 at 4:25 PM, the DON was interviewed. The DON indicated that it was the responsibility of the nurses to check the setting of the air mattress daily. The DON indicated that the air mattress should be set according to the resident's weight. She added that Resident #24's weight was 94 lbs. and the air mattress should have been adjusted at 94. The DON also indicated that she expected the staff to turn and reposition residents with pressure ulcers every 2 hours. The DON indicated that the night shift nurses were responsible for the weekly skin checks/assessments and they had initialed the Treatment Administration Records indicating that they had assessed the residents but they were not documenting the results of the assessments and they should. 3. Resident #105 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. A pressure wound assessment and care tool dated 4/6/16 indicated Resident #105 had pressure ulcers on the right and left heels. Measurements of the right heel was 5 centimeters (cm) in length x 4.6 cm in width x 1.2 cm in depth at stage 2 ( partial thickness loss of tissue presenting as a shallow open ulcer) and left heel measurements of 8cm in length x 5 cm in width x deep to bone at stage 4 (full bone exposure). Admission physician orders [REDACTED]. Clean wound bed with normal saline. Apply skin sealant to surrounding tissue (skin prep). Cut sponge to wound size and place in wound. Cover with transparent dressing. Attach wound vac at 125mm (millimeters) continuous suction to both right and left heels. A physician's order [REDACTED]. An Admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #105 was moderately impaired in cognition. He required extensive assistance with bed mobility, transfers (both 2 person), locomotion on and off the unit, dressing and toilet use. Limited assistance was needed with personal hygiene. Supervision was needed with eating. He was frequently incontinent of bladder and bowel. Pressure ulcers were noted as one stage 3 ((full thickness tissue loss) and one stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. The Care Area Assessment (CAA) for pressure ulcers stated Resident #105 was admitted to facility following a hospitalization related to left calcaneal osteo[DIAGNOSES REDACTED], right foot wound (status [REDACTED]. BKA (bilateral knee amputation) was not recommended per infectious disease consult and [DIAGNOSES REDACTED]. Pressure ulcers would be care planned. The pressure wound assessment and care tool dated 4/13/16 indicated the following: left heel pressure ulcer stage 4 measured 5cm in length x 5cm in width x 2 cm in depth with moderate bloody drainage. The right heel pressure ulcer measured 6 cm in length x 5 cm in width x 1 cm in depth at stage 3 with a moderate amount of bloody drainage noted. A care plan last revised on 4/21/16 indicated pressure ulcers on right and left heels. Interventions included: Pressure relief ankle foot orthosis (device worn on the foot to relieve pressure) to both heels when using wound vac. Monitor/ report increased temperature, excessive perspiration/sweating. Notify MD as needed for worsening condition or lack of improvement from treatment. Skin care and treatments per physician order. Wound vac per physician order. Pressure wound assessment and care tool documentation was reviewed and revealed the following: 4/20/16--right heel: 6 cm in length x 5 cm in width x 1 cm depth at stage 3 with moderate bloody drainage; left heel: 5cm in length x 5 cm in width x 2 cm depth at stage 4 with moderate bloody drainage. 4/27/16--right heel: 6cm in length x 5 cm in width x 1 cm depth at stage 3 with moderate bloody drainage; left heel: 5 cm in length x5 cm in width x 2 cm depth at stage 4 with moderate bloody drainage. 5/4/16--right heel: 6 cm in length x 5 cm in width x 1.0 depth with odor and drainage. The left heel measured 5 cm in length x 5 cm in width x 1.0 depth with odor and drainage. There was no further notes or description of the wound bed, type of odor or type of drainage for either pressure ulcer. 5/11/16-- right heel: 5 cm in length x 5 cm in width x 0.5 cm depth; left heel: 5 cm in length x 5 cm in width x 1.0 cm depth. There was no documentation regarding a description of the wound bed, if odor was present or type of drainage for either pressure ulcer. On 5/17/16 at 2:30PM, pressure ulcer care for Resident #105 was observed with nurse #1 and nurse #2. The left heel pressure dressing was intact and continued to be on the wound vac. The right heel had a dressing in place and was not on the wound vac. There was visible blood noted on the outside of the dressing. The dressing was removed and the pressure ulcer was cleansed with normal saline. The wound bed was beefy red with several scattered dark areas of tissue noted. The pressure ulcer measured 4 centimeters in length and 4 centimeters in width and 0.6 centimeters in depth. On 5/17/16 at 2:45PM, an interview was conducted with nurse #1. He stated he was the person who provided care and applied the wound vac. Nurse #1 stated if the wound vac was removed/ lost negative pressure, the nursing staff would leave him a note, call him or verbally tell him if a wound vac had come off and needed to be replaced. He stated he was not aware that Resident #105 ' s wound vac was off his right heel. He stated both heels should be on the wound vac and he did not know why the right heel was not on the wound vac. On 5/18/16 at 2:30PM, an interview was conducted with nurse #1. He stated Resident #105 was not seen by the wound physician that came to the facility but went to an outside wound clinic. He stated he only measured the wounds but did not describe what the wound appearance was or what stage the wound was because he felt that should be done when Resident #105 went to the wound clinic. He stated he had been on the floor working as a floor nurse and had not had time to write a wound care note during the month of May, 2016. On 5/19/16 at 4:13PM, an interview was conducted with the Director of Nursing. She stated she expected the wound vac to remain in place. If the wound vac was removed due to bleeding, the nursing staff should have written a note and called and/or left a note for nurse #1. The Director of Nursing stated there should have been documentation of the bleeding of the pressure ulcer and removal of the wound vac in a nursing note. The wound clinic should have been called and been notified of the bleeding to see if they wanted wound vac replaced. She also stated she expected the weekly wound assessment to include measurements and a description of the wound.

Based on observation, record review and staff interviews, the facility failed to provide a sufficient number of nursing staff to meet the needs of residents as determined by leaving a resident wet, placing a towel between resident's legs instead of using an incontinence brief and leaving a dependent resident in the middle of feeding for an extended period of time for 2 (Resident #35 and #31) of 3 sampled residents reviewed for dignity, failed to provide clean linens for one of three sampled residents observed for pressure ulcer care (Resident #105), failed to provide shower and nail care and failed to provide toileting and feeding assistance for 5 (Residents # 24, #62, #122, #104 & #35) of 6 sampled residents who were dependent or needed extensive assistance with personal hygiene, toileting and eating and failed to perform a comprehensive weekly skin and wound assessments of the pressure ulcers, failed to treat pressure ulcers as ordered and failed to obtain orders for the treatment of [REDACTED]. The facility also failed to turn and reposition residents and failed to properly adjust the setting of the air mattress for 3 (Residents #35, #24 & #105) of 3 sampled residents with pressure ulcers. The findings included: 1. Cross reference to tag 241. Based on record review, observation and staff interview, the facility failed to treat residents with respect and dignity by leaving a resident wet, placing a towel between resident ' s legs instead of using an incontinence brief and leaving a dependent resident in the middle of feeding for an extended period of time for 2 (Resident #35 and #31) of 3 sampled residents reviewed for dignity. 2. Cross reference to tag F254. Based on observation and staff interview, the facility failed to provide clean linens for one of three sampled residents observed for pressure ulcer care (Resident #105). 3. Cross reference to tag F312. Based on record review, observation and staff interview, the facility failed to provide shower and nail care and failed to provide toileting and feeding assistance for 5 (Residents # 24, #62, #122, #104 & #35) of 6 sampled residents who were dependent or needed extensive assistance with personal hygiene, toileting and eating. 4. Cross reference to tag 314. Based on record review, observation, resident and staff interview, the facility failed to perform a comprehensive weekly skin and wound assessments of the pressure ulcers, failed to treat pressure ulcers as ordered and failed to obtain orders for the treatment of [REDACTED]. The facility also failed to turn and reposition residents and failed to properly adjust the setting of the air mattress for 3 (Residents #35, #24 & #105) of 3 sampled residents with pressure ulcers. 5. On 5/15/16 at 3:43PM, an initial tour of the facility was conducted. It was observed that the meal carts were still on the hallway. NA#6 was observed to obtain a meal tray from the cart for Resident #62 and take it into the resident ' s room. When asked what meal she was giving to Resident #62, she stated it was the lunch tray. NA#6 stated she did not work on that hallway but had come over to assist the nursing assistants working on that hall. On 5/15/16 at 3:43PM, an interview was conducted with NA#7. She stated the lunch trays had arrived on the floor around 2:00PM. When asked why Resident #62 had not received her lunch tray until 3:43PM, she stated she had to get Resident #62 up and dressed before giving her the food tray. On 5/15/16 at 6:50PM, an interview was conducted with Nurse #8. She stated she worked on weekends on the night shift. She stated there were 3 nurses on the hall and usually had 4-5 nursing assistants (NAs). Nurse #8 stated last night (Saturday) there were only 3 NAs for 90 residents. She stated the 11:00PM-7:00AM started out with 2 NAs, then 1 NA came in late. Nurse #8 stated the nursing assistants were stretched thin and they got the job done but someone might not get changed as much as they would if they had enough staff. On 5/17/16 at 7:30AM, an interview was conducted with Nurse #10. She stated there was 1 nurse and 1 med aide on days 7:00AM-3:00PM (unless med aide gets pulled, 1 nurse and 1/2 med aide (med aide stayed ½ of the evening shift) on evenings 3:00PM-11:00PM and 1 nurse on her section at night (11:00PM-7:00AM). Nurse #10 stated she had 36 residents on her assignment and it was hard to get everything done. She said she had 2 regular nursing assistants who were responsible for resident care and she relied on them heavily for positioning of residents, that they have splints on, etc. Nurse #10 stated when she did not have 2 nursing assistants on her assignment, she helped the nursing assistant with direct patient care which cut down on her time to do resident assessments, skin assessments, etc. Nurse #10 stated they also had help from other facilities (name of the facilities) and stated they didn ' t get as much help from other facilities now. On 05/18/2016 at 1:10PM, an interview was conducted with NA#2. He stated he worked 7:00AM-3:00PM and had 10 residents on his assignment today but usually had 15 residents on his assignment. He stated there were times when he did not have enough time to really do his job well. NA#2 stated there were times when he did not have enough time to give showers to residents on their shower days but he would give them a bed bath instead. He did not give specific dates when this occurred. A review of the actual staff assignment for 7:00AM-3:00PM on 5/17/16 was done. There were 6 assignments on the staffing sheet. Five of the assignments had 15-16 residents per nursing assistant and one assignment had 14 residents per nursing assistant. On 5/19/16 at 4:13PM, an interview was conducted with the Director of Nursing and the Administrator. The Administrator stated ideally, he would like to have the following staffing ratios: 14 to 15 residents to one nursing assistant for days and evenings and, at the most, 21 residents to one nursing assistant at night. The Director of Nursing stated her expectation regarding staffing assignments was the following: First shift--10 residents to one nursing assistant, 4 licensed nursing staff, one med aide and 2 unit managers. Second shift-12-13 residents to one nursing assistant, 4 licensed nursing staff and one unit manager. Third shift---23 residents to one nursing assistant and 3 licensed nursing staff.

Based on record reviews, staff interviews, physician interview and the x-ray company ' s staff interviews, the facility failed to notify the physician of a positive x-ray result of the bilateral knees on 8/3/15 which revealed a fractured right femur for 1 of 3 residents (Resident #1) resulting in delayed medical treatment. The outcome resulted in Resident #1 having orthopedic surgery on 8/8/15 to bilateral fractured femurs. The Immediate Jeopardy began on 8/3/15 when Resident #1 had an x-ray to the bilateral knees and the positive results were not reported to the physician. The Immediate Jeopardy was removed on 9/3/15. The facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal that is not an immediate jeopardy (D). The facility was in the process of full implementation and monitoring their correction action. The facility needs to include the nurse aides in their corrective measures. Findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A record review of the Minimum Data Set (MDS) significant change of status assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired, dependent for transfers with assist of two. Extensive assist with one assist with bed mobility. Extensive assist with assist of one with personal hygiene, eating, dressing and locomotion off and on the unit and dependent with one assist with toileting. Resident #1 used a wheelchair and was always incontinent of bowel and bladder. A record review of a nurse ' s note written on 8/3/15 at 12:27 am revealed Nurse #1 heard Resident #1 calling for help. The nurse found the resident sitting on the floor next to her bed. The bed was in the lowest position. The resident complained of bilateral knee pain. The resident was unable to explain to the nurse how the fall happened. The nurse reported she notified the physician of the fall as well as the responsible party on 8/3/15 at approximately 1:30 am. A record review of a nurse ' s note written on 8/3/15 at 11:42 am revealed a urine sample was collected from Resident #1 for a urine analysis. Nurse #2 reported she also ordered an x-ray for the bilateral knees due to the swelling the nurse observed and the increased pain the resident was having. A record review of a radiology report dated 8/3/15 at 12:56 pm for Resident #1 revealed the resident had an acute oblique fracture involving the right distal femur with moderate displacement. The left knee resulted in no fracture or dislocation and showed modest [MEDICAL CONDITION]. A record review of a nurse ' s note written on 8/3/15 at 10:35 pm written by Nurse #2 revealed nurse received communication from the weekend nurse (Nurse #1) that Resident #1 fell and woke up in pain this morning to her bilateral knees. The nurse noted there was swelling to the resident ' s knees. The nurse ordered a bilateral knee x-ray. The nurse reviewed the x-ray and found the result to be negative. A record review of a nurse ' s note written on 8/6/15 by Nurse #2 at 12:23 pm revealed Resident #1 was continuing to complain of pain to her left knee. A physician's order [REDACTED]. A record review of a radiology report dated 8/6/15 at 12:04 pm revealed Resident #1 had a recent displaced spiral left femur fracture. A record review of a nurse ' s note written on 8/6/15 at 6:20 pm revealed Resident #1 had a positive x- ray result revealing a fracture to the left femur. The doctor assessed the resident and ordered the resident to be sent to the hospital. The resident was transported to the hospital via stretcher on 8/6/15. The responsible party was made aware of the transfer. A phone interview on 8/19/15 at 3:15 pm was conducted with Nurse #1 who noted the fall on 8/3/15 at 12:27 am. The nurse reported that she called the physician and left a message regarding the fall at approximately 1:00 am. The nurse reported she left a message for the physician that there was no injury and the range of motion did not change for the resident. The nurse also revealed she called the responsible party and left a message. The nurse reported the resident complained of pain to her knees but she had chronic pain to her knees due to [MEDICAL CONDITION]. Nurse #1 reported she was medicated with two tablets of pain medication at 4:40 am for increased pain. The nurse reported she told Nurse #2 at the change of shift that she might need an x-ray due to the increased pain. During an interview on 8/19/15 at 2:15 pm, with Nurse #2, the nurse revealed she ordered an x-ray on 8/3/15 due to the increased pain and swelling the resident had to her knees. The nurse ordered this x-ray at 9:15 am on 8/3/15 per the record review of the physician's order [REDACTED]. The nurse further added that she showed the results to the physician on 8/6/15 when the physician was at the facility. The nurse reported the resident was complaining of pain in the left knee and the physician ordered an x-ray on 8/6/15 of the left leg. The nurse was asked what the process was when you order an x-ray from the x-ray company. The nurse reported that first, you order the x-ray by phone. The x-ray company will come to the facility and do the x-ray. The x-ray company will fax the results to the facility. The nurse reported the nurse is to go to the fax machine and get the results or they are delivered to the nurse ' s station by the administrative staff. The nurse was asked why she did not get the results until after 10:00 pm when it was faxed from the x-ray company to the facility at 12:57 pm. The nurse replied, sometimes the nurses do not have time; the fax machine is on the other end of the room. An interview with Nurse #3 at 3:17 pm on 9/2/15 revealed Nurse #3 received a shift change report from Nurse #2. Nurse #2 reported to Nurse #3 Resident #1 had a fall on the morning of 8/3/15 and had an x-ray, but it was negative of a fracture. Nurse #3 did not receive in report the resident was having any pain nor did she see the x-ray. Nurse #3 reported on the night of 8/4/15 she assessed the resident when the NA came to her and told her the resident was in pain. The NA had just transferred the resident and was doing incontinent care and the resident was calling out in pain. The NA notified the nurse. The nurse found the resident to be in pain and medicated her with one tablet of [MEDICATION NAME] 5/325. The nurse reported when she reassessed the resident, she was sleeping. The nurse reported that her bilateral legs did not have any increased swelling. Nurse #3 reported the process when a nurse orders an x-ray is to call the x-ray company. They will come to the facility to do the x-ray and will fax the results to the facility. Nurse #3 also added that if the result is positive or there is an abnormal result, the x-ray company would call to speak to the nurse. If it is negative, the x-ray company sends the result via fax only. Nurse #3 said she would check the fax machine for results during her shift. If she does not see them, she will call the x-ray company to see if they resulted. Nurse #3 said if the results are positive she would call the doctor and the responsible party with the results. If the results are negative, she faxes the result to the doctor. An interview with Nurse #4 on 9/2/15 at 10:35 am revealed the resident had no complaints of pain while she worked the night shift on 8/3/15, 8/4/15, and 8/5/15. The nurse reported the resident slept during the night. The nurse reported she saw no increased swelling to her knees but the resident always had swelling to her knees down to her feet and she wore the topical medicated patches for pain due to her [MEDICAL CONDITION]. The nurse reported the pain patches were put on her knees at 8:00 pm and taken off at 8:00 am. Nurse #4 was told by Nurse #2 that she had a fall and an x-ray was done on 8/3 and that the results were negative. Nurse #4 did not see the x-ray results. Nurse #4 reported the process when getting an x ray is to order the x-ray by phone. The x-ray company performs the x-ray and faxes the results to the nurse ' s station. If the results are negative, the nurse faxes the result to the doctor. If the results are positive, the nurse calls the physician for further orders. Nurse #4 revealed she did not receive a phone call from the x-ray company informing the nurse of the positive result of the x-ray. A phone interview was conducted with a technician from the x-ray company at 11:33 am on 9/2/15 regarding the results of Resident #1 ' s x-ray on 8/3. The technician reported the x-ray was done on 8/3 at 12:15 pm and resulted at 12:57 pm and faxed to the facility at this time. An interview with the call center supervisor from the x-ray center, reported the result was phoned into (Nurse #4) on 8/5/15. The call center supervisor further added that the phone call is a courtesy call the x-ray company does. Sometimes they are very busy and cannot get to it right away but the name of the facility stays up on the call back screen until the x-ray company contacts the facility. The supervisor reported the x-ray company would only make this courtesy call for positive or abnormal results. An interview with Nurse #4 on 9/2/15 at 3:00 pm revealed Nurse #4 received a phone call from the x-ray company on 8/5/15 asking if we received the results for resident. Nurse #4 reported she asked Nurse #2 if we received the results and Nurse #2 said, yes. Nurse #4 was asked why she did not inquire about the x-ray when the x-ray company called. Nurse #4 reported that the x-ray company did not say it was a positive result, they just asked if we got the results. Nurse #4 was asked if the x-ray company is calling to verify results were received, doesn ' t it mean they were positive? Nurse #4 reported that they call us with negative and positive results. At 1:50 pm on 9/2/15, the Account Manager from the x-ray company arrived to facility. The Account Manager reviewed the x-ray results from 8/3 and 8/6 and reported she would have a case review done by the company ' s radiology group to review the x-ray films again from 8/3/15 The Account Manager also reported that the x-ray company only makes courtesy calls to the facility when the results are positive. They do not call the facility when the result is negative or normal. During an interview on 8/19/15 at 3:00 pm, with the physician, it was revealed she was not aware of the x-ray result on 8/3/15. The physician added that if she had known about the acute fracture to the right femur she would have ordered the facility to send the resident to the hospital right away. The physician recalled being at the facility on 8/6/15 and being told the resident was having knee pain. The physician reported she ordered an x-ray for the resident and it showed a left fractured femur. The physician reported she was shown the x-ray result from 8/3/15 on 8/6/15 by Nurse #2. The physician asked why she was not told about the 8/3/15 result and Nurse #2 reported, she read the upper part of the result and missed the lower part. The physician reported her expectation of the nurses is to report any abnormal diagnostic test or lab value immediately to the doctor via phone or fax. An interview with the physician was conducted on 9/2/15 at 12:30 pm. The physician was asked if the condition worsened to Resident #1 due to not having the resident evaluated as a result of the x-ray on 8/3/15. The physician suggested that maybe the radiologist missed it if there was no displacement in the fracture. The physician reported that if it was not displaced, the fracture could be hard to see. In addition, she reported that with any kind of repositioning or lifting with a resident with [MEDICAL CONDITION] a fracture could occur. The physician recommended speaking to the radiologist to get further clarification of the x-ray on 8/3/15. A record review of the case review form by the company ' s radiology facility on 9/2/15 revealed the exams from 8/6/15 and 8/3/15 were reviewed to determine if the fracture shown on 8/6 was not visible or present on the prior study. The review comment revealed the left femur spiral fracture described on 8/6/15 exam is not visible on images of the left knee on 8/3/15. The physician revealed the resident was sent to the hospital where she had splints placed on both her legs and was transported to another hospital. On 8/8/15, the resident had bilateral surgery to her fractured femurs. Resident #1 did not return to the facility. The resident was admitted to another nursing home. On 8/20/15 at 10:45 am, an interview with the Director of Nursing (DON) revealed the expectation of the nurses is to notify the physician immediately when there is a positive diagnostic or lab result via fax or a phone call. The DON reported her expectation is that the nurses also follow up to be sure the physician received the phone call or the fax to see if there are further orders from the physician. The DON further added that her expectation of the nurse is that if the nurse ordered the lab or diagnostic test, they should check the fax room thru out their shift for the result. The Administrator was notified of the immediate jeopardy on 9/2/15 at 12:00 pm. The facility provided an acceptable credible allegation on 9/3/15 at 12:30 pm Resident # 1 had a fall on 8/3/15. The nurse evaluated the resident post fall; finding no injuries, range of motion unchanged with complaint of bilateral knee pain. An x-ray was completed on 8/3/15 with positive results of a right fractured femur. The nurse read the results as negative and did not notify the physician. The resident had increased pain and swelling and a second x-ray was ordered and performed on 8/6/15. The results were positive for a left femur fracture. The resident was sent to the hospital via ambulance and was later admitted to another hospital where orthopedic surgery was performed to bilateral femurs to repair the fractures. The resident did not return to the facility after the surgery. The resident was admitted to another nursing home facility. On 8/10/15 the lab diagnostic tool was implemented and includes the resident name, room number, test type and date, date responsible party notified and dated the physician was notified. The order recap audit tool which consists of tracking all new orders within the previous 24 hours per nurse station was also initiated. Individual verbal re-education on accurately interpreting and communicating results of diagnostic studies to physician, family and resident was provided by the Regional Clinical Director to the employee involved on 8/10/15. · On 8/10/15, a physician order [REDACTED].). This audit was performed by the facility Unit Manager (UM) and Director of Nursing (DON) on current facility residents. · On 08/10/15, All Licensed Nurses (across all shifts including weekend and as needed scheduled) were educated by the UM and DON on facility notification process related to change in condition and promptly communicating changes with MD/RP. · Newly hired Licensed Nurses will be educated by the Staff Development Coordinator (SDC) during their orientation on facility notification process related to change in condition including ensuring x-ray results are promptly communicated with MD/RP. · On 08/10/15, All Licensed Nurses (across all shifts including weekend and as needed) were educated on importance of Licensed Nurses utilizing facility Point Click Care (PCC) dashboard to communicate change of condition between shifts. · On 8/10/15, newly hired Licensed Nurses will be educated by the SDC during their orientation period on importance of Licensed Nurses utilizing facility PCC dashboard to communicate change of condition between shifts. · An audit is being performed utilizing the Daily 24 Recap form and Lab/Diagnostic audit tool on all new physician orders [REDACTED]. The audit is being performed by the DON and UM since 08/10/15 and will continue daily including weekends for four (4) weeks, twice weekly for (4) weeks, weekly for (4) weeks. Change in Facility Notification Protocol: 08/10/15 and ongoing Ø Lab/Diagnostic results are to be communicated to Physician (MD), Resident or Legal Guardian/Interested Family Member promptly after results are received. Follow-up with x - ray/lab Company will occur if results are not received timely. Ø All change of condition, order changes or events will be noted on PCC dashboard by Licensed Nurse to ensure shift to shift communication. Ø If Licensed Nurses unable to contact MD or Legal Guardian/Interested Family Member, document attempt to contact with the reason and time in medical record and on PCC dashboard. Also, notify oncoming nurse of need for follow-up. All other residents were assessed utilizing the 24 hour report, chart reviews, staff interviews, the order recap review and the lab/diagnostic audit tool to ensure proper follow-up including physician and responsible party notifications of change in condition. This was done by the (UM) and the DON on 8/10/15. Validation on 9/3/15 at 12:30 pm verified the credible allegation was evidenced by interviews of direct nursing staff related to education on interpreting and communicating results of diagnostic studies to the physician by utilizing the order recap review tool, the lab/diagnostic audit tool, and the Point Click Care dashboard to communicate change of condition between shifts. The DON and the UM will utilize the Daily 24 Recap form and the Lab/diagnostic audit tool on all new physician orders [REDACTED].

Based on record reviews, staff interviews, physician interviews, and x-ray facility staff interviews, the facility failed to identify the need for a medical intervention for 1 of 3 residents (Resident #1) with a significant change of condition of increased pain and swelling to bilateral knees after sustaining a fall. The Immediate Jeopardy began on 8/3/15 when the resident developed pain and swelling after a fall. The resident had a positive x-ray result of a right fractured femur and she did not receive medical attention until 8/6/15. The immediate jeopardy was removed on 9/3/15 when the facility provided a credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal that is not an immediate jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. Findings Included: Resident #1 had [DIAGNOSES REDACTED]. A record review of the Minimum Data Set (MDS) significant change of status assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired, dependent for transfers with assist of two. Extensive assist with one assist with bed mobility. Extensive assist with assist of one with personal hygiene, eating, dressing and locomotion off and on the unit and dependent with one assist with toileting. Resident #1 used a wheelchair and was always incontinent of bowel and bladder. A record review of care plans updated on 5/20/15 revealed a care plan was in place for risk for falls. Interventions included getting resident out of bed to wheelchair upon waking in the morning if she chooses, cue for safety awareness, encourage out of room activities, keep call light within reach, and keep wedge on right side of bed while in bed. A care plan for impaired cognitive function related to dementia was in place with interventions to keep routine consistent and require approaches that maximize involvement in daily decision. A care plan for weakness related to decrease functional mobility and falls was in place. Interventions included offering assistance with toileting, provide two person assist with sit to stand transfers to and from wheelchair. A care plan for potential for pain related to gout/[MEDICAL CONDITION] was in place. Interventions included inviting and escorting as needed to activities of interest, medication for pain to knees as ordered and monitor effectiveness. The resident participated in activities daily. A record review of the physician's order [REDACTED]. The resident also had a physician's order [REDACTED]. A record review of the Electronic Medication Administration Record [REDACTED]. Additionally, the resident had not received any pain medication during the month of July. A record review of a nurse ' s note written on 8/3/15 at 12:27 am revealed that Nurse #1 heard resident #1 calling for help. The nurse found the resident sitting on the floor next to the bed. The bed was in the lowest position. The resident complained of bilateral knee pain. The resident was unable to explain to the nurse how the fall happened. The nurse reported she notified the physician of the fall as well as the responsible party on 8/3/15 at approximately 1:30 am. A record review of a nurse ' s note written on 8/3/15 at 4:40 am by Nurse # 1 revealed the nurse administered two tablets of a pain medication for severe pain. A record review of a nurse ' s note written on 8/3/15 at 11:42 am by Nurse # 2 revealed a urine sample was collected from Resident # 1 for a urine analysis. Nurse #2 reported she also ordered an x-ray for the bilateral knees due to the swelling the nurse observed and the increased pain the resident was having. A record review of a radiology report dated 8/3/15 at 12:56 pm for Resident #1 revealed the resident had an acute oblique fracture involving the right distal femur with moderate displacement. The left knee resulted in no fracture or dislocation and showed modest [MEDICAL CONDITION]. A record review of a nurse ' s note written on 8/3/15 at 8:21 pm revealed Nurse # 2 administered two tablets of pain medication ([MEDICATION NAME] 5/325 milligrams) for severe pain. A record review of a nurse ' s note written on 8/3/15 at 10:35 pm revealed Nurse #2 received communication from the weekend nurse (Nurse #1) that Resident #1 fell and woke up in pain this morning to her bilateral knees. Nurse #2 noted there was swelling to the resident ' s knees. The nurse ordered a bilateral knee x-ray. The nurse reviewed the x-ray and found the result to be negative. A record review of a nurse ' s note written on 8/4/15 revealed Resident # 1 received pain medication on 8/4/15 at 5:00 pm. At 9:45 pm on 8/4/15, the resident received one tablet of pain medication for moderate pain. Resident #1 received one tablet of pain medication for moderate pain on 8/5/15 at 10:00 pm. A record review of a nurse ' s note written on 8/6/15 by Nurse #2 at 12:23 pm revealed Resident #1 was continuing to complain of pain to her left knee. A physician's order [REDACTED]. A record review of a radiology report dated 8/6/15 at 12:04 pm revealed Resident #1 had a recent displaced spiral left femur fracture. A record review of a nurse ' s note written on 8/6/15 at 6:20 pm revealed Resident #1 had a positive x- ray result revealing a fracture to the left femur. The doctor assessed the resident and ordered the resident to be sent to the hospital. The resident was transported to the hospital via stretcher on 8/6/15. The responsible party was made aware of the transfer. A phone interview on 8/19/15 at 3:15 pm was conducted with Nurse #1 who noted the fall on 8/3/15 at 12:27 am. The nurse reported that she called the physician and left a message regarding the fall at approximately 1:00 am. The nurse reported she left a message for the physician that there was no injury and the range of motion did not change for the resident. The nurse also revealed she called the responsible party and left a message. The nurse reported the resident complained of pain to her knees but she had chronic pain to her knees due to [MEDICAL CONDITION]. The nurse added the resident wears pain patches to her bilateral knees for the chronic pain. Nurse # 1 reported she was medicated with two tablets of pain medication ([MEDICATION NAME] 5/325 milligrams) at 4:40 am for increased pain. The nurse reported she told Nurse #2 that she might need an x-ray due to the increased pain. Nurse # 1 reported there was no increased swelling noted at the time she administered the pain medication. During an interview on 8/19/15 at 2:15 pm, with Nurse #2, the nurse revealed she ordered an x-ray on 8/3/15 due to the increased pain and swelling the resident had to her knees. The nurse ordered this x-ray at 9:15 am on 8/3/15 per the record review of the physician's order [REDACTED]. The nurse reported she looked at the results quick and she thinks she faxed it to the doctor, but she could not remember. The nurse further added that she showed the results to the physician on 8/6/15 when the physician was at the facility. The nurse reported the resident was complaining of pain in the left knee and the physician ordered an x-ray on 8/6/15 of the left leg. The nurse was asked what the process was when you order an x-ray with the x-ray company. The nurse reported that first, you order the x-ray by phone, and the x-ray company will come to facility and do the x-ray. The x-ray company will fax the results to the facility. The nurse reported the nurse is to go to the fax machine and get the results or they are delivered to the nurse ' s station by the administrative staff. The nurse was asked why she did not get the results until after 10:00 pm when it was faxed from the x-ray company to the facility at 12:57 pm. The nurse replied, sometimes the nurses do not have time; the fax machine is on the other end of the room. An interview with Nursing Assistant (NA) #1 at 9:35 am on 9/2/15 revealed the NA recalled Resident #1 had complained about pain after the fall on 8/3/15. NA #1 reported it was getting harder to assist her. The resident was a two-person assist with transfers and was only a one person most of the time with activities of daily living (ADL ' s) but after her fall, she needed two people to assist her at all times. The NA noticed swelling to her left leg and reported it to the nurse. The resident stayed in bed on the day shift on 8/3/15 and the resident refused to get out of bed due to her pain. When the resident complained of pain, the NA told the Nurse #2. The NA believes she was medicated with pain medication. The NA reported the resident had a lot of pain when being repositioned. Prior to the fall, the resident would sit at the edge of the bed and bath the upper part of her body. She would get out of bed every day after breakfast and go to activities. The resident liked to be up and out of bed early. The NA did not recall if the resident had any pain prior to the fall. An interview with NA #2 at 4:27 pm on 9/2/15 revealed when the NA arrived to her shift at 3:00 pm, the resident is up and in her wheelchair. NA #2 revealed she was there the night the resident fell . NA #2 reported the resident slid out of bed. The resident ' s bed was in the lowest position and the wedge was by the bed. The resident complained of leg pain but NA #2 could not remember which leg. The NA could not tell if she had swelling after the fall, but before the fall she was fine, she had no swelling. The NA reported the resident fell after shift change. NA # and Nurse #1 assisted the resident back to bed. The NA reported the resident had no complaints of pain at the time that she could recall. The NA reported that Resident #1 did not walk and reported she did not have any complaints of pain prior to the fall on 8/3/15. The NA reported the resident ' s routine was to stay up until after dinner. Around seven or so depending on her mood, she would go to bed. The resident ate dinner in her room. The resident utilized a sit to stand lift to transfer with an assist of two NAs. The resident did not have any complaints of pain during her transfers prior to the fall. The resident did complain of pain after her fall during the transfers. The interventions that were in place were to have the bed in the lowest position and a wedge positioned on her right side while in bed. The resident was complaining of pain on Tuesday 8/4/15 and the NA reports she made Nurse #3 aware. The resident did get out of bed on Tuesday but on Wednesday and Thursday, she was in bed when the NA started the shift at 3:00 pm. A phone interview with NA #3 on 9/2/15 at 12: 15 pm revealed Resident #1 got up every day using the Sit and Stand Lift. The NA reported she had no complaints of pain and the resident always wanted to get up and get ready to go in the morning. The resident had breakfast in her room and then got ready to go to activities. The resident ate lunch in the dining room. The NA reported that after the fall, she did refuse to get out of bed and she noticed the resident had swelling to her knees. The NA reported she told Nurse #2. The NA said the resident had arthritis and did complain her knees ached, but she wore the patches to help with that. A phone interview with NA #4 on 9/2/15 at 1:08 pm revealed Resident #1 had a lot of pain after the fall. She did not want to be moved or have anyone touch her legs. The NA reported she told Nurse #2 about her pain and the swelling which the NA observed. The NA reported she does not know what the nurse did, but she knows the nurse went in to see the resident. The NA reported the resident was resting quietly in bed and it was not until you moved the resident, that she said she had pain to her legs. An interview with Nurse #3 at 3:17 pm on 9/2/15 revealed Nurse #3 (3-11 shift) received change of shift report from Nurse #2 (7-3 shift) on 8/4/15. Nurse #2 reported Resident #1 had a fall on the morning of 8/3/15 and had an x-ray, but it was negative of a fracture. Nurse #3 did not receive in report the resident was having any pain nor did she see the x-ray. Nurse #3 reported on the night of 8/4/15 she assessed the resident when the NA came to her and told her the resident was in pain. The NA had just transferred the resident and was doing incontinent care and the resident was calling out in pain. The NA notified the nurse. The nurse found the resident to be in pain and medicated her with one tablet of [MEDICATION NAME] 5/325. The nurse reported when she reassessed the resident, she was sleeping. The nurse reported that her bilateral legs did not have any increased swelling. Nurse #3 reported the process when a nurse orders an x-ray is to call the x-ray company. The x-ray company will come to the facility to do the x-ray. The x-ray company will fax the results to the facility. Nurse #3 also added that if the result is positive or there is an abnormal result, the x-ray company would call to speak to the nurse. If it is negative, the x-ray company sends the fax only. Nurse #3 said she would check the fax machine for results during her shift. If she does not see them, she will call the x-ray company to see if they resulted. Nurse #3 said if the results are positive she would call the doctor and the responsible party with the results. If the results are negative, she faxes the result to the doctor. An interview with Nurse #4 on 9/2/15 at 10:35 am revealed the resident had no complaints of pain while she worked the night shift on 8/3/15, 8/4/15, and 8/5/15. The nurse reported the resident slept during the night. The nurse reported she saw no increased swelling to her knees but the resident always had swelling to her knees down to her feet and she wore the topical medicated patches for pain due to her [MEDICAL CONDITION]. The nurse reported the Salon pas were put on at 8:00 pm and taken off at 8:00 am. Nurse #4 was told by Nurse #2 that she had a fall and an x-ray was done on 8/3 and that the results were negative. Nurse #4 did not see the x-ray results. Nurse #4 reported the process when getting an x ray is to order the x-ray by phone. The x-ray company performs the x-ray and faxes the results. The faxes go to a fax machine at the nurse ' s station. If the results are negative, the nurses fax the result to the doctor. If the results are positive, the nurse calls the physician for further orders. Nurse #4 revealed she did not receive a phone call from the x-ray company informing the nurse of the positive result of the x-ray. A phone interview was conducted with an employee from the x-ray company at 11:33 am on 9/2/15 regarding the results of Resident #1 ' s x-ray on 8/3. The employee reported the x-ray was done on 8/3 at 12:15 pm and resulted at 12:57 pm and faxed to the facility at this time. An interview with the call center supervisor from the x-ray company, reported the result was phoned into (Nurse #4) on 8/5/15. The supervisor further added that the phone call is a courtesy call that the x-ray company does. Sometimes they are very busy and cannot get to it right away but the name of the facility stays up on the call back screen until the x-ray company contacts the facility. The supervisor reported that the x-ray company would only make courtesy calls for positive or abnormal results. On 9/2/15 at 1:50 pm, the account manager from the x-ray company arrived at the facility. The account manager reviewed the x-ray results from 8/3 and 8/6 and reported she would have a case review done by the x-ray company ' s radiology facility to review the x-ray films again from 8/3/15. The account manager also confirmed the x-ray company only makes courtesy calls to the facility when the results are positive. They do not call the facility when the result is negative or normal. On 8/20/15 at 10:45 am, an interview with the Director of Nursing (DON) revealed the expectation of the nurses is to notify the physician immediately when there is a positive diagnostic or lab result via fax or a phone call. The DON reported her expectation is that the nurses also follow up to be sure the physician received the phone call or the fax to see if there are further orders from the physician. The DON further added that her expectation of the nurse is that if the nurse ordered the lab or diagnostic test, they should check the fax room thru out their shift for the result. The DON provided in-services to licensed nurses on all shifts on 8/10/15 that if a fall occurs the nurse on duty would perform the following post fall actions: 1. Provide immediate care to address any injuries and resident safety 2. Evaluate resident for any additional injury which would require medical intervention which includes: >Vital Signs >Skin Evaluation >Musculoskeletal assessment >Change of condition >Pain Assessment >Neurological assessment as indicated 3. Thoroughly document clinical findings in medical record 4. Interview resident and staff to determine if cause of fall can be determined 5. Notify MD in person or by telephone of all falls, assessment findings and document in the medical record. 6. Notify family and document notification in medical record 7. Complete post fall assessment and formulate interventions based off evaluated clinical information. 8. Communicate established interventions to the care giving staff 9. Document post fall every shift for 72 hours. During an interview with the DON and the Administrator, The DON reported at 12:00 pm on 9/2/15 that when the nurses order an x-ray the process is for them to call the x-ray company. The x-ray company performs the x-ray; the results are faxed to the facility. The DON or the secretary will check the fax machine in the morning and deliver any faxes to the nurses if they are sent to their fax machines, or the nurses will receive the result via fax at the nurse ' s station. The DON added the x-ray company would call the facility and speak to the nurse if they have a positive result. During an interview on 8/19/15 at 3:00 pm, with the physician, it was revealed she was not aware of the x-ray result on 8/3/15. The physician added that if she had known about the acute fracture to the right femur she would have ordered the facility to send the resident to the hospital right away. The physician recalled being at the facility on 8/6/15 and being told the resident was having knee pain. The physician reported she ordered an x-ray for the resident and it showed a left fractured femur. The physician reported she was shown the x-ray result from 8/3/15 on 8/6/15 by Nurse #2. The physician asked why she was not told about the 8/3/15 result and Nurse #2 reported, she read the upper part of the result and missed the lower part. The physician reported her expectation of the nurses is to report any abnormal diagnostic test or lab value immediately to the doctor via phone or fax. An interview with the physician was conducted on 9/2/15 at 12:30 pm. The physician was asked if the condition worsened to Resident #1 due to not having the resident evaluated as a result of the x-ray on 8/3/15. The physician suggested that maybe the radiologist missed it if there was no displacement in the fracture. The physician reported that if it was not displaced, the fracture could be hard to see. In addition, she reported that with any kind of repositioning or lifting with a resident with [MEDICAL CONDITION] a fracture could occur. The physician recommended speaking to the radiologist to get further clarification of the x-ray on 8/3/15. A record review of the case review form by the x-ray company ' s radiology facility on 9/2/15 revealed the exams from 8/6/15 and 8/3/15 were reviewed to determine if the fracture shown on 8/6 was not visible or present on the prior study. The review comment revealed the left femur spiral fracture described on 8/6/15 exam is not visible on images of the left knee on 8/3/15 The physician revealed the resident was sent to the hospital where she had splints placed on both her legs and was transported to another hospital on [DATE] where the resident had bilateral surgery to her fractured femurs on 8/8/15. A phone interview was conducted on 9/9/15 at 10:40 am with the radiologist who read the x-ray results on 8/3/15 of the right knee and the left knee. The radiologist reported that the results on 8/3/15 were accurate. He could not see a fracture to the distal femur. The radiologist reported the 8/3/15 x-ray was also read by another radiologist. The other radiologist confirmed the 8/3/15 results were accurate. A phone interview was conducted on 9/9/15 at 11:14 am with the radiologist who read the x-ray result on 8/6/15 of the left femur. The radiologist reported that the fracture looks new as it shows no signs of healing. The radiologist felt that the fracture happened within one week. The administrator was notified of the immediate jeopardy on 9/2/15 at 12:00 pm. The facility provided an acceptable credible allegation on 9/3/15 at 12:28 pm. Resident # 1 was found on the floor beside her bed on 8/3/15. The nurse evaluated the resident post fall; finding no injuries, range of motion unchanged with complaint of bilateral knee pain. An x-ray was completed on 8/3/15 resulting in a right fractured femur. The nurse read the results as negative and did not notify the physician. Resident had increased pain and swelling and a second x-ray was ordered and performed on 8/6/15. The results were positive for a left femur fracture. The resident was sent to the hospital via ambulance and was later admitted to another hospital where orthopedic surgery was performed to bilateral femurs to repair the fractures. The resident did not return to the facility after the surgery. The resident was admitted to another nursing home facility. All NAs will be educated on the ability and necessity of completing the interact stop and watch tool on their Point of Care input screens when they notice a change of condition of the resident on 9/2/15. This information automatically shows up on the Point Click Care Clinical Alert dashboard for the nurses to see. All nurses were educated on 9/2/15 of the positive confirmation phone call from the x-ray company until the change in procedure occurs on 10/1/15. The new procedure includes a positive watermark across the entire page for all positive results. All newly hired licensed nurses will be educated by the Staff Development Coordinator on post fall assessments and documentation during their orientation period. The DON and the Unit Managers are responsible for the implementation and monitoring of the Falls Management Program. All fall occurrences will be reviewed ongoing daily (Monday - Friday) at stand up meeting, weekly in Quality Assurance Risk Management meeting by the DON/Unit Managers and the Week-end Supervisor/On Call Administrative Registered Nurse on Saturday and Sunday. Beginning 9/2/15 all residents will be assessed post fall within 24 hours by the facility Unit Manager, Director of Nursing or Nurse Supervisor. All other residents were assessed utilizing the 24 hour report, chart reviews, staff interviews and resident observations for changes in condition as a result of a fall on 9/3/15 by the DON. Validation on 9/3/15 at 12:30 pm verified the credible allegation was evidenced by interviews of direct nursing staff related to education on reading and reporting positive x-rays results to the physician as well as accurate assessments and implementing interventions post fall. In-services to NAs and nurses related to falls and completing accurate assessments were implemented on 8/10/15. The DON and Unit Manager verified they will assess post fall residents within 24 hours which was implemented on 9/2/15.

Based on record review and staff interview, the facility failed to prevent a significant medication error by administering [MEDICATION NAME], a long acting insulin, to a resident who did not have a [DIAGNOSES REDACTED].#252) and did not have an order for [REDACTED].#245). The immediate jeopardy began on 7/12/15 when a long acting insulin ([MEDICATION NAME]) was administered to Resident #252 and a long acting insulin ([MEDICATION NAME]) was not administered to Resident #245. The immediate jeopardy was removed on 7/30/15 at 4:55 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of D (no actual harm with the potential for more than minimal harm) that is not immediate jeopardy to ensure monitoring systems put into place are effective. The findings included: 1. Resident # 252 was admitted to the facility on [DATE] and was discharged from the facility on 7/21/15. Cumulative [DIAGNOSES REDACTED]. A physician order [REDACTED]. On 7/13/15, a physician's orders [REDACTED]. A record of blood sugars for July 2015 was reviewed and blood sugar was 96 on 7/13/15, 113 on 7/14/15, (not recorded) on 7/15/15, and 172 on 7/16/15. A 5 day Minimum Data Set ((MDS) dated [DATE] indicated Resident #252 was severely impaired in cognition, Diabetes mellitus was not checked as a [DIAGNOSES REDACTED]. The MDS indicated four insulin injections were received during the assessment period. The July Medication Administration Record (MAR) was reviewed and revealed Resident #252 received [MEDICATION NAME] 20 units subcutaneously at 9:00PM on 7/12/15, 7/14/15, 7/15/15, and 7/16/15. It was noted that the [MEDICATION NAME] was not administered on 7/13/15 due to a blood sugar of 94. A physician progress notes [REDACTED].#252 being started on insulin. Resident #252 was mistakenly started on [MEDICATION NAME]. They were reassured that the blood sugars were stable and she did not have any low blood sugars as a result of giving her [MEDICATION NAME]. The [MEDICATION NAME] and blood sugars were discontinued. A medication variance report dated 7/17/15 stated a medication ([MEDICATION NAME]) was entered by (name of nurse) on 7/11/15 and was supposed to be ordered for (Resident #245) but was ordered for (Resident #252). Resident #252 received [MEDICATION NAME] dose on 7/12/15, 7/14/15, 7/15/15, and 7/16/15 (4 doses). This was a transcription issue. Notification: supervisor, attending physician, administrator, resident/ family. Investigation was conducted on 7/17/15 and was found to be a transcription error. Consultation was done with the physician assistant and pharmacist. Blood sugars were normal with therapy. No long term effects noted. Action: blood sugars monitored; monitored for signs and symptoms of [DIAGNOSES REDACTED]. Accuchecks (blood sugars) discontinued. Medication discontinued. Action plan implemented. An in-service dated 7/17/15 given by the Director of Nursing was reviewed. The contents of the in-service included the following: confirmation of all orders with two nurses. There would also be an order re-cap performed by the 11-7 nurses nightly and all of this included all physician orders. The in-service was completed on 7/27/15 with two nurses not receiving the in-service. The in-service will be given to those two nurses prior to their working on the floor. On 7/29/15 at 8:28AM, Administrative staff #2 was interviewed. She stated, on 7/11/15, the nurse who was working 3-11 shift had checked a blood sugar on Resident #245 and called the physician assistant to get an order because the blood sugar was high. Resident #245 was already a diabetic and on high doses of insulin at that time. The physician assistant on call gave an order to start the following day giving a low dose basal insulin ([MEDICATION NAME]) at bedtime. The nurse put the order in the computer and the order went in on the incorrect patient (Resident #252). The next day, the nurse checked the blood sugar and gave the insulin to Resident #252. On 7/13/15, the [MEDICATION NAME] was not given because the blood sugar was low. The [MEDICATION NAME] was then given on 7/14/15, 7/15/15, and 7/16/15. On the 17th, the MDS (minimum data set) nurse reviewed Resident #252's chart for MDS purposes and noted that the insulin order was new for Resident #252. She started the investigation because she had not noted a diabetes diagnosis. Administrative staff #2 reviewed the orders and asked the physician assistant to review the chart, evaluate Resident #252 and notify the family of the medication error. Resident #252 was monitored for any signs and symptoms of [DIAGNOSES REDACTED]; the pharmacist was notified who stated the blood sugars were normal with the therapy and there were no long term effects and did not cause any harm. On 7/17/15, a process was put into place that the nurses would write the orders on paper when they received a telephone order prior to putting the order into the computer and the order would be checked by a second nurse when the order was entered onto the computer. A recap of all residents' orders was done on 7/17/15 and was ongoing. Administrative staff #2 in-serviced all nursing staff on 7/17/15 and finished 7/25/15 (weekend and regular staff). The night nurses did a recap of every physician order [REDACTED]. Any error was to be reported to the unit managers immediately and notification of any change of orders to the family prior to administration of medication. Random monitoring would be done by the unit manager. Administrative staff #2 stated they had already put an action plan in place effective 7/17/15 and were following the results to be discussed in Quality Assurance and Performance Improvement meetings. On 7/29/15 at 11:00AM, Nurse #2 stated she worked 3-11 shift on 7/11/15. She stated she had notified the physician for orders for [MEDICATION NAME] for another resident who had very high blood sugars. When she was putting the physician orders [REDACTED]. Nurse #2 stated, when she returned to work on 7/17/15, she was asked by the MDS nurse if she had put the insulin order she had received on 7/11/15 in the computer under Resident #252. Nurse #2 stated she did not know how it happened that the insulin order was placed under Resident #252's orders. On 7/29/15 at 4:30PM, Administrative staff #2 was interviewed regarding random monitoring. She stated the unit manager would randomly check physician orders [REDACTED]. She stated Nurse #3 was performing the monitoring. On 7/29/15 at 4:45PM, Nurse #3 stated she reviewed physician orders [REDACTED]. Nurse #3 stated she had not monitored specifically for insulin orders or checked orders on residents already in the facility-only new admissions. No random monitoring had been done or recorded by Nurse #3. 2. Resident #245 was admitted to the facility on [DATE] and was discharged from the facility on 7/20/15. Cumulative [DIAGNOSES REDACTED]. An Admission MDS dated [DATE] stated Resident #245 had a [DIAGNOSES REDACTED]. Physician orders [REDACTED].#245 were reviewed and revealed the following: *7/9/15 Humalog 100 unit/ ml (insulin [MEDICATION NAME])-inject 1 dose subcutaneously every 6 hours (12midnight--6:00AM-- 12noon-6:00PM) for diabetic sliding scale insulin BG (blood glucose)-140 divided by 40 = number of units to give. This order was discontinued on 7/13/15. *7/10/15 Insulin [MEDICATION NAME] ([MEDICATION NAME]) 40 units subcutaneously daily (6:30AM). The medication was administered times one dose and the order was discontinued on 7/10/15. *7/11/15 insulin [MEDICATION NAME] ([MEDICATION NAME]) 60 units subcutaneously daily (6:30AM). The insulin was administered on 7/11/15, 7/12/15, 7/13/15 and discontinued on 7/13/15. *7/13/15 Humalog (insulin [MEDICATION NAME]) inject 15 unit subcutaneously every 6 hours (12midnight-6:00AM-12noon-6:00PM). Do not give if BS<(less than) 80, give 6 units if BS 80-120. The MAR indicated Resident #245 received the [MEDICATION NAME]until discharge from the facility on 7/20/15. *7/13/15 insulin [MEDICATION NAME] ([MEDICATION NAME]) 78 units subcutaneously daily (6:30am). Hold if BG <80, give 40 units if BG between 80-120-begin 7/14/15. The MAR did not indicate this medication was given and the order was discontinued on 7/14/15. *7/14/15 insulin [MEDICATION NAME] ([MEDICATION NAME]) inject 85 units subcutaneously daily (6:30AM). Hold of BG <80, give 40 units if BG between 80-120. The MAR indicated the insulin was administered from 7/15/15 through 7/20/15. A review of the blood glucose levels for Resident #245 documented with insulin [MEDICATION NAME] ([MEDICATION NAME]) for 6:30AM from 7/11/15 through 7/20/15 revealed the following: 7/11/15-320; 7/12/15--369; 7/13/15--377; 7/14/15--381; 7/15/15-211; 7/16/15-168; 7/17/15-269; 7/18/15-256; 7/19/15-128; 7/20/15-178. Sliding scale insulin with blood glucose checks done every 6 hours (12 midnight-6am-12 noon-6pm) and sliding scale coverage was reviewed with the following blood sugars noted from 7/11/15 through 7/17/15: 7/11/15 6PM--424 7/12/15 12midnight-412; 6AM-369; 12noon-392; 6PM-399 7/13/15 12midnight-406; 6AM-377; 12noon-353; 6PM-536 7/14/15 12midnight-466; 6AM-381; 12noon-417; 6PM-175 7/15/15 12midnight-259; 6AM-211; 12noon-210; 6PM-146 7/16/15 12midnight-193; 6AM-168; 12noon-248; 6PM-124 7/17/15 12 midnight-211; 6AM-269; 12noon-281; 6PM-268 On 7/29/15 at 4:30 PM, Administrative staff #2 stated the facility had completed a medication variance report on 7/17/15 for Resident #245. Administrative staff #2 stated the unit manager would randomly check physician orders [REDACTED]. She stated Nurse #3 was performing the monitoring. A review of the Quality Assessment action plan revealed the following; 1. Resident/ family and physician were notified of the medication error on 7/17/15. 2. Resident #245 was evaluated by the PA (physician assistant). 3. All nurses and medication aides were in-serviced by the Director of Nursing. The contents of the in-service included the following: confirmation of all orders with two nurses. There would also be an order re-cap performed by the 11-7 nurses nightly and all of this included all physician orders. The in-service was completed on 7/27/15 with two nurses not receiving the in-service. The in-service will be given to those two nurses prior to their working on the floor. 4. 1:1 review was conducted with the nurse involved in the transcription error for Resident #252 and #245. 5. systemic change-confirming nurse to verify orders and initial (double check) and 11-7 nurse to do order recap (review the past 24 hours of physician orders [REDACTED]. 6. All charts were audited on 7/17/15 and no variances were noted. 7. Decision was made to take to QA on 7/17/15. 8. Order reviews to be done by unit manager at random. On 7/29/15 at 4:30PM, Administrative staff #2 stated the facility had completed a medication variance report on 7/17/15 for Resident #245. Administrative staff #2 stated the unit manager would randomly check physician orders [REDACTED]. She stated Nurse #3 was performing the monitoring. On 7/29/15 at 4:30 PM, Administrative staff #2 was interviewed regarding random monitoring . She stated the unit manager would randomly check physician orders [REDACTED]. She stated Nurse #3 was performing the monitoring. On 7/29/15 at 4:45PM, Nurse #3 stated she reviewed physician orders [REDACTED]. Nurse #3 stated she had not monitored specifically for insulin orders or checked orders on residents already in the facility-only new admissions. On 7/29/15 at 6:30PM, the administrator was notified of the immediate jeopardy. The facility provided the following credible allegation on 7/29/15 at 4:55PM for F 333 as follows: Address how the corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #252 is currently discharged from the facility to home on 7/21/15. Upon discovery of medication variance on 07/17/15 for Resident #252 during her stay at the facility, the facility Director of Nursing (DON) began an investigation and initiated an action plan on 07/17/15. The action plan included the following: Medication Variance Worksheet completed on 07/17/15. [MEDICATION NAME] and Accuchecks were discontinued and new order was received from the Physician Assistant to monitor resident for signs and/or symptoms of [DIAGNOSES REDACTED] from 07/17/15. Resident was monitored for signs and symptoms of [DIAGNOSES REDACTED] every shift from 7/17/15 through 7/21/15 (date of discharge) and was documented on the Medication Administration Record (MAR). Responsible Party was notified of medication variance by Physician Assistant on 07/17/15. Pharmacy Consultant was notified of medication variance on 07/17/15. Physician notified of medication variance by DON on 07/17/15. Resident #252 was evaluated and medical record reviewed by Physician Assistant on 07/17/15. Director of Nursing performed comprehensive physician order [REDACTED]. After review, no other medication variances were noted. This was completed 7/17/15. Education was provided by the facility DON to Licensed Nurses including the medication aide related to medication variance prevention, transcription order accuracy with verification of accuracy by another nurse and the facility 24 hour order recap process by the 11-7 shift nurses. This was completed on 7/26/15. Resident #245 is currently discharged from the facility. Medication Variance Worksheet completed on 07/17/15. Responsible Party was notified by Physician Assistant on 7/17/15. Physician notified by DON on 07/17/15. Resident #245 was evaluated and medical record reviewed by Physician Assistant on 07/17/15. Pharmacy Consultant was notified of medication variance. Director of Nursing performed comprehensive physician order [REDACTED]. After review, no other medication variances were noted. This was completed on 7/17/15. Although the medication variance was identified on 7/17/15, Resident #245 did have changes to her hyperglycemic drug regimen on 07/13/15 to include increasing scheduled [MEDICATION NAME] and [MEDICATION NAME] doses. Resident #245 ' s blood sugar results had improved after the changes in the insulin doses. The blood sugar results were 377 (7/13), 175 (7/14), 211 (7/15), 168 (7/16), 269 (7/17), 256 (7/18), 128 (7/19) and 178 (7/20). Resident #245 was discharged to the hospital on [DATE] due to abdominal distention. Individual re-education on accurate physician order [REDACTED]. How corrective action will be accomplished for those residents having potential to be affected by the same deficient practice: On 7/29/15, a physician order [REDACTED]. After review, no other transcription errors were noted. On 7/29/15, a diabetic audit was performed by the facility Unit Manager and DON on current residents with a [DIAGNOSES REDACTED]. Three (3) residents' physician orders [REDACTED]. On 7/29/15, a care plan audit was performed by Unit Manager on facility residents with [DIAGNOSES REDACTED]. After review, all residents with a [DIAGNOSES REDACTED]. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not occur: Licensed Nurses were educated by the Director of Nursing and Regional Clinical Director on the following date: 7-30-15 on the following: 1) Accurately transcribing physician orders [REDACTED]. A Licensed Nurse will obtain a secondary nurse to confirm that the transcription of new orders is accurate in the electronic medical record by comparing the new physician order [REDACTED]. A notation (with verifying nurse ' s initials) will be written on the new physician order [REDACTED]. 2) Licensed Nurses to ensuring blood glucose results are documented under supplementary documentation in electronic medical record after results are obtained. 3) Daily 24 hour order recap process. This process includes reviewing new physician orders [REDACTED]. Licensed Nurses on 11p - 7 am shift will perform a daily 24 hour recap audit of all new physician orders [REDACTED]. This audit will include a review of all new physician orders [REDACTED]. Newly hired Licensed Nurses will be trained by the facility Staff development Coordinator during their orientation period on ensuring accuracy of transcription for new physician orders, documentation of blood glucose results in electronic medical record when obtained and ensuring verification of accuracy for new physician orders [REDACTED]. Any Licensed Nurses not available for the education will be removed from the schedule and education will be required to be completed prior to nurse working on an assignment. On 7/30/15 at 4:55PM, the credible allegation was validated. All resident's orders were audited for accuracy on 7/29/15. In-servicing of all licensed staff was completed on 7/29/15. Staff interviews with licensed nursing staff over all shifts revealed the facility had implemented the following: a double check with two nurses when a telephone order was obtained by writing the physician order [REDACTED]. The night shift nursing staff (11-70 would run a re-cap of all physician orders [REDACTED].