Every finding on record at Sunterra Springs Riverview

Based on record review and staff interview, it was determined the facility failed to ensure pharmacist recommendation were addressed by the physician. This was true for 1 of 5 residents (Resident #31) whose pharmacy recommendations were reviewed. This failure created the potential for Resident #31 to receive medications that were ineffective. Findings include:Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including aftercare for fracture of right femur, bipolar disorder, and major depressive disorder.Resident #31's record documented the following physician's orders:lurasidone (an antipsychotic medication) oral tablet 20 mg, give 20 mg by mouth one time a day: take with 80 mg for 100 mg total. Start 12/18/25.An Interim Medication Regimen Review form included a section for the pharmacist to write his/her detailed description of irregularity and recommendations and a section for the physician to make a comment regarding the pharmacist recommendation.Resident #31's Interim Medication Regimen Review form dated 12/23/25, documented the Pharmacist wrote, Lurasidone: Per manufacturer's recommendation: Administer lurasidone with a meal. Medication is dependent on food for absorption.Resident #31's Interim Medication Regimen Review form dated 12/23/25, was signed by the physician's but did not indicate accept or decline of the pharmacist's recommendation for lurasidone to be taken with food.On 1/7/26 at 11:30 AM, RN #1 reviewed Resident #31's MAR and stated the medication was scheduled to be administered between 1400 (2:00 PM) and 1600 (4:00 PM), but no indication it was to be administered with a food.On 1/7/26 at 10:24 AM, the ADON with the DON present, reviewed Resident #31's Interim Medication Regimen form and stated the physician should have marked that they acknowledged the recommendation one way or the other and they did not.

Based on observation, record review, policy review, and interviews, it was determined the facility failed to ensure the interdisciplinary team had determined it was safe for a resident to self-administer medications. This was true for 1 of 1 resident (Resident #29) reviewed for self-administration of medications. This failure created the potential for adverse outcome if Resident #29 was to take her medications inappropriately. Findings include:The facility's Resident Self-Administration of Medication policy, revised 7/2024, documented residents had the right to self-administer medication and may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including hypertension, and GERD (a chronic digestive disorder where stomach acid frequently flows back into the esophagus). Resident #29's care plan revised 12/15/25, documented she had impaired vision secondary to being legally blind. A physician order dated 12/12/25, documented the following:calcium carbonate (Tums) tablet chewable 500 mg: Give 1 tablet by mouth every 6 hours as neededacetaminophen (Tylenol) tablet 325 mg: Give 2 tablets by mouth every 6 hours as needed A Self-Administration Evaluation dated 12/12/25, documented Resident #29 did not want to self-administer medication while in the facility. On 1/5/26 at 2:06 PM and 1/6/26 at 8:49 AM, a bottle labeled antacids was observed on top of Resident #29's bedside table. Inside the bottle were several white oblong shaped pills mixed with round colored tablets. When asked about the white oblong shaped pills, Resident #29 stated the white pills were Tylenol. When asked how often she takes the antacids and Tylenol, Resident #29 stated she took the antacids and Tylenol whenever she needed them. On 1/6/26 at 10:02 AM, the DON accompanied the surveyor to Resident #29's room and verified the antacid bottle at Resident #29's bedside was Tums, and the white pills were Tylenol. The Self-Administration Evaluation was reviewed with the DON who confirmed the assessment documented Resident #29 did not want to self-administer medications. The DON stated Resident #29 should not be self-administering medications.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure pharmacy labels matched the physician's order. This was true for 1 of 5 residents (Resident #40) whose medication administration was observed. This failed practice created the potential for harm if Resident #40's Prazosin (blood pressure medication) was administered at the wrong dose. Findings include: The State Operations Manual, Appendix PP revised 7/23/25 documented . labeling of the medication or device pursuant to a prescription/order.Resident #40 was admitted to the facility on [DATE] and re-admitted on [DATE], with multiple diagnoses including hypertensive heart disease with heart failure (when long-standing high blood pressure strains the heart, resulting in heart failure).A physician's order, dated 1/2/26 documented Resident #40 was to receive the following:Prazosin HCl 1 mg capsule: 2 capsules by mouth two times a day for hypertension for systolic blood pressure less than 110 and heart rate less than 60.On 1/7/26 at 7:54 AM, LPN #2 prepared Resident #40's medication which included the Prazosin and administered the oral medication at 8:11 AM. The Prazosin pharmacy label documented Give 1 capsule by mouth twice daily.On 1/7/26 at 10:57 AM, when asked to confirm the Prazosin pharmacy card label, LPN #2 stated the label read to give 1 capsule by mouth twice daily, but the physician order changed to 2 capsules by mouth twice daily. On 1/8/26 at 11:28 AM, when the DON was asked if the physician order and the pharmacy card label were to match, the DON confirmed the label should match the physician order.

Based on record review and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 12 residents (#31 and #56) reviewed for medications. This deficient practice created the potential for harm if residents received the wrong dosage of medications. Findings include: The online Nursing 2025 Drug Handbook accessed on 1/12/26, stated the eight rights of medication administration were:Right drugRight patientRight doseRight timeRight routeRight reasonRight responseRight documentation 1. Resident #31 was admitted to the facility on [DATE], with multiple diagnoses including aftercare for fracture of right femur, bipolar disorder, and major depressive disorder.Resident #31's record documented the following physician's orders:Lurasidone oral tablet 20 mg, give 20 mg by mouth one time a day for antipsychotic: take with 80 mg for 100 mg total. Start 12/18/25.Resident #31's MAR dated 12/18/25 through 12/27/25 documented she received lurasidone as follows:At 6:00 AM lurasidone oral tablet 20 mg by mouth one time a dayAt 2:00 PM lurasidone oral tablet 80 mg by mouth one time a [NAME] Nursing Progress Note dated 12/27/25, documented Resident #31requested her lurasidone 20 mg and 80 mg oral tablets to be administered together in the evening medication pass. On 1/7/26 at 2:15 PM, the DON reviewed Resident #31's physician's order and December 2025 MAR and stated she did not know why the dose was divided from 12/18/25 through 12/27/25. 2) Resident #56 was admitted to the facility on [DATE] with multiple diagnoses including aftercare following joint replacement surgery, osteoarthritis of left knee, and dementia.A Medication error report dated 10/3/25, documented LPN #3 administered Resident #56 Lyrica 75 mg (a controlled medication) and auvelity 45-105 mg (an antipsychotic medication) in error. The report documented the medication was intended for a resident in a different room. Per the report, both the resident and her husband were upset about the error, but no physical harm noted.On 1/7/26 at 2:30 PM, the DON reviewed the medication error report and confirmed LPN #3 reported the medication error to her and took full responsibility for the mistake.

Based on personnel record review and staff interviews, it was determined the facility failed to ensure licensed nurses performed tasks which they had the knowledge, skills, and competencies. This was true for 1 of 5 licensed nurses reviewed for completion of the required trainings and competencies necessary to care for resident's needs. This failure had the potential to affect all residents in the facility and increased the risk of harm to residents if staff were not trained on how to provide care and services to residents. Findings include:LPN #1's hire date was 9/26/25. Review of her personnel file did not document she had completed her onboarding training. LPN #1 completed 3 out of 24 of the assigned modules.On 1/9/26 at 12:00 PM, the Administrator confirmed LPN #1 had not completed her required training beyond the three she completed on 1/7/26 and stated she should not have been working with residents without completing all her training.On 1/9/26 at 12:15 PM, the DON stated all newly hired staff must complete their assigned training by the due date prior to working with residents. When questioned about LPN #1's training, the DON stated she was not aware the training had not been completed and had not addressed it with LPN #1.

Based on observation, record review, and interviews, the facility failed to ensure professional standards of care were followed for 3 of 12 residents (#48, #51, and #55) reviewed for quality of care. Resident #48 and #51's medications were not clarified from the physician. Resident #55 did not receive her therapy session as scheduled. These failed practices had the potential to adversely affect residents whose care and services were not delivered according to accepted standards of clinical practice. Findings include:1. Resident #48 was admitted to the facility on [DATE] with multiple diagnoses including, mild cognitive impairment, dysphagia (difficulty swallowing), sepsis, and Parkinson's disease with dyskinesia (a progressive neurological disorder affecting movement). Resident #48's record documented the following Progress Notes: A Nursing Progress Note dated 11/1/25 at 3:04 PM, Resident #48's spouse brought medication in a bottle to the facility that read Carbidopa / Levodopa (medication for Parkinson's) ODT 25-100 mg tablet - dissolve 1 tablet on top of tongue three times a day. Resident #48's spouse stated this dosing may be better for resident as she had difficulty swallowing. A Nursing Progress Note dated 11/2/25 at 10:07 AM and 11/2/25 at 1:24 PM, Resident #48 was unable to swallow safely and the DON, ADON, and provider was notified. A Nursing Progress Note dated 11/2/25 at 1:31 PM, the on-call provider approved ODT Carbidopa / Levodopa per spousal request. An Order Type Progress note (tracking various clinical orders) dated 11/2/25 at 1:31 PM Carbidopa / Levodopa tablet 25-100 mg give 1 tablet sublingually five times a day exceeds the usual frequency of 2 times per 7 days to 4 times per day. There was no documentation on Resident #48's records that the order had been clarified with the provider regarding the frequency dosing of the medication. On 1/9/26 at 11:37 AM, when asked about the Order note dated 11/2/25 at 1:31 PM regarding the five times per day entry, the DON stated, I think this is a transcription error and confirmed Resident #48 had previously been taking the medication three times per day. 2. Resident #51 was admitted to the facility on [DATE], with multiple diagnoses including chronic lymphocytic leukemia. A Hospital After Visit Summary dated 12/28/25, documented Resident #51 was to receive Voriconazole (anti-fungal) 200 mg tablet, one tablet by mouth every 12 hours for 23 doses. A January 2026 MAR, documented Resident #51 was to receive Voriconazole oral tablet 50 mg. Give 200 mg by mouth every 12 hours for fungal infection for 175 administration SIX 50 MG TABLETS EQUALS 300 MG. On 1/8/26 at 11:29 AM, the DON reviewed Resident #51's physician's order and stated, This is confusing and the dosing doesn't add up, the order should have been clarified from the physician. 3. Resident #55 was admitted to the facility on [DATE], with multiple diagnoses including aftercare following a surgical procedure on the digestive system, and heart failure. A Physical Therapy Evaluation and Plan of Treatment dated 12/20/25, documented Resident #55 was to receive Therapeutic Activities 5 times per week. On 1/6/26 at 9:40 AM, Resident #55 stated she was supposed to have physical therapy five times a week, but did not have therapy the week before. Resident #55 stated she did not know if she was done with her physical therapy since she was told she could walk in her room and go to the bathroom without assistance. A COTA progress note dated 12/24/25, documented Resident #55 missed her occupational therapy session due to NSG [nursing] completing care/colostomy care in afternoon, unable to see despite several attempts. The progress note did not document how many attempts were attempted or if Resident #55 refused the therapy. There was no documentation on why Resident #55 missed her physical therapy on 12/24/25 and occupational therapy on 12/26/25. On 1/6/26 at 2:19 PM, the Physical Therapist stated he evaluated Resident #55 and recommended for her to have PT/OT five times a week. The Physical Therapist stated they were working on her transfer and ambulation. When asked if Resident #55 had completed her PT/OT program, the Physical Therapist stated he works part-time in the facility and did not know if Resident #55 had completed her physical and occupational therapy program. On 1/7/26 at 9:19 AM, the OTA stated when a resident missed their physical or occupational therapy during the weekdays, generally they would provide an extra session during the weekend to cover the missed therapy. The OTA stated there was no progress notes for the missed PT session on 12/24/25 and OT session on 12/26/25. Resident #55's PT/OT record did not have documentation she had PT/OT on the following weekend to cover her missed PT/OT session. On 1/7/26 at 2:51 AM, the DON with the Administrator present reviewed Resident #55 PT and OT progress notes and stated, from the notes there was an issue on wound care. When asked if colostomy wound care would last that long, the DON stated she would look for the documentation for the missed OT session. On 1/7/26 at 3:07 PM, the DON provided a Physical Therapy progress note dated 1/7/26, which documented Per nursing, extended time would be needed today for wound changes 3 attempts at therapy were made, unable to see pnt [patient] d/t [due to] nursing needs such as wound changes and pain management timing issues. This progress note was made 14 days after the missed session.

Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 1 of 12 residents (Resident #54) whose care plan was reviewed. This created the potential for adverse outcomes if resident #54's care and services provided were not ordered by the physician. Findings include:Resident #54 was admitted to the facility on [DATE], with multiple diagnoses including repeated falls, major depressive disorder, and anxiety.Resident #54's care plan initiated 12/29/25, documented Resident #54 was at risk for falls secondary to left sided weakness and directed staff to encourage the use of the call light and to keep resident's room free of clutter and tripping hazards.On 1/5/26 at 11:38 AM, Resident #54's bed was observed against the wall by the window. When asked about the location of her bed, Resident #54 stated staff moved her bed against the wall after she fell out of bed.On 1/8/26 at 10:50 AM, When asked if the resident's bed against the wall was in the care plan, the DON stated, I do not see it in the care plan. On 1/8/26 at 10:55 AM, the DON and the RNC accompanied the surveyor to Resident #54's room and confirmed the bed against the wall and stated the bed should have been care planned for fall intervention.

Based on record review and interview, it was determined the facility failed to ensure resident specific discharge paperwork was provided to the hospital during transfer. This was true for 1 of 2 residents (Resident #47) whose records were reviewed. This deficient practice had the potential for harm if resident required health information not provided to the hospital. Findings include:The State Operations Manual Appendix PP issued 7/23/25, documented when the facility discharged a resident under any circumstances, the facility must ensure that the transfer or discharge was documented in the resident's medical record.Resident #47 was admitted to the facility on [DATE] with multiple diagnoses including aftercare following a surgical procedure.Resident #47's Nursing Notes documented the following:On 11/6/25 at 9:47 AM - Resident #47 had scattered scabs on his hands and arms.On 11/6/25 at 2:41 PM - Resident #47 at the hospital.Resident #47's record did not include documentation why he was at the hospital.On 1/6/26 at 3:13 PM, the DON stated on 11/6/25 Resident #47 was driven to his appointment at the Infectious disease clinic. The DON stated Resident #47 refused to get out of the transport vehicle due to severe pain and was diaphoretic. The PA at the clinic assessed him and was sent to the emergency room. When asked why the Nursing Notes did not include documentation of the Resident #47's reason for hospitalization, the DON stated, I guess the best practice is to document the resident went to the hospital.

Based on policy review, staff interview, record review, and review of the State Long Term Care Reporting System, it was determined that facility failed to ensure residents were free from misappropriation of property and exploitation. This was true for 3 of 3 residents (#57, #58, and #59) reviewed for abuse, neglect, misappropriation of resident property, and exploitation. This failed practice created the potential for all facility residents to experience exploitation and misappropriation of property. Findings include:The facility's Abuse, Neglect and Exploitation policy revised 4/2025, stated the facility would prevent all types of abuse, neglect, exploitation and misappropriation of residents' property. The CMS SOM, Appendix PP dated 7/23/25, defined:- Exploitation, as taking advantage of a resident for personal gain, through the use of manipulation, intimidation, threats, or coercion.- Misappropriation of resident property, as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consents. 1) Resident #57 was admitted to the facility on [DATE] with multiple diagnoses including several fractured bones including lower right leg, sacrum, and right pubis, and dementia.Resident #57's physician's order for oxycodone (narcotic pain medication) 5 mg, give one-half tablet once daily. (Scheduled for 1 PM daily)2) Resident #58 was admitted to the facility on [DATE] with multiple diagnoses including aftercare following surgery on the digestive system.Resident #58's physician's order for oxycodone 10 mg, give one tablet every 6 hours as needed for moderate pain. 3) Resident #59 was admitted to the facility on [DATE] with multiple diagnoses including fracture of vertebra T7-T8, and congestive heart failure.Resident #59's physician's order for oxycodone 5 mg, give one-half to one and one half tablet every 4 hours as needed for pain. A Facility Reported Incident dated 7/2/25, included an investigation summary which documented on 7/2/25, LPN #4 was found to have diverted medications intended for resident use.The investigative summary documented LPN #4 was observed by the DON to drop multiple pills on the floor, one of the pills appeared to be an oxycodone (a controlled medication). The DON referred to the facility video footage and noted LPN #4 had removed several controlled medications into the same medicine cup and signed them out of the controlled medication logbook. LPN#4 was questioned about the location of the drugs, she first stated she disposed of them in the sharps container and when that was disproved, she then claimed she disposed of them in the trash. The trash was searched by the DON and Administrator, and the drugs were not located in the trash. LPN #4 refused to allow the Administrator and DON to search her personal bag and left the building. Upon review of the controlled drug logbook, the MAR, and resident interviews, the DON noted five total medications were signed out but had not been administered to the identified residents. The missing drugs belonged to the following residents:Resident #57's physician's order for oxycodone 5 mg, 1 tabletResident #58's physician's order for oxycodone 10 mg, 1 tabletResident #59's physician's order for oxycodone 5 mg, 3 tabletsThe facility's investigation substantiated LPN #4's diversion of controlled substances belonging to Resident #57, #58, and #59 and due to suspicion of diversion and refusal to assist in search of missing medications LPN #4's employment was terminated.On 1/8/26 at 2:50 PM, the Administrator confirmed LPN #4 was charged with diverting medications intended for resident use from Resident #57, #58, and #59.These findings represent past non-compliance with this regulatory requirement. The facility did the following:-LPN #4's employment was terminated immediately in accordance with facility policy and Idaho State Regulations.-A comprehensive audit conducted of controlled substance inventory and documentation.-The identified residents were interviewed and pain level assessed and treated-Report made to state authority-Police report made to Boise PD-Board of Nursing Licensure was notified-Pharmacy was notified and their representative came to facility and performed audit of all controlled substances.-All licensed staff were given an in-service training discussing the facility policy, Potential Diversion and Controlled Substance Accountability. Training for all licensed nurses completed on 7/2/25.There was sufficient evidence the facility corrected the non-compliance as of 7/2/25 as there were no further exploitation and misappropriation of property reported after this date.At the time of the survey, the facility was in substantial compliance for this regulation and therefore does not require a plan of correction.

Based on policy review, record review, and interviews, it was determined the facility failed to ensure the physician was notified of a change in condition. This was true for 3 of 3 residents (#19, #37, and #48) reviewed for physician notification. This failure had the potential for harm if the physician was not provided with information necessary to make decisions to initiate and/or alter interventions to meet a resident's changing needs. Findings include: The facility's policy and procedure for Weight Monitoring revised on 7/2024, documented the physician was to be notified of significant weight variances, which included gain or loss if any of the following occurred: 5% weight change in 30 days 7.5% weight change in 90 days 10% weight change in 180 days 1. Resident #19 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the right femur, diabetes, and Crohn's Disease (a chronic inflammatory disease in the digestive tract). A Comprehensive MDS assessment dated [DATE], documented Resident #19 was cognitively intact and he required set-up only for eating. Resident #19's care plan dated 12/12/25, documented he was at risk for nutritional deficits and would not experience any untreated weight variances. On 1/5/26 at 1:59 PM, Resident #19 stated he felt he had lost about 10 pounds since admission and thinks it may be due to recent decreased appetite and the food not appealing to him. Resident #19's weight log documented the following: 12/12/25 weight of 163.2 pounds 1/7/26 weight of 137.2 pounds The weight loss between 12/12/25 and 1/7/26 resulted in a 14.9% weight loss since admission (27 days). On 1/8/26 at 9:04 AM, the DON stated she could not find documentation that the physician had been informed of Resident #19's change in weight. 2. Resident #37 was admitted to the facility on [DATE], with multiple diagnoses including fracture of the right femur, B-12 deficiency anemia, and hyperlipidemia. Resident #37's Comprehensive MDS assessment dated [DATE], documented she was cognitively intact, and she required set-up only for eating. Resident #37's care plan dated 10/13/25, documented she was at risk for nutritional deficits and would not experience any untreated weight variances. Resident #37's weight log documented the following: 10/14/25 weight of 138.0 pounds 1/5/26 a weight of 121.6 pounds The weight loss between 10/14/25 and 1/5/26 resulted in a 11.66% weight loss since admission (84 days). On 1/8/26 at 1:30 PM, the DON stated she could not find documentation that the physician had been informed of Resident #37's change in weight. On 1/8/26 at 9:40 AM, the physician assistant stated he would want to be notified of any significant weight loss. He also stated if he were notified of a resident's significant weight loss, he would see them face to face and write a short progress note in the EMR and add any orders needed. 3. Resident #48 was admitted to the facility on [DATE] with multiple diagnoses including, mild cognitive impairment, sepsis, and Parkinson's disease with dyskinesia (a progressive neurological disorder affecting movement). Resident #48's record documented she had the following vital signs: 11/2/25 at 7:00 AM, BP: 108/61, Temp: 97.5, HR: 89, Resp: 18. 11/2/25 at 9:58 PM, BP: 95/57, Temp: 99.3, HR: 103, Resp: 20 There was no documentation on Resident #48's record the DON or the physician were notified of the decrease of blood pressure or the increase in temperature or heart rate taken on 11/2/25 at 9:58 PM. Resident #48's Nursing Progress Note documented the following: 11/3/25 at 3:40 AM resident was found pulseless. Emergency protocol was activated, and family was notified. Despite paramedics' effort, resuscitation was unsuccessful. 11/3/25 at 5:08 AM, documented Resident #48 passed away. 11/3/25 at 6:40 AM, documented resident #48 was monitored every hour during the shift. There was no documentation on Resident #48's records she was monitored every hour per the Nursing Progress Note. On 1/9/26 at 11:03 AM, when asked what monitoring was in place every hour, the DON stated hourly rounds were done to check on the residents. When asked if hourly checks include taking vital signs, the DON stated vitals were not done hourly, the checks were just to put eyes on the residents. On 1/9/26 at 11:14 AM, when asked about the expectation of nursing staff when there is a change in vital signs, the DON stated the expectation was for vitals to be rechecked to confirm vitals were abnormal. When asked if Resident #48's vitals were rechecked, the DON stated, not that I can see in the documentation. When asked if the nurse notified the physician of the change in vitals, the DON stated there was nothing indicated in the chart that the physician was notified of a change.

Based on record review and staff interview, it was determined the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when a psychoactive medication was administered without adequate indication for its use. This was true for 1 of 5 residents (Resident #39) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without clear indication of need. Findings include:Resident #39 was admitted to the facility on [DATE] with multiple diagnoses including depressive disorder, hypertension, and osteoporosis.Resident #39's physician's order for lorazepam (anti-anxiety medication) oral tablet 0.5 mg, give one by mouth every 24 hours as needed for anxiety.Resident #39's MAR documented she was administered lorazepam 0.5 mg oral tablet on 1/3/26 and again on 1/6/26.Resident #39's Monitor For Anxiolytic Use did not indicate she had anxiety symptoms or behaviors on 1/3/26 and 1/6/26.On 1/7/26 at 9:35 AM, the DON reviewed Resident #39's records and confirmed she was administered an anti-anxiety medication on 1/3/26 and on 1/6/26 with no documentation of symptoms or behaviors. The DON stated her expectation was for her staff to document anxiety symptoms or behaviors present when administering anti-anxiety medications prescribed to be given as needed.

Based on medical record review and staff interview, it was determined the facility failed to ensure accuracy of 1 of 12 resident records reviewed. This was true for Resident #146 and placed him at risk for harm when he was administered a medication that was listed on his allergy list. Findings include: Resident #146 was admitted to the facility on [DATE] for care following a lumbar fracture. On 1/24/25 Resident #146's medical record documented he had an allergy to opioid analgesics. Resident #146's physician orders and medication administration record (MAR) documented he had been prescribed and was receiving oxycodone (an opioid analgesic) since 12/15/24. On 1/24/25 at 11:10 AM, the DON confirmed Resident #146's allergy list documented he had an opioid analgesic allergy and he had been prescribed and had received opioid analgesics without complication. On 1/24/25 at 11:25 AM, the DON stated the documents from the transferring hospital did not include an allergy to opioid analgesics and it appears it was transcribed to his allergy list in error. The DON confirmed this error in Resident #146's medical record went unnoticed when his physician orders were verified and with each opioid medication administration.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure pharmacy recommendations were followed or addressed by the attending physician. This was true for 2 of 5 residents (Resident #4 and #10) reviewed for pharmacy recommendations and had the potential for harm if residents' medications were administered without a clinical rationale. Findings include: The facility's policy for Pharmacy Medication Regimen Review (MRR), undated, stated the pharmacist will send monthly medication reviews to Director of Nursing (DON)/Designee who then prints the pharmacist recommendations and give to the medical provider to review and sign. 1. Resident #4 was admitted to the facility on [DATE], with multiple diagnoses including displaced fracture of first, second, third, and fourth metatarsal bones of the right foot, depression, and anxiety. A physician's order, dated 12/23/24, with no end date, documented Resident #4 was prescribed alprazolam 0.25 mg once daily as needed for depression. A pharmacy consultation report, unsigned by the physician, dated 1/8/25, documented Resident #4's alprazolam order currently had no stop date and per regulations all PRN psychotropic medications must be re-evaluated by provider after 14 days to see if continuation is justified. 2. Resident #10 was admitted to the facility on [DATE], with diagnoses which included orthopedic aftercare for surgical amputation and osteomyelitis (infection of the bone). A physician's order dated 12/31/24, documented Resident #10 was prescribed vancomycin 1,000 mg, intravenous every 24 hours for his osteomyelitis. A pharmacy consultation report, unsigned by the physician, dated 1/8/25, documented Resident #10's vancomycin order was missing a duration of therapy and recommended a duration of at least 6 weeks when used to treat osteomyelitis. On 1/24/25 at 1:00 PM, the DON stated they had received the pharmacy recommendations for the month of December 2024 on 1/8/25 and the physician would review December 2024's MRR's at the January Quality Assurance and Performance Improvement (QAPI) meeting, scheduled to be held the third week of the month, but was rescheduled due to survey entrance. The DON stated she could not provide evidence the physician had addressed the pharmacist' recommendation for Resident #4's alprazolam or Resident #10's vancomycin.

Based on observation, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' bedroom temperatures were maintained at a comfortable level. This was true for 3 of 30 residents (#10, #127, and #144) whose bedrooms were observed. This deficient practice created the potential for harm if residents became too cold or hot and it compromised their health status. Findings include: The Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM) Appendix PP, rev.225; issued: 8/8/24, S483.10(i) defines comfortable and safe temperature levels as the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia, or hyperthermia, or and is comfortable for the residents. The facility's Resident Environment Quality policy, dated 7/2021 and revised 6/2023, documented, resident rooms and activity areas should be of a comfortable temperature for the resident. Resident behavior should be observed (wearing sweaters, wrapping in blankets, etc.) to determine the appropriate temperature levels. 1. On 1/22/25 at 2:17 PM, Resident #10 stated his room is always too cold. He was observed sitting in a chair in his bedroom with a thick blanket over his lap. Resident #10 stated he told staff about it, and they adjusted the thermostat, but the room was still cold. The wall thermostat control unit was set at 78 degrees Fahrenheit (F), and the thermostat documented the room temperature was 73 degrees F. During the observation it was noted that his room felt drafty and cold. On 1/23/25 at 8:43 AM, the Director of Nursing (DON) confirmed the wall thermostat in Resident #10's room was set at 78 degrees F, the thermostat showed the room was 73 degrees F. The DON stated she did not feel the room was too cold although was noted to be wearing a wool winter coat during the observation. The DON stated the Maintenance Director would check the temperature in the bedroom using an ambient temperature gauge. On 1/23/25 at 12:57 PM, the Maintenance Director stated he was able to check the thermostats for the resident bedrooms from his computer. He added it should not have felt cold in Resident #10's bedroom because his computer was showing the thermostat was set to 75 degrees F and showing the room to be 75 degrees F, but he had not gone to the room to take the ambient air temperature reading. On 1/23/25 at 1:00 PM, Resident #10 was in his bedroom sitting in his chair with a heavy blanket on when the Maintenance Director was observed measuring the ambient temperature of Resident #10's bedroom to be 71 degrees F. The Maintenance Director added the ambient temperature should have measured closer to the thermostat reading and thought the thermostat may need to be repaired. 2. On 1/22/25 at 3:31 PM, Resident #127 stated her room is always too cold, especially the bathroom. She was observed sitting in her bedroom in a chair with a thick blanket over her and pulled up to her chin. She stated the cold makes my joints hurt and going into the bathroom is like going to the north pole and the toilet seat feels like sitting on an iceberg. The bathroom door was observed to be open, and a cold draft was felt blowing into the bedroom. Resident #127 stated she told staff about it and the staff placed towels on the toilet seat for warmth, and the toilet seat was observed to have towels draped over it. On 1/23/25 at 8:40 AM, Resident #127 was observed telling the DON she asked staff to turn the heat up, and it improved but the bedroom and bathroom were still too cold and was causing her pain. The thermostat was observed to be set at 76 degrees F and read the temperature in the bedroom was 70 degrees F, the bathroom was noted to be substantially colder than the bedroom. On 1/23/25 at 12:57 PM, the Maintenance Director stated if Resident #127 told staff she was cold, those staff did not report that information to him and he was unaware of her concerns. He added his computer documented the room was within 71-81 degrees F as regulation stated. On 1/23/25 at 1:05 PM, Resident #127 was observed sitting in the chair in her bedroom with the same heavy blanket covering her from the chest down, she stated the room was a little bit warmer but it her joints were still bothering her because it was too cold. The Maintenance Director confirmed the thermostat was set at 75 degrees F and read the temperature to be 76 degrees F, he then tested the temperature next to the ceiling vent with the ambient temperature gauge and stated it read 77 degrees F. The Maintenance Director was then observed measuring the ambient air temperature in the bathroom, which read to be 68 degrees F. 3. On 1/22/25 at 3:51 PM, Resident #144 stated her room was too cold in the mornings and too hot in the evenings, and she had to keep her bedroom door open to let the heat out. Her room was noticeably very warm, and the door was open during the observation. On 1/23/25 at 8:38 AM, Resident #144 was observed sitting in the chair in her bedroom and telling the DON her room was too cold and requested a lap blanket. The thermostat was observed set to 69 degrees F and the thermostat read the room was 68 degrees F. Resident #144's room was noted to feel cool and cold air was felt blowing from the ceiling vent. On 1/23/25 at 1:08 PM, Resident #144 was observed telling the Maintenance Director she would like to move to another room because it was too cold in the mornings and too hot in the evenings, and she was uncomfortable. He responded by saying there were no other rooms available and the temperature fluctuation was likely caused by the large windows in her room. The thermostat was observed to be set to 75 degrees F and read the room was 77 degrees F. When he tested the ambient temperature of the bedroom it was 71 degrees F. On 1/23/25 at 3:00 PM, the Administrator stated none of the resident rooms were reading on the Maintenance Directors computer to be out of the 71-81 degrees F range specified in the regulation, but the facility policy documented the residents bedrooms and common areas needed to be a kept at a comfortable temperature for the residents.

Based on record review, review of the State Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for Resident #171 and placed this resident in immediate jeopardy of serious harm, impairment, or death when LPN #1 and RN #2 failed to administer a high-risk medication. Findings include: Resident #171 was admitted to the facility on [DATE], with multiple diagnoses including pneumonia caused by influenza, hypertension, and longstanding persistent atrial fibrillation (an irregular and often very rapid heart rate which can lead to blood clots and stroke). Resident #171's physician orders on admission included Xarelto (medication to treat or prevent blood clots) 20 mg by mouth, once a day at bedtime for prevention of deep vein thrombosis (blood clots). The US Food and Drug Administration approved medication guide written by the manufacturer of Xarelto stated, Do not stop taking Xarelto without talking to the doctor who prescribes it for you. Stopping Xarelto increases your risk of having a stroke. Resident #171's MAR, dated 12/11/23-12/25/23, documented the following regarding Xarelto: -12/18/23- Not Administered: Drug/Item Unavailable, signed by LPN #1 -12/19/23- Not Administered: Drug/Item Unavailable, signed by RN #2 -12/20/23- Not Administered: Drug/Item Unavailable, signed by RN #2 -12/21/23- Not Administered: Drug/Item Unavailable, signed by LPN #1 A nursing progress note, dated 12/25/23 at 6:20 PM, documented the nurse was called to Resident #171's room for a change in condition. Resident #171 was unable to respond to any questions when asked, had right sided facial drooping, and diminished strength in her right hand. The note documented, 911 called immediately. Resident sent to ER to eliminate stroke. A provider's progress note, dated 12/26/23 at 4:32 PM, documented Resident #171 was diagnosed with Acute Ischemic Stroke at 7:26 PM on 12/25/23. An ischemic stroke occurs when something blocks blood supply to part of the brain which can cause lasting brain damage, long-term disability, or death. On 12/26/23 at 7:00 PM, the facility administrator entered a report into the State Agency's Long-Term Care Reporting Portal. The report stated [Resident #171] ran out of Xarleto [sic]. Medication was ordered via pharmacy over the holiday and was not delivered. Medication was reordered and again not delivered. Resident missed a few consecutive doses and was subsequently sent to the hospital for significant history of atrial fibrillation and cardiac issues with symptoms similar to CVA. Numerous other contributing comorbidities related to care. The facility's investigation report of this incident, undated, included the following: - 12/18/23 - [LPN #1] reported the medication Xarelto was out of stock. [LPN #1] reports marking this medication as unavailable and placing the order for the missing medication to [the pharmacy]. - 12/19/23 - [RN #2] arrives on duty and notes this medication is unavailable. [RN #2] marks it as unavailable and reports reordering it from the pharmacy. - 12/20/23 - [RN #2] returned to shift and recorded medication unavailable. [RN #2] reports marking it as unavailable and reordering the medication through pharmacy. - 12/21/23 - [LPN #1] returned to shift and recorded medication not available. [LPN #1] reports marking it as unavailable and reordering the medication through pharmacy. The pharmacy record of all medications ordered for Resident #171 in December 2023 did not include requests to reorder Xarelto after her admission on 12/11/23. On 2/23/24 at 10:00 AM, the DON stated it was unacceptable LPN #1 and RN #2 did not contact the physician or pharmacy before skipping a dose of a high-risk medication. On 2/23/24 at 10:30 AM, the Medical Director stated LPN #1 and RN #2 were not qualified to make the decision to withhold a dose of a high-risk medication and that decision must be made by a prescriber. The facility took the following corrective action in response to the medication errors after they were identified: - The facility suspended LPN #1 and RN #2 from employment on 12/26/23. - LPN #1 and RN #2 were terminated from employment on 12/28/23 for failing to contact the physician or pharmacy regarding the missing medication. - The facility stopped all new admissions on 12/26/23. - The facility conducted an audit of all missed medications for every resident on 12/26/23. - The facility created and implemented a new policy titled Guidelines for Unavailable Medications to supplement their Medication Reordering policy already in place. - The facility provided education and evaluated all staff for competency regarding abuse and neglect. - The facility provided education and evaluated all licensed nurses for competency regarding medication reordering and anticoagulants. I & A reports and facility grievances were reviewed from 12/26/23 to 2/23/24. There were no additional reports of residents not receiving their high-risk medications as prescribed. The State Agency's Long-Term Care Reporting Portal was reviewed for missed doses of high-risk medications from 12/26/23 to 2/23/24, and no instances were identified. MARs for 12 residents currently residing in the facility were reviewed for administration of high-risk medications and no concerns were identified. Based on the corrective action taken by the facility and no other evidence of missed high-risk medications after 1/6/24, the facility was cited for past non-compliance.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure baseline care plans were developed within 48 hours of the residents' admission to establish care and monitoring for psychotropic medication use. This was true for 2 of 12 residents (#24, and #36) reviewed for baseline care plans. This failure created the potential for harm when the care plan failed to provide directions for care. Findings include: The facility's Psychotropic Medication Monitoring policy received on 2/22/24, documented the facility's psychotropic review process, including reviewing the residents who are on psychotropic medications upon admission and establishing a baseline care plan. The psychotropic medication care plan should be appropriate and individualized to the behaviors and interventions specified to the resident and updated after each psychotropic meeting. The staff should audit residents' care plans to ensure that the care plan accurately reflects current psychotropic medications and individual resident behaviors. The care plan must include nonpharmacological interventions. 1. Resident #24 was admitted on [DATE] with multiple diagnoses, including anxiety disorder. Resident #24's MAR for February 2024, documented she received duloxetine (antidepressant) 20 mg, one capsule, once a day for pain, start 2/9/24. Resident #24's baseline care plan for psychotropic medication use, dated 2/20/24, included the following: - Monitor for adverse side effects to medications every shift - notify the physician if present. - Monitor for behaviors and documenting as needed. Resident #24's baseline care plan did not include documentation what resident specified target behaviors, medication specified adverse effects should be monitored or offered. The care plan did not include intervention to offer nonpharmacological interventions. On 2/23/24 at 11:50 AM, the DON reviewed Resident #24's record and stated the target behavior and adverse effect monitoring should be in place and specified, and nonpharmacological interventions should be offered, and documented in the care plan. 2. Resident #36 was admitted on [DATE] with multiple diagnoses, including anxiety disorder and depression. Resident #36's MAR for February 2024, documented she received fluoxetine (antidepressant) 40 mg, one capsule, once a day for depression, start 2/16/24. Resident #36's baseline care plan for psychotropic medication use, dated 2/20/24, included the following: - Medication as prescribed. - Monitor for adverse side effects to medication every shift; notify the physician if present. - Monitor behaviors and document as needed. - Psychotropic committee review per facility. Resident #36's baseline care plan did not include documentation what resident specified target behaviors, medication specified adverse effects, and nonpharmacological interventions were to be monitored or offered. On 2/23/24 at 11:50 AM, the DON reviewed Resident #36's record and stated the target behavior and adverse effect monitoring should be in place and specified, and nonpharmacological interventions should be offered, and documented in the care plan.

Based on record review and staff interview, it was determined the facility failed to ensure residents receiving psychoactive medications had resident-specific target behaviors identified and monitored and offered nonpharmacological interventions. This was true for 3 of 6 residents (#7, #24, #36) reviewed for psychoactive medications. This deficient practice created the potential for harm if residents received medications that may result in negative outcomes without a clear indication of need and monitoring. Findings include: The facility's Psychotropic Medication Monitoring policy, received on 2/22/24, documented the Psychotropic medications would be audited by the facility staff daily to ensure the following: - Psychotropic behavior tracking should be individually tailored to residents' need for the medication and try to make it as patient-centered as possible. - The adverse effects tracking should be placed appropriately in the electronic medical system. - The prescribed medication is appropriate for the behavior in which the medication was initiated. - Nonpharmacological measures should be taken. The physician should be notified for every attempt of non-pharmacological measures prior to discontinuing the medication. 1. Resident #7 was admitted on [DATE] with multiple diagnoses, including anxiety disorder and depression. Resident #7's MAR for February 2024, documented she received psychotropic medications ordered by the physician as follows: - Bupropion (antidepressant) 300 mg, one tablet, once a day for mood, start 1/31/24. - Sertraline (antidepressant) 100 mg, one and a half tablets, once a day for mood, start 1/31/24. Resident #7's TAR for February 2024, documented she was to be monitored for the following: - Monitor negative life statements related to antidepressant drug use, start 3/30/24. - Monitor for signs and symptoms of adverse effects related to psychotropic drug use, start 1/30/24. Resident #7's record did not include documentation of: - What specific target behaviors did she manifest for depression, anxiety, and being monitored. - What specific signs and symptoms of adverse effects were she being monitored for. - What nonpharmacological interventions were offered. On 2/22/24 at 11:16 AM, The DON stated monitoring for Negative Life Statements R/T Anti-Depressant was the company policy for every resident. She stated Resident #7's target behavior was tearfulness, it should have been monitored, and there was no documentation it was being done. The DON confirmed there was no documentation what nonpharmacological interventions were given, and no documentation what specific adverse effects were being mentored. She stated it should have been detailed by the drug class as dry mouth, dry eyes, constipation, urinary retention, sedation, drowsiness, blurred vision, muscle tremor, agitation, rash, weight loss, or weight gain. 2. Resident #24 was admitted on [DATE] with multiple diagnoses including anxiety disorder. Resident #24's MAR for February 2024, documented she received duloxetine (antidepressant) 20 mg, one capsule, once a day for pain, start 2/9/24. Resident #24's TAR for February 2024, documented she was to be monitored for the following: - Monitor for verbalized anxious statements for anxiolytic drug use, start day 2/8/24. - Monitor for signs and symptoms of adverse effects related to psychotropic drug use, start 2/8/24. Resident #24's record did not include documentation of: - What specific target behaviors did she manifest for depression, anxiety, and being monitored. - What specific signs and symptoms of adverse effects were she being monitored for. - What nonpharmacological interventions were offered. On 2/23/24 at 11:50 AM, the DON reviewed Resident #24's record and stated the target behavior and adverse effect monitoring should be in place and specified, and the nonpharmacological should be offered. 3. Resident #36 was admitted on [DATE] with multiple diagnoses, including anxiety disorder and depression. Resident #36's MAR for February 2024, documented she received fluoxetine (antidepressant) 40 mg, one capsule, once a day for depression, start 2/16/24. Resident #36's TAR for February 2024, documented she was to be monitored for the following: - Monitor negative life statements related to antidepressant drug use, start 2/15/24. - Monitor for signs and symptoms of adverse effects related to psychotropic drug use, start 2/15/24. Resident #36's record did not include documentation of: - What specific target behavior she manifested for depression, anxiety, and monitoring of the behaviors. - What specific signs and symptoms of adverse effects were to be monitored. - Nonpharmacological interventions offered for psychotropic medication use. On 2/23/24 at 11:50 AM, the DON reviewed Resident #36's record and stated the target behavior and adverse effect monitoring should be in place and specified, and nonpharmacological interventions should be offered.

Based on observation, staff interview, and record review, it was determined the facility failed to ensure infection control and prevention practices were followed to provide a safe and sanitary environment during a COVID-19 outbreak. COVID-19 is an infectious disease caused by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death. These failures placed residents at risk for adverse outcomes from cross-contamination of COVID-19. Findings include: 1. The Centers for Disease Control and Prevention (CDC) website for SARS-CoV-2 Rapid Testing Performed in Point-of-Care Settings, accessed on 2/26/24, documented after performing a COVID-19 test, the staff should decontaminate the testing area using an approved disinfectant, proper dilution, contact time, and safe handling of the used test specimens. On 2/20/24 at 7:25 AM, multiple COVID-19 test specimens were observed on top of the facility's conference room table. The MDS nurse said positive COVID-19 tests were confirmed in the facility on 2/19/24, and the facility conducted many COVID-19 tests for the staff and left the specimens on the table overnight after completion. On 2/20/24 at 7:32 AM, the MDS nurse stated the specimens should not have been left on the table overnight. On 2/20/24 at 3:30 PM, the DON stated the COVID-19 test kits should have been thrown away within 15 minutes after use into the red trash bag as medical waste. 2. The CDC website for Interim Infection Prevention and Control Recommendations for Healthcare Personnel, updated 5/8/23, and accessed on 2/26/24, documented when caring for a patient with suspected or confirmed SARS-CoV-2 infection, healthcare professionals should use a respirator face mask with N95 filters or higher, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face). On 2/20/24 at 9:00 AM, one PPE storage container was observed outside of Resident #6's room, and there were three signs on the door: - One stated contact precautions with instructions for using gloves, gowns, and disinfecting reusable equipment. - One had instructions on putting on PPE, including gown, gloves, goggles, mask, or respirator - One had instructions on removing PPE, including gown, gloves, goggles, mask, or respirator. On 2/20/24 at 9:01 AM, RN #1 stated Resident #6 tested positive for COVID-19 on 2/19/24. She stated staff members wore full PPE with face shields, gowns, gloves, and N95 masks when entering the room. She stated staff members were instructed to reuse the face shield for one shift by placing it in a plastic bag with the staff's name. On 2/20/24 at 10:00 AM, CNA #1 was observed in Resident #6's room with a surgical mask on without a face shield and then left the room with the same surgical mask. CNA #1 did not wear an N95 mask and face shield when entering Resident #6's room and did not dispose of the contaminated surgical mask when leaving Resident #6's room. On 2/20/24 at 2:20 PM, CNA #1 was observed leaving Resident #6's room with a surgical mask and face shield. He closed Resident #6's door, removed his face shield, and stored it in the reusable plastic bag. He wore the same surgical mask and left Resident #6's room. On 2/20/24 at 2:21 PM, when asked, CNA #1 confirmed he had worn a surgical mask without a face shield when he entered Resident #6's room. He stated he did not sanitize the face shield and wore the same surgical mask when he left the room the second time. CNA #1 stated he should wipe his face shield after use before reusing it, and he should have removed his used surgical mask and switched to a new one when leaving the room. When asked about his training, he corrected his statement and said he should wear an N95 mask, not a surgical mask when entering the isolation room. On 2/20/24 at 3:30 PM, the DON stated staff should wear an N95 mask, not surgical masks, when entering the room, and a face shield should be sanitized before storing it in the reused bag.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents who were offered and consented to the pneumococcal vaccine, received the vaccine. This was true for 2 of 5 residents (#6 and #24) reviewed for pneumococcal vaccinations. This failure placed the residents at increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death. Findings include: The facility's Infection Prevention and Control Program policy, dated 1/12/24, documented the following: - Residents will be offered the pneumococcal vaccine recommended by the CDC upon admission unless contraindicated or received the vaccine elsewhere. - Education will be provided to residents and representatives regarding the benefits and potential side effects of immunization prior to offering the vaccines. - Residents will have the opportunity to refuse the immunization. - Documentation will reflect the education provided and details regarding whether or not the resident received the immunization. The facility's pneumococcal vaccine consent form included the CDC's pneumococcal recommendation as follows: - If you have never received any pneumococcal vaccine, the CDC recommends receiving one dose of PCV (pneumococcal conjugate vaccine) 15 or PCV 20. - If you have previously received PPSV (pneumococcal polysaccharide vaccine) 23, the CDC recommends receiving one dose of PCV 15 or PCV 20 at least one year after administration of PPSV 23. - If you have received PCV 13 and PPSV 23, the CDC recommends receiving one dose of PCV 20 for at least five years after the last pneumococcal vaccine. 1. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including diabetes mellitus and hypertension. Resident #6's record included her pneumococcal vaccine history which documented she received PPSV 23 on 11/7/02 and 8/6/15. She received PCV 13 on 11/18/16. Resident #6's consent for the pneumococcal vaccine, dated 2/4/24, documented Resident #6 consented to the PCV 20 vaccine, and there was no documentation in the record the PCV 20 was administered. On 2/23/24 at 10:00 AM, the IP reviewed Resident #6's record and stated he could not find documentation the PCV 20 was admnistered. 2. Resident #24 was admitted to the facility on [DATE], with multiple diagnoses including left femur (thigh bone) fracture. Resident #24's record documented she received one dose of the PPSV 23 vaccine on 3/26/02, and there was a past due recommendation for PCV 20 on 3/26/02. Resident #24's consent for the pneumococcal vaccine, dated 2/8/24, documented Resident #28 consented to the PCV 20 vaccine and there was no documentation in the record that the PCV 20 was administered. On 2/23/24 at 10:00 AM, the IP reviewed Resident #24's record and stated he could not find documentation the PCV 20 was administered.

Based on policy review, record review, and staff and resident interview, it was determined the facility failed to ensure a resident's advance directive was obtained and documented in his record. This was true for 1 of 4 residents (Resident #7) whose advance directives were reviewed. This deficient practice created the potential for harm or adverse outcomes if the resident's wishes regarding their advance care planning were not followed or documented. Findings include: The facility's Resident's Rights Regarding Treatment and Advanced Directives policy, dated 11/1/22, stated: 1. On admission, the facility will determine if the resident has exhausted an advanced directive and, if not, determine whether the resident would like to formulate an advanced directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advanced directive. 3. Upon admission, should the resident have an advanced directive, copies will be made and placed on the chart and communicated to the staff. The State Operation Manual, Appendix PP, defined an advance directive as, a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's current medical condition into consideration. A POLST [or POST] paradigm form is not an advance directive. Resident #7 was admitted on [DATE] with multiple diagnoses, including acute respiratory failure. Resident #7's Consent For Treatment form in the facility's admission agreement was electronically signed by Resident #7 without a signature date, included the following: Advance Directives The Resident has been given written materials about his or her right to accept or refuse medical treatments as provided by state law and has been informed of the right to formulate Advance Directives. The Resident/Legal Representative understands the Facility must have the Resident's Attending Physician's do not resuscitate (DNR) order on file. In the event a DNR is not on file and it becomes necessary to respond to a Resident, the Facility's policy is to always resuscitate the Resident. The Resident understands that he/she is not required to have an Advance Directive in order to receive treatment at the Facility. Resident #7's Face Sheet (a document that gives a resident's information at a quick glance) documented Resident #7's advance directive was Do Not Resuscitate (DNR). The advance directive section, Copy on File, was left blank. Resident #7's record did not include a copy of her advance directive. On 2/21/24, at 3:45 PM, the social worker said she did not know the advance directive was a requirement. She confirmed Resident #7 did not have an advance directive in her record, and there was no documentation the facility communicated with Resident #7 or her representative to obtain a copy of her advance directive if she already had one. On 2/21/24 at 4:26 PM, Resident #7 said she signed the admission agreement because she did not need a new advance directive. She said she had an advance directive in place completed long ago and filed with the hospital where she was treated before being admitted to the facility. Resident #7 said no one in the facility asked her if she had an advance directive or if they could have a copy.

Based on observation, record review and resident and staff interviews, it was determined the facility failed ensure residents received necessary cares as ordered by the physician for 5 of 12 sampled residents (#2, #4, #5, #6, and #8). This deficient practice resulted in harm to Residents #8 and #4. Resident #8 experienced psychosocial harm when the resident endured escalating aching pain though the night and into the next day due to delayed procurement of pain medication. Resident #4 was harmed when she did not get her sleep medication for six nights and as a result, felt miserable due to lack of sleep. The deficient practices also created the potential for more than minimal harm to: a) Residents #2, #3, and #8 when medications were not administered as ordered by the physician; b) Resident #8 when the resident's oxygen orders were not clarified; and Resident #5 when the staff did not identify and assess a small necrotic wound and potential allergic reactions. Findings include: 1. Resident #8 was admitted on [DATE] following a cervical laminectomy and spinal fusion surgery. The resident's admitting [DIAGNOSES REDACTED]. a. Physician order [REDACTED]. * 4/12/16 [MEDICATION NAME] 650 mg every 6 hours as needed for pain. * 4/15/16, [MEDICATION NAME] HCL (opioid [MEDICATION NAME]) was discontinued and [MEDICATION NAME] HCL (opioid [MEDICATION NAME])1-2 tablets every 4 hours as needed for pain was ordered. * 4/19/16 [MEDICATION NAME] (opioid [MEDICATION NAME] and [MEDICATION NAME]), 1-2 tablets every 6 hours as needed for pain. Review of Resident #8's care plan dated 4/19/16, identified the resident had acute neck/upper back pain r/t recent neck surgery and chronic pain r/t recent lumbar back surgery in 2015. The interventions included: administer [MEDICATION NAME] as per orders; anticipate (Resident #8's) need for pain relief and respond immediately to any complaint of pain; and notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Review of the Medication Administration Record [REDACTED] *4/19/16 one [MEDICATION NAME] tablet at 9:39 pm; *4/20/16 two [MEDICATION NAME] tablets at 8:37 pm; *4/21/16 two [MEDICATION NAME] tablets at 7:26 pm; *4/26/16 two [MEDICATION NAME] tablets at 12:10 pm, and 9:18 pm; *4/24/16 two [MEDICATION NAME] tablets at 6:03 am, 2:14 pm, and 11:34 pm; *4/25/16 two [MEDICATION NAME] tablets at 8:42 am, 5:52 pm, and 11:17 pm; *4/26/16 two [MEDICATION NAME] tablets at 7:39 am, 3:56 pm, and 10:19 pm; *4/27/16 two [MEDICATION NAME] tablets at 8:09 am, and 3:44 pm. Nursing Progress Notes documented, on 4/27/16 at 8:09 am, pt. reports aching pain to cervical surgical site; at 3:44 pm, aching pain to cervical incision. [MEDICATION NAME] 2 tablets given; at 4:44 pm the resident was seen by the NP and the resident stated, .pain is tolerable with pain medication. On 4/27/16 at 1:30 pm, during an interview with Resident #8 and family members, they stated the biggest issue with the resident was getting her pain under control. Resident #8 had stopped eating and drinking due to her pain, resulting in dehydration that required IV fluids. They stated the resident was doing better now with the [MEDICATION NAME]. On 4/28/16 at 6:45 am, LN #1 stated Resident #8 had two separate pain medications ordered, [MEDICATION NAME] and [MEDICATION NAME], which were staggered at different times to cover the resident's pain. She stated the resident had been out of [MEDICATION NAME] since yesterday, and she would request a refill from pharmacy when they (pharmacy) opened at 9:00/9:30 am. She stated she was giving Resident #8 [MEDICATION NAME] and Tylenol until the facility got the [MEDICATION NAME]. She stated she had informed the DON. On 4/28/16 at 3:51 am, Nursing Progress Notes documented, [MEDICATION NAME] 2 tablets was given for, aching head and back pain; at 6:44 am, pt. reports aching to cervical site/head/neck and bilateral legs: at 8:12 am, aching pain to cervical site and legs per patient; at 9:34 am, spoke with (name) from Pharmerica regarding [MEDICATION NAME] refill, requested stat (immediate) delivery on refill at this time, pharmacy tech (technician) stated she would try to get a rush on delivery. 4/28/16 at 10:35 am, Resident #8 was observed lying in bed twitching with spastic movements. Resident #8 stated she, had not had [MEDICATION NAME] all night, and was waiting for it to get here, the nurse was supposed to call the pharmacy at 9:30 am. The resident stated the other medications did not work completely and she needed the [MEDICATION NAME]. Resident #8 stated she would rate her pain at 7 or 8 if up and moving and 5-6 now lying down. On 4/28/16 at 10:55 am, LN #1 stated the [MEDICATION NAME] should be at the facility by 11:45 am. She stated the pharmacy opened at 9:00 am. When asked about needing a medication after hours, she stated the after-hours phone number just sent a message to the pharmacy to deliver the medication when the pharmacy opened the next day. The pharmacy technician at the pharmacy could not give a code for the Pyxis system (locked medication dispensing system at the facility) for a refill. The pharmacy delivered twice a day at 2:00 pm and 8:30 pm and for stat (immediate) requests, the pharmacy would have a courier deliver the medication. The Pyxis system could not be used for refills and the facility did not use another service. She stated she reported medication issues to the DON, who reported to the Administrator, who would then contact the pharmacist. On 4/28/16 at 11:10 am, the DON stated she could not override the Pyxis system for refills. When the DON was told that Resident #8 rated her pain at 5-6, she stated the resident had other pain medications, she did not want the resident in pain and they (facility) were trying to get the medication. The Controlled Substance Log documented the Resident #8's refill for [MEDICATION NAME] was received on 4/28/16 at 11:30 am and the resident was given [MEDICATION NAME] 2 tablets. At 2:55 pm, Resident #8 was observed resting quietly with her eyes closed. On 4/28/16 at 2:55 pm, LN #1 stated the nurses were responsible for getting refills and faxing over the refill requests. She stated the reorder was faxed over last night for the resident, but the request was not documented anywhere. On 4/28/16 at 3:00 pm, the Administrator stated the after-hours phone numbers for the pharmacy were effective in getting medication. He stated that sometimes medications were obtained through a local drug store after hours. He further stated there were exceptions to the rule that the Pyxis system could be used for refills. He stated this exception required the DON to call the pharmacy. On 4/28/16 at 3:30 pm, the DON stated the [MEDICATION NAME] was PRN (as needed) and she was not aware the resident had asked for the [MEDICATION NAME]. She stated the request for the refill had been faxed the night before, but she had not retained documentation or tracking of the request. She stated the facility did not have a policy regarding refill requests or who was responsible. Resident #8 remained in pain through the night and into the next day. The Pyxis system was not overridden or other measures taken to get the resident the [MEDICATION NAME] pain medication. b. On 4/11/16, Resident #8 was ordered [MEDICATION NAME] (long acting insulin) 10 units in the morning for diabetes mellitus. Administration of the medication was ordered based upon Resident #8's morning BG. The order documented, hold (insulin) for BG < 125. The MAR indicated [REDACTED] *4/12/16, blood glucose was 112. The medication was checked and initialed as administered. *4/18/16, blood glucose was 102. The medication was checked and initialed as administered. *4/20/16, blood glucose was 99. The medication was checked and initialed as administered. *4/24/16, blood glucose was 112. The medication was checked and initialed as administered. On 4/28/16 at 6:45 am, LN #1 stated a check mark on the MAR under the blood glucose documentation indicated the medication was given and the initials documented that the nurse administered the medication. She stated that anything outside the parameters of the order should be documented in the Nursing Progress Notes and the physician notified. Medication error investigation documentation for the facility contained two incidents related to antibiotic therapy in December and January. Neither investigation contained a medication error reporting form. On 4/28/16 at 9:10 am, the DON stated she was responsible for auditing medication and medication errors. Her audits were based on reports by the nurses and random audits. The DON stated she only had two medication errors, for which she had produced copies for the survey. She stated the facility did not have a policy on medication errors. The DON stated the PCC computerized documentation system did not have built in alarms when blood glucose readings were outside the ordered parameters for medication administration. She stated she would look for a medication error form. On 4/28/16 at 4:15 pm, after reviewing Resident #8's MAR, LN #1 stated the 4 days in which the resident was given insulin (4/12, 4/18, 4/20, and 4/24), the medication should have been held since Resident #8's blood glucose was less than 125. LN #1 confirmed her initials on 2 of the 4 days. She stated Resident #8 had requested the insulin because she was worried about her mighty shakes (supplement), increasing her blood glucose. She stated she did not notify the physician or document in Nursing Progress Notes, but should have. The LN #1 confirmed each incident would be a medication error and the physician should have been notified and the incident documented. She stated she had never identified a medication error and did not know of a paper or computer form to fill out and would have to ask the DON help her. On 4/28/16 at 4:35 pm, the Clinical Compliance Auditor stated there was a form in the system, but the DON had been changing things. At 5:00 pm, the Clinical Compliance Auditor produced a Medication Error Reporting Form. On 4/28/16 at 5:05 pm, LN #3 and LN #4 were asked what they would do if they had identified a medication error. LN #3 stated there was a form. LN #4 stated they (LN #3 and LN #4) needed to go get a supervisor before they talked to the surveyor. When asked if the form was kept at the nurses station, LN #3 stated she would go get a supervisor and LN #4 stated they needed to have a supervisor to answer. A response to the question of whether the form was kept at the nurses' station was not provided by LN #3 or LN #4. The interview ended at that time. 2. Resident #4 was admitted on [DATE] with [DIAGNOSES REDACTED]. a. Review of Resident #4's acute hospitalization medication record, dated 4/20/16, documented the resident received [MEDICATION NAME] (antidepressant used for [MEDICAL CONDITION]) 100 mg 1 tablet at bedtime. Medications ordered/recommended to be continued for Resident #4 did not include an order for [REDACTED].>On 4/25/16 at 7:30 am, during the survey's initial tour, Resident #4 was observed sitting in her chair eating cereal. When the surveyor introduced herself and stated the purpose of the visit, Resident #4 stated she thought the state was here because she had not been getting her sleeping medication, [MEDICATION NAME]. Resident #4 stated she had been at the facility since last Wednesday and had not been able to sleep because she did have the [MEDICATION NAME], and was miserable. Nursing Progress Notes documented that on 4/25/16 at 4:50 pm, the NP saw Resident #4. Resident #4 had requested an order for [REDACTED]. The documentation noted Resident #4 was not happy. On 4/26/16 at 2:27 pm, Social Service Progress Notes documented Resident #4 told the LSW she had not had her [MEDICATION NAME] for sleep since she was admitted and told the nurse yesterday and had seen the NP, but had to wait for laboratory results. Resident #4 had stated she wanted to transfer to another facility. On 4/27/16 at 8:10 am, Resident #4 stated she had taken the medication at home for years and had told the nurses over and over she needed her sleeping pill. She stated she had taken it in the hospital, but was told it had not made it on the medication sheet for the facility. Resident #4 stated she had finally gotten the [MEDICATION NAME] last night. Resident #4 stated she did not understand why someone could not have contacted the hospital or her primary physician. On 4/27/16 at 9:10 am, LN #2 stated that on Monday morning (4/25/16), there was a note from the night nurse to contact the NP about an order for [REDACTED]. LN #2 stated that although Resident #4's History and Physical and hospital records documented the use of [MEDICATION NAME], no one had contacted the hospital or the resident's primary physician to clarify. The procedure was to wait for the NP or physician to see Resident #4 and reorder the medication. LN #2 stated information between shifts was passed on through reports, daily nursing assessments, and progress notes. On 4/28/16 at 9:10 am, the DON stated the facility or nurse does not make any changes to admitting orders and would not call the hospital or the resident's physician to clarify the orders. She stated they (facility) would request at some point to talk to the NP or call the NP. The NP visited the facility on Monday, Wednesday and Friday. She stated there were progress notes that the NP had saw Resident #4 on 4/25/16 and was waiting for lab reports. No further explanation or documentation was provided. Admitting orders were not thoroughly checked against orders for medications taken in the hospital. Resident #4 did not receive a medication she had taken for years and depended upon for sleep. The Black box warning for [MEDICATION NAME] included: Taper when stopping; do not stop abruptly (Karch, A. M., Lippincott ' s Pocket Drug Guide for Nursing, (2016) Wolters Kluwer: Philadelphia, 354). b. An Order Summary for Resident #4 dated 4/21/16, documented the resident used a [MEDICAL CONDITION] machine with 2 Liters of oxygen at night for sleep apnea. On 4/21/16, Resident #4's Care Plan identified her as requiring oxygen therapy related to [MEDICAL CONDITION] and asthma related to [MEDICAL CONDITION] and [MEDICAL CONDITION] and the use of oxygen as needed to keep her oxygen saturation levels above 90%. The Nursing Progress Notes did not contain documentation regarding oxygen, use of a [MEDICAL CONDITION], oxygen or discussions regarding the issue. On 4/25/16 at 7:30 am, during the survey's initial tour, Resident #4 was observed to have a [MEDICAL CONDITION] machine at her bedside connected to an oxygen concentrator. Resident #4 stated the [MEDICAL CONDITION] machine was hers that she used at home. On 4/27/16 at 8:10 am Resident #4 stated she had used the [MEDICAL CONDITION] machine in the hospital, but the facility had not connected it to the oxygen right away because they did not know how to hook it up and did not have respiratory in the facility. She stated she had not been sleeping. She stated she had tried to get them to call (oxygen supplier) to have them come out and fix it. She stated she did not understand the reason they (facility) could not have called someone or ask her what to do. On 4/27/16 at 9:10 am, LN#1 stated Resident #4 did not have an order for [REDACTED].#2 confirmed the [MEDICAL CONDITION] machine was the resident's and the resident had brought it in with her from the hospital. LN #2 stated everything should be documented in the Nursing Progress Notes. LN #1 and LN #2 confirmed no one was contacted on 4/20/16 and Resident #4 was without oxygen for her [MEDICAL CONDITION] the night of 4/20/16. On 4/27/16 at 9:10 am, the Regional Compliance Officer stated Resident #4 did not have oxygen for her [MEDICAL CONDITION] the night of 4/20/16. 3. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. a. On 4/18/16 Nursing Progress Notes documented Resident #5 was admitted from the hospital with a right leg shin laceration related to a fall at home. On 4/21/16, a Braden scale for predicting pressure sore risk identified Resident #5 as high risk. Daily Skilled Nursing Assessments, dated 4/21/16-4/23/16, did not identify skin issues other than the right leg laceration. On 4/24/16, an assessment identified skin irritation under Resident #5's left breast, pannus and abdominal folds. Assessments for 4/24/16, 4/25/16, and 4/26/16 did not identify new or additional skin issues. On 4/25/16 at 12:00 pm, during a dressing change to Resident #5's right leg laceration, LN #5 was asked to remove the resident's socks. Directly on top of the tip of the resident's right second toe, there was an approximately 1 cm x 1 cm circular callous area with approximately 0.5 cm x 0.5 cm black area in the center. LN #5 stated she was unaware of this area. At this time, Resident #5 stated she had a callous on the toe where her sock and shoe rubbed. She stated she would periodically peeled off the callous and that it had been there for a long time. A Late Entry Nursing Progress Note for 4/25/16 at 9:53 am, documented the right second toe had been identified as a skin issue. Nursing Progress Notes from 4/18/16- 4/24/16 did not contain documentation of skin issues related to the right second toe. On 4/27/16 at 10:30 am, during an observation of the toe with the DON, the DON stated the toe issue had been discovered on 4/25/16. The DON measured the area noting a 1 cm x 1.04 cm callus area with 0.5 cm x 0.4 cm blacken eschar to right second toe. She stated daily skin assessments and weekly skin checks were completed by the nurse. She stated the physician had saw Resident #5 and had referred her to the wound clinic, but the resident had refused to go. On 4/28/16 at 9:10 am, the DON stated the admitting nurse performed the initial skin assessment and floor staff did weekly assessment. She stated any skin issue should be documented and noted. She stated she would have expected to see documentation about Resident #5's toe in the initial and weekly assessments. She stated there was no additional documentation and could not provide additional information. b. Nursing Progress Notes documented Resident #5 refused her gastric reflux medication, Pantoprazole on 4/24/16 and 4/25/16. On 4/25/16, the resident refused her diuretic medication [MEDICATION NAME], stating she did not want the generic form of [MEDICATION NAME] (diuretic). On 4/25/16 at 4:00 pm, Resident #5 was up in her wheelchair in the therapy room with PT. The resident complained of nausea. She stated it was the diuretic making her sick, because she could not take the generic form of [MEDICATION NAME]. On 4/27/16 at 8:00 am, the resident stated she was allergic to generic medications. Resident #5 stated they (medications) made her nauseous and have trouble breathing. She stated she had previously had reaction experiences from medications and knew what they felt like. She stated at first she thought it was her medication for heartburn, but then thought it was the [MEDICATION NAME]. She stated she paid more for insurance just so she could get brand name medications. The resident stated she had told the nurses she was reacting to a medication, but they did not do anything, so she started refusing the medications. On 4/27/16 at 10:30 am, the DON stated she heard something about the resident reacting to [MEDICATION NAME]. She stated the physician should have been notified and whatever the resident had voiced should have been documented in the Progress Notes. The DON stated the facility did not have a policy that addressed allergic reactions or medication reactions. On 4/27/16 at 10:40 am, LN #5 stated Resident #5 had complained of allergic reactions to medications. Resident #5 had stated she had reacted to medications previously, and had to take the brand names because the others made her nauseous and short of breath. LN #5 stated Resident #5 had the right to refuse medications, and Resident #5 had refused medications. The refusals were documented in the progress notes. LN #5 stated that although Resident #5 had voiced she was reacting to the medication, she had not noticed any signs or symptoms of reactions, such as shortness of breath or nausea. The Nursing Progress Notes did not contain documentation of Resident #5's complaints of medication reactions or discussions with her regarding her actual or potential reaction to medications. 4. Resident #6 was admitted to the facility on [DATE] with multiple diagnoses, including diabetes mellitus. The Order Summary Report for April 2016 contained four insulin orders, including [MEDICATION NAME] pen-injector, 12 units sub-q in the morning with instructions to hold the [MEDICATION NAME] if Resident #6's BG was less than 160. It was ordered 4/19/16 and started 4/20/16. The April 2016 MAR indicated [REDACTED]. The [MEDICATION NAME] was administered when Resident #6's BG was 149 on 4/21/16, 140 on 4/22/16, and 124 on 4/25/16. On 4/27/16 at 2:00 pm, the DON and Regional Compliance Officer said the [MEDICATION NAME] was not held three times, as ordered, when Resident #6's BG was less than 160. 5. Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #2's hospital discharge orders, dated 4/15/16, documented [MEDICATION NAME] 400 mg by mouth two times a day for 1 week, then 400 mg every day for 1 week, then 200 mg every day. Resident#2's facility Order Summary Report for April 2016 documented 3 orders for [MEDICATION NAME] with the order, start, and end dates as follows: * [MEDICATION NAME] 400 mg by mouth 2 times a day for 1 week, order and start date 4/15/16, and end date 4/22/16. * [MEDICATION NAME] 400 mg by mouth in the morning for 1 day, order date 4/15/16, start date 4/23/16, and end date 4/24/16. The typewritten word day had a single line drawn through it with the handwritten word week next to it. The date of the change from day to week was not documented and there were no initials to identify who made the change. * [MEDICATION NAME] 200 mg by mouth in the morning, order date 4/15/16, start date 4/24/16. No other [MEDICATION NAME] orders were found in Resident #2's clinical record. A nurse signed the April 2016 Order Summary Report on 4/15/16. The physician and a different nurse signed the same Order Summary Report two days later on 4/17/16. Resident #2's April 2016 MAR indicated [REDACTED]. It was administered at bedtime on 4/15/16, twice a day on 4/16/16 through 4/23/16, and once on 4/24/16 and 4/25/16. Resident #2 received an extra dose of the antiarrhythmic medication on 4/23/16. On 4/26/16 at 1:25 pm, LN #2 and the Clinical Compliance Auditor reviewed Resident #2's orders and MAR. LN #2 said that [MEDICATION NAME] 400 mg two times a day was administered more than 7 days. The Clinical Compliance Auditor said she would research the issue and get back with the surveyor. On 4/27/16 at 2:15 pm, the DON said she did not have more information about the [MEDICATION NAME] issue.

Based on record review and staff interview, it was determined the facility failed to identify weight loss trends and failed to implement interventions in a timely manner after the resident's weight loss became significant. This failed practice harmed 1 of 9 residents (#1) sampled for weight loss. The resident was harmed when she experienced severe weight loss of 10% within the first 3 months of admission to the facility. Additionally, this failed practice had the potential to harm any resident who experienced a compromised nutritional status. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Admission MDS Assessment, dated 6/10/14, documented: *Required limited assistance of one person for eating. * Weight 141 pounds and height 65 inches. The resident's most recent Quarterly MDS Assessment, dated 9/10/14 documented: *Required set up help only for eating. *Weight 139 pounds and height 65 inches The resident's Weight and Vitals Summary, dated 6/4/14 through 9/3/14, documented the resident experienced a 15 pound weight loss during her first 3 months of admission. The resident's Weight and Vitals Summary documented, in part, the following: 6/4/14 147.4 lbs (pounds) 7/2/14 139.6 lbs -5.0% change. 7/30/14 132.8 lbs - 7.5% change. 9/3/14 132.4 lbs -10% change. Guidance at F-325 documented greater than 5% weight loss in a 1 month period was considered significant and 7.5% weight loss in a 3 month period was considered severe The resident's Phone Communication (physicians order) dated, 6/4/14, documented: "Boost or Equivalent three times a day for nutritional supplement. Regular diet, mechanical soft texture, nectar consistency." In addition, the resident's record contained the following orders: 6/25/14- discontinue regular diet, mechanical soft texture. 6/25/14- (Begin) regular diet, regular texture. 8/8/14- Boost or equivalent one time a day for supplement dietary to mix in milkshake form (strawberry flavor) per patient's request and serve with dinner. Start date: 8/9/14. 8/21/14- Discontinue Boost or equivalent one time a day. Due to patient refusing. 9/3/14- Two-cal or equivalent (supplement) two times a day. 9/12/14. D/C (discontinue) 2 cal (Two-cal) supplement due to refusal. The resident's Care Plan documented, in part: *Focus areas: Dysphagia related [MEDICAL CONDITION](cardio vascular accident) and potential for alteration in nutrition related to unable to verbalize preferences. Date initiated: 6/13/14. *Goals: Demonstrate safe intake of highest recommended diet levels and she maintain weight and nutritional balance through the review date. Date initiated: 6/13/14. Target date: 12/7/14. *Intervention: All staff to be informed of resident's special dietary and safety needs. Regular diet to be followed as prescribed. Regular diet. Family providing snacks in room and favorite foods for example milkshakes. Ensure proper set up. Family member insisting on making her food preferences when many times she did not want what he ordered. Continue to observe and document meal food and fluid intakes. Weight and document weekly. The resident's Dietary Note, dated 9/22/14 at 9:24 AM, documented, "Quarterly review - (Resident's name) is in (on) a regular diet with regular textures. She has eaten on average 76-100% of her meals and consumed on average 950 cc (milliliter) with meals. She has accepted 8 out of 10 snacks. She has gained 6 lbs (pounds) in the last 2 weeks. She has had no significant weight loss/gain. She is receiving 2 cal (two-cal) or equivalent BID (twice a day) given by nursing." However, the resident's Weights and Vitals Summary documented a weight loss of 2 pounds during the two weeks prior to 9/22/14 and a 15.2 pound weight loss since admission. Also, the Physicians Orders, dated 9/12/14, stated, "D/C (discontinue) 2 cal supplement due to refusal." The resident's MAR dated 6/4/14, included an order for [REDACTED]. The resident's MAR also included an 6/4/14 order for I&O (intake and output) every day and night shift. The MAR provided evidence that the I&O was not documented 28 times (10 times in 6/14, 14 times in 7/14 and 4 times in 8/14) before it was discontinued on 8/13/14. The resident's progress notes of 8/3/14 documented: "I&O every day and night shift, this is no longer occurring. Patient is still incontinent and can not (sic) be measured." On 6/11/14, the resident's RD/CDM Nutritional Evaluation documented in the weight history section, "No significant weight change." The Calculations of Estimated Needs section documented, "Calories, 1363." On 11/4/14 at 3:10 PM,when the RD was asked whether that calorie intake was sufficient to maintain the resident's admission weight, she stated, "Yes I do." The Nutritional Summary, dated 6/11/14, documented, " Husband indicates...UBW (usual body weight) is 145 (pounds). Monitor intakes, wt's (weights) and advancement with therapies ..." The resident's Intake records were reviewed from 8/1/14, through 10/31/14 and it was documented that the resident refused the "Brunch" 10:00 AM meal 9 times, the "Siesta" 1:00 PM snack 14 times, and the "HS" 8:00 PM bedtime snack 63 times. Review of the resident's medical record did not provide evidence of nutritional interventions except for Boost, Two-cal for 10 days during the month of 9/14 and a diet change to "Regular" texture and fluid consistency. The resident was observed on 11/3/14 and 11/4/14 at 10:25 AM (both days) during the "Brunch" meal. Family and others were present at her table in the resident's dinning room. Resident #1 was observed to consume 100% of both meals severed. On 11/3/14 at 7:55 AM, the CDM was asked for information on any resident with significant weight loss. She stated, "We do not have any significant weight loss at this time. I check the weights every Monday morning. I just checked and there are no (residents with) weight loss." During an interview on 11/4/14 at 1:45 PM, the RD, when asked about Resident #1's diet, stated, "Before the diet change (to regular) on 6/25/14 her eating was hit and miss." During a second interview with the RD on 11/5/14 at 11:50 AM, the RD was informed that the Boost was not documented as being offered from 6/4/14 to 8/6/14. When informed of the facility's lack of consistent I&O documentation, the RD stated "Not being in the MAR is a concern, I am not denying we have a problem (with weight loss) and need to get it under control." On 11/5/14 at 4:00 PM, the Administrator and DON were made aware of the concern regarding weight loss. No further information was provided by the facility.

Based on a complaint from the public, staff interview, record review, and policy review, it was determined the facility failed to ensure staff clarified confusing admission orders [REDACTED]' BG levels were low. The facility's policy and standing orders contained conflicting information regarding [DIAGNOSES REDACTED]. This was true for 2 of 3 sample residents (#s 1 & 4) reviewed for diabetes management and had the potential to affect any resident who was at risk for low BGs. Resident #4 was harmed the resident was harmed when the resident experienced a [MEDICAL CONDITION] related, in part, to [DIAGNOSES REDACTED] (BG less than 70) after the facility failed to clarify two very different orders for insulin administration per sliding scale. Sliding scale insulin was administered when the resident's BG was 60. The resident received scheduled insulin then declined breakfast and the BG dropped again and was not rechecked after an intervention. The failure also created the potential for more than minimal harm when interventions were not consistently implemented and BGs rechecked when Resident #1's BG was low. Findings included: The American Diabetes Association (ADA), at http://www.diabetes.org states, in part, "[DIAGNOSES REDACTED] is...characterized by abnormally low blood glucose...usually less than 70 mg/dlmilligrams...per deciliter (mg/dL)...may also be referred to as an insulin reaction when the level of glucose in the blood is too low (at or below 70 mg/dL)...symptoms...include hunger, nervousness, shakiness, perspiration, dizziness or light-headedness, sleepiness, and confusion. If left untreated, [DIAGNOSES REDACTED] may lead to unconsciousness. [DIAGNOSES REDACTED] is treated by consuming a carbohydrate-rich food such as a glucose tablet or juice. It may also be treated with an injection of [MEDICATION NAME] if the person is unconscious or unable to swallow...The only sure way to know whether you are experiencing [DIAGNOSES REDACTED] is to check your blood glucose...Severe [DIAGNOSES REDACTED] has the potential to cause accidents, injuries, coma sleep-like state...Treatment Consume 15-20 grams of glucose or simple carbohydrates Recheck your blood glucose after 15 minutes If [DIAGNOSES REDACTED] continues, repeat. Once blood glucose returns to normal, eat a small snack if your next planned meal or snack is more than an hour or two [MEDICATION NAME] If left untreated, [DIAGNOSES REDACTED] may lead to a [MEDICAL CONDITION] or unconsciousness (passing out, a coma)...Injectable [MEDICATION NAME] kits are used as a medication to treat someone with diabetes that has become unconscious from a severe insulin reaction..." 1. Resident #4 was admitted to the facility 1/21/14 with multiple [DIAGNOSES REDACTED]. The resident was transferred via ambulance to a local emergency department on 1/23/14. The resident's Interagency/Interfacility Physician order [REDACTED]. * "Medications: see: ADMRO (Admission/Discharge Medication Reconciliation Orders) (and) MTF (Medication Transfer Form)..." * "Additional Physician Orders: See ADMRO (and) MTF..." * The ADMRO, dated 1/15/14 - included orders for [MEDICATION NAME] 24 units sub-Q (per subcutaneous injection) daily in the morning and, "Special Instructions: In morning prior to brkfst (breakfast) insulin [MEDICATION NAME] (Humalog) Subcutaneous (Resume) Yes" and "(I)nsulin [MEDICATION NAME] (Humalog) Subcutaneous Before Meals (last dose) 1/14/2014...(Resume) Yes " and "Blood Sugar (glucose) Range... 51 to 60 give 1 (unit), 61 to 79 give 2 (units), 80 to 150 give 2, 151 to 200 give 3, 201 to 250 give 5, 251 to 300 give 6, 301 to 351 give 7, 351 to 400 give 8..." In handwriting next to the ss orders was, "**No insulin is given after dinner insulin if given" and "**Do not give (with) [MEDICATION NAME]. May switch back to Humalog if pt desires**" * The MTF, dated 1/21/14, included orders for [MEDICATION NAME] 24 units sub-Q daily; and, "Insulin [MEDICATION NAME] ([MEDICATION NAME])" per the following sliding scale: "0 total unit (from) 1 (to) 80, 0 total unit(s) (from) 81 (to) 150, 4 total unit(s) (from) 151 (to) 200, 6 total unit(s) (from) 201 (to) 250, 8 total unit(s) (from) 251 (to) 300, 10 total unit(s) (from) 301 (to) 350, 12 total unit(s) (from) 351 (to) 999. Notify MD if: BG (less than) 70...Chart total dose given. Scale is 0 units prandial plus custom correction protocol. Do not adm(ister) if pt. (patient) is NPO (nothing by mouth). Hold dose and inform MD...;" and, "Insulin [MEDICATION NAME] ([MEDICATION NAME])... 2 units (from) 251 to 300, 4 units (from) 301 (to) 350, 6 units (from) 351 (to) 999. Notify MD if: BG (less than) 70...Chart total dose given, check BG at (3:00 a.m.) and follow bedtime correction if needed..." In handwriting next to the ss orders was, "Do not give with humalog (sic)" and "May switch back to Humalog if patient (and) family desires." NOTE: The Interagency/Interfacility Physician order [REDACTED]. The resident's facility orders called an "Order Summary Report" included: * "HumaLOG Solution (Insulin [MEDICATION NAME] (Human)) Inject as per sliding scale if (BG): 51-60 = 1 (unit of insulin); 61-150 = 2 (units); 151-200 = 3; 201-250 = 5; 251-300 = 6; 301-350 =7; 351-400 = 8; 401+ call md (physician), subcutaneously before meals for Diabetes." These orders were dated 1/21/14; * [MEDICATION NAME] 24 units sub-Q one time a day, dated 1/21/14; * "[MEDICATION NAME] 1 milligram (mg) Inject 1 dose subcutaneously as needed for [DIAGNOSES REDACTED]. Give one dose for inability to arouse and s/sx (signs/symptoms) of [DIAGNOSES REDACTED] with bg less than 50. Patient should arouse in 15 minutes. Call MD after administration." It was dated 1/23/14; and, * Glucose Gel 40% (percent)...Give 1 dose by mouth as needed for [DIAGNOSES REDACTED] Give 1 dose orally PRN (as needed) for BG less than 50 not resolvable by food." It was dated 1/31/14. The resident's January 2014 MAR indicated [REDACTED] * [MEDICATION NAME] administered at 6:30 a.m. on 1/22 and 1/23; * BG to be checked at 7:00 a.m., 10:00 a.m., and 4:00 p.m.; * 1/22 at 7 a.m. BG = 60 and Humalog insulin 1 unit administered; * 1/23 at 10:00 a.m. BG = 50 with "See Progress Note" noted; * The area to document [MEDICATION NAME] Kit on 1/23 was blank; and * The area to document Glucose Gel on 1/23 was blank. The resident's Progress Notes (PN) documentation included: * 1/22 at 7:48 a.m. - "...eMAR- (electronic medication administration record)...Note Text: not indicated per bg (BG) parameters BG 60." NOTE: This entry indicated the ss insulin was not administered despite the eMAR documentation that Humalog insulin 1 unit was administered when the resident's BG was 60 at 7:00 a.m. on 1/22. Please refer to F 514 for details regarding the medical record accuracy issue. NOTE: There were no other entries about the low BG on 1/22. * 1/23 at 9:23 a.m. - "...eMAR- ...Note Text: Patients (sic) BG 50. Orange juice and a snack given. Will continue to monitor." NOTE: There was no documentation regarding the resident's level of consciousness at the time, what the "snack" consisted of, if the resident consumed the juice and/or snack, how much was consumed, or that the BG was rechecked afterward. There were no other entries until 3:08 p.m. * 1/23 at 3:08 p.m. - "Note Text: Staff notified nursing at (1:15 p.m.) that patient was having a [MEDICAL CONDITION] assessment was having abnormal extremity movements, with eyes rolled back...Duration of [MEDICAL CONDITION] was less than one minute. Vital signs immediately after [MEDICAL CONDITION] stable aside from o2 (oxygen) saturation was 83-85% on RA (room air). Pupils pinpoint and fixed immediately after [MEDICAL CONDITION]. BG immediately after [MEDICAL CONDITION] 111...called MD...send patient to hospital...Emergency responders called...Transport staff left at (2:45 p.m.) with patient..." A complainant stated that on 1/23/14, sometime between 9:30 a.m. and 10:00 a.m., the resident, who was a Type I insulin-dependent diabetic, was in "diabetic shock" and "so out of it" the resident was unable to chew a peanut butter sandwich staff were trying to feed to the resident. A family member asked a staff person to get the resident some juice or some glucose. Staff left the room but did not return. The family member then found a glucose tablet among his/her things, crushed it and gave it to the resident and after that the resident started to come around. Two staff who assisted the resident to the bathroom were informed that a glucose tablet had been given to the resident because no staff returned with anything to alleviate the low blood sugar. The resident's Meal Intake records contained no documented evidence the resident ate any food before the brunch meal (at 10:00 a.m.) on 1/23/14. The records documented the resident consumed 76-100 % of the brunch meal and 76-100 % of the dinner meal (4:00 p.m.) on 1/23/14. However, the resident was not in the facility after 2:45 p.m. on 1/23/14. (Refer to F 514 for the details regarding the medical record accuracy issues.) NOTE: On 1/23/14, the resident received [MEDICATION NAME] 24 units at 6:30 a.m. but did not eat anything until about 10:00 a.m., 3 1/2 hours, after the insulin was administered. On 2/26/14 at 9:00 a.m., the DON referred the surveyor to the NL for questions regarding Resident #4. The NL was asked what medication was "not indicated" on 1/22/14 at 7:00 a.m. when the resident's BG was 60 and ss insulin was administered per the eMAR. The NL said he thought the ss insulin was not given though it was documented on the eMAR. The NL stated, "It's dependent on the nurse to write the follow up note if there's a low BG. If they (nurses) noted it, it would be in the nurses' notes (also called progress notes)." On 2/26/14 at 10:30 a.m., the DON was asked to provide the facility's policy regarding [DIAGNOSES REDACTED]. Also on 2/26/14 at 10:30 a.m., the NL was asked about the 2 different Interagency/Interfacility Physician order [REDACTED]. The NL picked up the 1/15/14 ADMRO and stated, "These are the orders I used." When shown the 1/21/14 MTR sliding scale orders, the NL indicated he was not aware of them. The NL acknowledged the MTR orders were the most current sliding scale orders. He stated, "There was a lot to clarify with these orders. I remember talking to the (spouse) and I thought I wrote a note. I've looked extensively and I can't tell you why the note wasn't made. I used the wrong sliding scale orders." On 2/26/14 at about 1:00 p.m., the DON provided the resident's 1/23/14 emergency department and acute care hospital stay records, as well as the facility's Diabetic Blood Glucose Monitoring policy, and the facility's Standing Orders. The emergency department records, dated 1/23/14, and acute care records included: * [DIAGNOSES REDACTED]. * H&P (history and physical) which documented, in part, "[MEDICAL CONDITION]. Suspected by course - potential contributors in [MEDICAL CONDITION] (low sodium level) and [DIAGNOSES REDACTED]; and, * Discharge Summary, dated 1/30/14, which documented, in part, "[MEDICAL CONDITION]: Etiology is probably multifactorial...There is potential that the patient might have mild [MEDICAL CONDITION] secondary to [DIAGNOSES REDACTED] and [MEDICAL CONDITION]" The facility's Diabetic Blood Glucose Monitoring policy documented, in part: "... 7...blood glucose will be monitored ac and hs (before meals and at bedtime) or per physicians' order... 10. If patient (sic) blood glucose level is less than 60mg/dl administer 120 ml (milliliters) of fruit juice or 2 glucose tablets may repeat every 15 minutes until blood glucose is above 60mg/dl. 11. Repeat blood glucose every 15 minutes until blood glucose is above 60mg/dl... 13. Notify physician if blood glucose level does not stabilize after 2 doses or 30 minutes. 14. Notify physician when patient stabilizes. 15. Document incident in patient chart." The facility's Standing Orders documented, in part: "...12. May provide oral glucose for BG (less than) 70 not resolved by providing food 13. May provide [MEDICATION NAME] kit (1 mg) IM (per intramuscular injection) for unrouseable patient with BG (less than) 70 and symptoms of [DIAGNOSES REDACTED]. Client should rouse within 15 minutes. Call MD after administration." On 2/26/14 at 3:00 p.m., the ED and DON were informed their policy did not meet the ADA recommendations for [DIAGNOSES REDACTED] and that the policy and the Standing Orders for treatment of [REDACTED]. The DNS stated, "All patients admitted to the facility have these standing orders." The DNS and ED both acknowledged that the policy and the Standing Orders were different. The ED indicated the policy and the Standing Orders would be updated to reflect the ADA recommendations for [DIAGNOSES REDACTED]. The resident was harmed by a [MEDICAL CONDITION], caused in part by [DIAGNOSES REDACTED], when the facility failed to clarify which of 2 very different admission sliding scale insulin orders were to be used, administered ss insulin when the resident's BG was 60 on 1/22, and did not recheck the resident's BG after an intervention for a BG of 50 on 1/23. On 2/26/14 at 4:30 p.m. the Administrator and the DON were informed of the issues. No other information or documentation was received from the facility which resolved the issues. 2. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's February 2014 MAR indicated [REDACTED] * 2/12/14 - at 4:00 p.m. the BG was 63. NOTE: The resident's 2/13/14 Progress Notes (PN) did not document the BG was rechecked or any interventions were provided regarding the low BG. * 2/17/14 - at 10:0 a.m. BG was 66. The PN for 2/17/14 at 10:05 a.m. documented "insulin held per patient & nurse d/t (due to) BG being 66. Patient eating breakfast and orange juice." The PN documented at 12:05 p.m. the insulin was not given "this a.m." due to the BG of 66, but the PN did not provide evidence that nursing staff rechecked the resident's BG. *2/24/14- at 4:00 p.m. the BG was 68. The only PN on 2/24/14 regarding BG levels documented at 11:27 a.m. (prior to BG of 68 at 4:00 p.m.) "no signs of hyper/[DIAGNOSES REDACTED]." The PN notes for 2/24/14 did not document the low BG at 4:00 p.m., if the BG had been rechecked or if interventions were provided. On 2/26/14 at 9:00 a.m. the NL stated the low BGs should have been rechecked and documented in the PN. The NL also stated interventions to address the low BGs sugars should have been documented in the PN. On 2/26/14 at 4:30 p.m. the Administrator and the DON were informed of the above concerns. The facility provided no further information.