Every finding on record at Surprise Health and Rehabilitation Center

Based on observations, staff interviews, and policy review, the facility failed to ensure that the food item was stored in accordance with professional standards for food service safety. The deficient practice could increase the risk of foodborne illness.Findings Include: During an initial walk-through of the kitchen dry storage on March 24, 2026, at 8:26 a.m., with the Kitchen Dietary Manager (staff #65), a gallon-sized container of Pace Chunky Salsa was observed to have approximately 1/10 of its contents used and stored in non-refrigerated dry storage with two different labels dated as February 2, 2026 and March 2, 2026. Then, the Kitchen Dietary Manager opened the lid of the Pace Chunky Salsa, noting that the safety seal had been opened and a portion of the salsa had been used. The Kitchen Dietary Manager immediately discarded the opened container of Pace Chunky Salsa in the trash located in the kitchen. An interview was conducted on March 24, 2026, at approximately 8:28 a.m., with the Kitchen Dietary Manager (Staff #65), who stated that the gallon of opened Pace Chunky Salsa should be in the walk-in refrigerator by the salad dressing area on the top shelf and expressed not knowing what those differing dates indicated. The Kitchen Dietary Manager stated that having an open gallon of Pace Chunky Salsa not properly dated and refrigerated after opening for use does not meet his expectations because it can cause foodborne illness. An interview was conducted on March 26, 2026, at 09:32 a.m., with the [NAME] (Staff #411), who stated that the facility's process for storing open salsa is that it should be dated and refrigerated after it is opened. He stated that, on the morning of March 24, 2026, he opened a new gallon-sized container of Pace Chunky Salsa to fill two little cups of salsa for a resident. The [NAME] stated he ran, back to hustle on the line. He then stated he should have refrigerated the Pace Chunky Salsa after opening. He stated that the risk associated with not refrigerating the salsa after opening is that someone can get sick. A follow-up interview was conducted on March 27, 2026, at 08:25 a.m., with the Kitchen Dietary Manager (Staff #65), who stated that the facility's process for storing open salsa is to first date when the salsa is opened, then put into the walk-in refrigerator. Then he stated that if open salsa is not refrigerated, it can cause foodborne illness, which would not meet his expectation or the facilities' expectations. An Interview was conducted on March 27, 2026, at 08:44 a.m., with the Chief Executive Officer (CEO/staff #264), who stated that the expectation is that opened salsa is refrigerated. He then stated that if there is a risk, it would be that the food would change after being left open in the dry storage. The facility policy titled Food Storage, last revised in 2014, revealed that food should be stored at appropriate temperatures and by methods to prevent contamination or cross-contamination. It also revealed that TCS (Time/Temperature Control for Safety) foods must be maintained at or below 41 degrees Fahrenheit.

Based on observation, staff interviews, and the facility policy and procedures, the facility failed to ensure one medication cart was secured when left unattended. The deficient practice could result in residents, visitors and/or staff members having unrestricted access to medications. The census was 98.Findings include:An observation was conducted on March 26, 2026 at 11:10 a.m. on the C Wing on the first floor, a staff member was preparing medications at the medication cart. The staff member ( Registered Nurse (RN), Staff #165) collected the medication cup with the prepared medications and walked around the cart and into the resident room that was located next to the medication cart. The medication cart was left facing out into the hallway, was left unattended and unlocked.Assistant Director of Nursing (ADON) Staff #69 was then observed walking up to the medication cart, and locking the cart.An interview was conducted on March 26, 2026 at 11:11 a.m. with ADON Staff #69. Staff #69 stated that the policy is to lock the carts when you walk away and if you don't, patients or anyone can get into the medications. An interview was conducted on March 26, 2026 at 11:13 a.m. with RN, Staff #165. Staff #165 stated that she thought she had locked her medication cart but it must not have happened and the policy is to lock medication cart. RN Staff #165 concluded the interview by stating the risk for not locking the medication cart, is that someone can get into it.An interview was conducted on March 26, 2026 at 11:15 a.m. with director of nursing (DON) Staff #63 who stated that the policy is to lock medication cart when a nurse walks away. The DON stated that the medication cart can only be open when a nurse is present and stated the risk for leaving a medication cart unlocked and unattended is that anyone can get into it.A review of the facility policy titled, Medication Access and Storage, E kit access, revised July 2023 and reviewed July 2025, revealed that it is the policy of the facility to store all drugs and biologicals in locked compartments.

Based on a clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that Specialized Durable Medical Equipment (DME) services were provided to one resident (#100). The census was 98. The deficient practice could result in immobility and isolation. Findings include: Resident #100 was re-admitted to the facility on [DATE], with diagnoses that included heart failure, anoxic brain damage, and chronic kidney disease. A comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had several impairments in cognitive skills related to daily description-making. The MDS further revealed no use of a mobility device. A physician's order dated May 07, 2025, included a Physical Therapy (PT) / Occupational Therapy (OT) evaluation for a wheelchair. A Quarterly MDS assessment dated [DATE], revealed severe impairment in cognitive skills related to daily decision-making. The MDS also revealed that no mobility device or wheelchair was being used. A Nurse Practitioner (NP)/ Physician Assistant (PA) progress note dated November 06, 2025, indicates that the resident has mobility limitations that significantly impact his ability to participate in one or more MR Activities of Daily Living (ADLs) at home. The progress note also indicated that the resident would be a full-time wheelchair user and would require individualized fittings and adjustments. A facsimile Transmittal Sheet dated November 07, 2025, indicated that fax documentation was sent to the DME company. A care plan dated November 24, 2025, revealed an intervention for a Restorative Nursing Assistant (RNA) to transfer the resident to a wheelchair twice a week to improve posture and positioning. However, the Care Plan did not reference Durable Medical Equipment (DME). A Quarterly MDS assessment dated [DATE], revealed severe impairment in cognitive skills related to daily decision-making, and there was no indication of wheelchair use. A Nursing Home MDS assessment dated [DATE], revealed severe impairment in cognitive skills related to daily decision-making. The MDS further revealed no prior use of a wheelchair. A Therapy Progress Note dated March 26, 2026, indicated that the DME company was contacted regarding the status of the wheelchair order placed in November, and it was confirmed that the order was placed in November. The progress note then stated that the DME company attempted to contact the resident in January and March, but the writer clarified that the resident had been residing at the facility when the order was sent. The progress notes also indicated that the resident is unable to communicate independently. The Progress note then indicated that the facility and family attempted to obtain information, but due to HIPAA constraints, no information was provided. The progress note further indicated that, for April 13, 2026, the resident was scheduled for a wheelchair evaluation. Additionally, the Progress Note stated that writer would be the primary point of contact to ensure accurate coordination of care, appropriate location, and communication of patients' needs. The progress note also stated that the DME company was unable to reach the resident until January, when a home evaluation was scheduled for January 15, 2026. However, the resident was not present at that time, resulting in a reschedule. The progress note further revealed that the DME company was not advised that the resident was at the facility. The progress then stated that the writer will remain the primary point of contact to facilitate coordination and prevent further delays in equipment procurement. A call log dated March 26, 2026, to the DME company included a note that the Therapy Program Manager (Staff #167) had requested to speak with a representative and was given three different email addresses for the DME company. A second call log dated March 26, 2026, to the DME Company home care corporate notes that the Therapy Program Manager (Staff #167) called to follow up on the process and status. The representative for the DME company reported that the evaluation was attempted twice and that there was one scheduled for April 13th. The note further indicates that (Staff#167) called for an update/status but was told that a return call would be made to her. An interview was conducted on March 26, 2026, at 9: 35 AM with Resident # 100's daughter, who stated that they had spoken to the Therapy Department about a year ago to request a customizable wheelchair and were told it would take a long time to receive it. She then stated that, about five to six months into her father's admission to the facility, she contacted the Durable Medical Equipment (DME) company and was told that no order had been placed. She further stated that approximately three months ago, her father was reassessed for a custom wheelchair by the facility because the order had been lost. She also stated on March 28, 2026, she was told by rehab staff to call the DME company, and that the company told her there were no orders for it. An interview was conducted on March 26, 2026, at 11:04 AM with (Staff # 167), who stated that the facility's wheelchairs were not suitable for the resident, and they will rent or provide a customized wheelchair for the resident. She then stated that on November 06, 2025, an evaluation was completed for the customizable wheelchair for Resident 100. She then stated that the DME company prefers for the family to stay in contact with them. She also stated that the previous Director of Rehab had begun the process for the customizable wheelchair; however, after she stepped in as Director of Rehab, the process had to be restarted. She further stated that, with this particular company, it typically takes approximately 4 to 6 months to receive a response.A request was made on March 27, 2026, at 8:57 AM for any follow-up documentation with the DME company. The Clinical Resource (Staff #551) noted that there was no documentation of any follow-up with the DME company after November 2025. A review of a document received on March 27, 2026, regarding a call log to the DME company with the date of November 07, with a note written by an Occupational Therapist (OT/Staff# 166) that the DME company inquired about the process and confirmed the fax number, and that the DME company was asked if the facility or therapy would be contacted, and was told no. However, there was no additional documentation confirming that this information was provided or that a follow-up discussion occurred.Review of a document received on March 27, 2026, revealed that (Staff #167) had reached out to three different DME companies on March 26, 2026, regarding Resident 100's DME order for the wheelchair. Further review of the document revealed that two out of three companies did not receive any orders for the resident. Also, one of the companies returned the call and indicated that they had received the resident's facesheet in April 2025 and reported that they were not contracted with the resident's insurance. An interview was conducted on March 27, 2026, at 9:54 AM with Clinical Resource (Staff #551), who stated that there had been follow-ups regarding the wheelchair; however, there was no documentation to support these actions. She then stated that the Director of Rehab had made phone calls to the company a few times, but there is no documentation of this. She further stated that, based on the information gathered, the delay in completing the evaluation is due to a leadership transition in the Director of Rehabilitation. She also stated that they had reached out to the former Rehab Director, who did not recall working with any specific company, particularly regarding the customized wheelchair for this resident. She stated that the former Director of Rehabilitation had identified three possible wheelchair companies, and this information had been used to guide follow-up efforts. She then stated that they had instructed the current Rehab Manager to contact the 3 possible companies and that the resident's insurance covered only one of the DME companies. One of the three companies not covered by the resident's insurance stated that it had received the evaluation for the custom wheelchair in April 2025 or May 2025, but there is no documentation to support this. Staff #551 also stated that any follow-up regarding resident services should have been documented. She then stated that the current Rehab Director stated that follow-ups with the wheelchair company had occurred on March 11 and March 19, but these interactions had not been documented. She also stated that there is no documentation regarding follow-up for the customizable wheelchair. She further stated that the facility reviews other residents who are pending evaluations to identify similar issues. She then stated that it would take six to nine months to receive the customizable wheelchair. She further stated that there should have been communication with the family regarding the wheelchair process. An email dated March 27, 2026, at 11:23 AM from DME company to (Staff#167) revealed that DME company was unable to reach out to the resident in January, and they had scheduled a home eval on January 15, 2026, but unfortunately, the resident was not home, and they had to reschedule for March 11, 2026. The email further revealed that the DME company was not informed that the resident was residing at the facility until the family advised them. The email also revealed that the resident was scheduled for an evaluation on April 13. The email further revealed that there needs to be a therapist eval signed by the same prescribing doctor, and a signed written order. An interview was conducted on March 27, 2026, at 11:17 AM with a Service Representative for the DME Company (Staff #777) who processes the customizable wheelchair is that an order needs to be placed. She then stated that the facility's PT and OT departments will conduct an evaluation and send over that information to the provider for approval. She then stated that once that information is in their system, they would send out a specialist for evaluation. She then stated that once they have completed their evaluation, they will get a price range, enter that information into the system, and the provider will sign off on it as approval. She then stated that the resident's insurance company would decide whether to process. She further stated that residents would call, but they would expect the facility to call them as well. She then stated that if a resident is not able to communicate due to their disease, they would expect a caregiver or nurse to call for an update. She also stated that she received a call from (Staff # 167) on March 26, 2026, regarding the customized wheelchair, but there had been no prior communication from the facility about it. She further stated that the only order on file for the resident was dated November 13, 2025. She then stated that because the order was valid for only 6 months, the facility would need a new prescription, OT, and PT evaluation, as well as a charting note. A further interview was conducted on March 27, 2026, at 11: 38 AM with (Staff #167), who stated that she had gotten the Director position in August 2025 and was informed in October 2025 that Resident #100 had not received the custom wheelchair. She then stated that she had contacted the wheelchair company and was told there was no documentation on file for the wheelchair evaluation that was submitted to them. Staff #167 stated that in May 2025, an evaluation was completed, but the necessary paperwork had not been submitted to the customized wheelchair company. She also stated that on October 17, 2025, ( Staff #166) had conducted an evaluation to determine whether the resident was appropriate for rehabilitation services. Staff #167further stated that on November 07, 2025, Resident #100 was evaluated for a customized wheelchair, and a call was placed to the wheelchair company; however, there was no documentation to support this. She also stated that it takes about 3 to 6 months for a response from the customized wheelchair company. She then stated that she had verbally told the resident's family to reach out to the DME company, and the resident's daughter attempted to make contact with the DME Company back on March 19, 2026, but t there is no documentation of this. She also stated that there is no documentation of the facility staff contacting the wheelchair company. She further stated that the facility should have documented any phone calls to the wheelchair company. She then stated that on March 26, 2026, she had called the wheelchair company and was told that in January 2026, a home visit was made to evaluate the resident, but the resident resides at the facility. Staff # 167 then stated that the morning of April 13, 2026, the resident is scheduled to be evaluated by the customized wheelchair company. She further stated that the expectation is for the evaluations to be submitted to the customized wheelchair company, and physician orders should be followed. She also stated that when they receive orders, they will complete them on the day they receive them or within 3 days. Staff #167 stated that the risk of not following through with physician orders results in noncompliance with provider directives and does not meet the expectations of the resident's family. Staff #167 also stated that the risk of not following through with a physician's order is that they are not being compliant with the provider's orders and with the family. She then stated that the importance of the customizable wheelchair was to provide leisure and allow him to be out of the room. She further stated that the risk of not following through with physician orders results in noncompliance with provider directives and does not meet the expectations of the resident's family. An interview was conducted on March 27, 2026, at 12:03 PM with (Staff #166), who stated that in November 2025, she had completed a wheelchair evaluation, and that a prior evaluation had been conducted for the resident in May 2025. She also stated that they would typically maintain documentation for any communication with the wheelchair company. Staff #166 stated that on November 07, 2025, she completed the wheelchair evaluation and sent over the face sheet, fax sheet, and face-to-face note to the company. However, she was unable to recall the date she attempted to contact the company and noted that this was not documented, which it should be. She also stated that a CNA had notified her that the family had asked about the customized wheelchair, and she had provided the company's phone number for the family to contact the company. She also stated that she was unsure if this incident was even documented. (Staff #166) stated that, for some time, they were using a geri-chair for the resident, but at some point, the family did not want to get up in the geri-chair due to discomfort. She stated that although there were several loner wheelchairs, the geri-chair was the safest for the resident, but he would need to be supervised. She then stated that they did not have a suitable wheelchair for the resident because of his height, weight, and size. She also stated that when the customized wheelchair arrives, they would have to assess its safety. She also stated that the risk of not communicating with family regarding the status of the wheelchair process could result in them becoming upset. A request was made on March 27, 2026, at 1:40 PM for a Durable Medical Equipment (DME) policy and a Quality of Care (QofC) Policy. Facility staff had noted on the request form that there were no specific policies for this request on March 27, 2026. An interview was conducted on March 27, 2026, at 1:41 PM with a Certified Nursing Assistant (CNA/Staff # 527), who stated that Resident #100 is totally dependent on care and is nonverbal. He then stated that the family never brought any concerns regarding the customer's wheelchair to his attention, but there were times when he had helped the resident up onto a recliner. He also stated that the Restorative Nursing Assistant (RNA) staff was working with the Resident on his range of motion. He further stated that the resident is bedbound and that he had not seen the resident outside his room. He then stated that, as humans, we are social beings and need interaction and time outside. He added that, as humans, individuals require social interaction and time outside of their rooms for overall well-being.An interview was conducted at 1:53 PM with a Licensed Practical Nurse (LPN/Staff #69) who stated that she manages the staff, ensures they know what they are doing, and addresses resident requests. She then stated that the resident is totally dependent on care, and she had never seen him with a wheelchair. She then stated that the nursing staff would work on changing, repositioning, and bathing the resident. She then stated that the risk of a resident constantly being in their rooms depends on their condition. She further stated that they should try to get the resident out of the room for activities like bathing, getting sunlight, and socializing. She then stated that if a resident is in their room constantly and is bed-bound, then it can affect their mood depending on the resident. An interview was conducted on March 27, 2026, at 2:29 PM with the Director of Nursing (DON/Staff #63), with the Clinical Resource (Staff #552) present. DON stated that when there is a physician's order, it is confirmed and communicated through all departments. DON then stated that, for this resident, the only note she had seen regarding the customizable wheelchair dated back to November 2025, with no additional documents. DON then stated that the purpose of the customizable wheelchair is to provide the resident with leisure and to allow the resident to leave the room. DON then stated that she would have expected the therapist to follow up on the wheelchair customization and communicate updates to the family. DON also stated that she would have expected the information regarding the customizable wheelchair to have been brought up during the stand-up meeting since the nursing staff would not have access to therapy notes. Clinical Resource (Staff #552) stated that there were two additional residents that have been identified as not being provided continuous care for rehab services. A review of the titled policy Accommodation of Needs, reviewed August 2025, revealed that facility to assure that a resident has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences.

Based on clinical record review, facility documentation, interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#5) received weight monitoring for dialysis treatment per physician orders. The deficient practice could lead to a lack of adequate monitoring during dialysis treatment. Findings Include: Resident #5 was admitted into the facility on [DATE], with diagnoses that included respiratory failure, diffuse large B-cell lymphoma in remission, end stage renal disease, and dependence on renal dialysis. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident's Brief Interview for Mental Status (BIMS) assessment was not conducted due to the resident being rarely or never understood. A care plan dated January 30, 2025, revealed Resident #5 required hemodialysis due to renal failure. Interventions included for the resident to receive bedside dialysis, and for staff to obtain vital signs and weight. A physician order dated January 30, 2025, indicated to weigh the resident before each scheduled bedside dialysis treatment. Physician orders dated January 29 and February 3, 2025, indicated the resident was on bedside hemodialysis every Monday, Wednesday, and Friday, or as otherwise directed by renal. An additional physician order dated February 13, 2025, indicated to weigh the resident before each scheduled dialysis. Review of the Medication and Treatment Administration Record (MAR / TAR) for January 2025 revealed the resident received a dialysis treatment on January 31, 2025. The record indicated that the resident's weight was not recorded that date. The Weight Summary log also revealed that no weight was recorded on that date. Review of the Medication and Treatment Administration Record for February 2025 revealed the resident had received dialysis treatments on February 3, 5, and 14. The record indicated that the resident's weight was not recorded on any of those dialysis treatment dates. Additionally, the Weight Summary log also revealed no weights were recorded on the treatment dates. An interview was conducted on March 11, 2025, at 11:33 AM, with a certified nursing assistant (CNA / Staff #3) who stated that there are two restorative nursing aides in the facility who help obtain residents' weights, however nurses and CNAs can obtain residents' weights as well. The CNA stated that the floor nurse would alert the CNAs if a resident needed to be weighed. An interview was conducted on March 11, 2025, at 11:41 PM, with a licensed nursing assistant (LNA / Staff #12) who stated that for residents receiving bedside dialysis treatments, that the facility's process for obtaining the residents' weights would be for the nurse to notify the CNAs when the weights were needed, and the CNAs would obtain the weights. An interview was conducted with the Director of Nursing (DON / Staff #28) on March 1, 2025, at 12:32 PM. The DON stated that her expectation would be for staff to follow physician orders. She stated that the importance of monitoring residents on dialysis is to assess for a change of condition so that the interdisciplinary team could address it. The DON stated that weight fluctuations are common with residents receiving dialysis treatments, and that staff would notify the provider if a weight fluctuation was noted. The DON stated that if weights were not adequately monitored, then this could impact a provider being aware of the resident's status. The DON stated that the facility's process for monitoring weights of residents on dialysis was that there are physician orders that trigger a notification to the nurse, and that the nurse would communicate to the CNAs, who are responsible for obtaining the resident's weight. The clinical record was reviewed with the DON who confirmed that the weight monitoring for Resident #5 was not on the MAR for January or February; and that, this is where it should have been recorded. The DON confirmed that the weight monitoring was not recorded anywhere else in the clinical record, and that this would not meet her expectation. Review of the facility policy titled Vital Signs, Weight and Height, revised May, 2007, revealed that the weight of the resident will be recorded at the time of admission and monthly, unless otherwise indicated by the physician. If the resident is unable to be weighed the reason shall be recorded, and other provisions shall be taken to monitor the resident's size. Review of the facility policy titled Physician Orders, reviewed August 2024, revealed it is the policy of this facility to accurately implement orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on clinical record review, observations, staff interviews, and policies and procedures, the facility failed to ensure that a request for a modification of a health care institution was approved by the state agency prior to establishing a dialysis center and provided dialysis treatment(s) from November 22, 2024 through March 06, 2025. Currently 3 residents are having bedside hemodialysis inside the facility. The deficiency may result in non compliance with federal, state, and local laws and professional standards. Findings include: During the complaint survey conducted on March 6, 2025 through March 6, 2025, an initial request for documentation was made which included copies of dialysis contracts, the facility's modified license for in-house dialysis services, license for contracted dialysis provider, and a list of residents receiving in-house dialysis services from the contracted dialysis provider. A review of the list of residents receiving in-house hemodialysis services with the actively contracted dialysis provider included the following residents: Resident #1 was originally admitted to the facility on [DATE] and then currently readmitted on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. Hemodialysis is scheduled for every Monday, Wednesday and Friday. The resident has had 5 sessions of bedside hemodialysis in the facility. Resident #2 was originally admitted to the facility on [DATE] and then currently readmitted on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. Resident is scheduled for bedside hemodialysis every week or as otherwise directed by renal. The resident has had 15 sessions of bedside hemodialysis in the facility. Resident #3 was admitted to the facility on [DATE] with the diagnoses of end stage renal disease and dependence on renal dialysis. Resident is scheduled for bedside hemodialysis every Monday, Wednesday, Friday or as otherwise directed by Renal. The resident has had 18 sessions of bedside hemodialysis in the facility. A review of the facility assessment updated November 2024, revealed the facility has an average census of 98, with a current census of 96. No details regarding the amount of residents with end stage renal disease or how many are receiving bedside hemodialysis. An interview was conducted with Certified Nursing Assistant (CNA) staff #3 on March 6, 2025 at 2:39 pm and revealed that there are residents in the hall she is caring for today that are on hemodialysis. An interview was conducted with Licensed Practical Nurse (LPN) staff #5 on March 6, 2025 at 2:40 pm revealed that he was aware of bedside dialysis starting over a month ago in the rooms. An interview was conducted with Executive Director (ED) staff #6 on March 6, 2025 at 3:49 pm revealed that the facility was unable to obtain a copy of the license to provide dialysis and is immediately terminating the contract with the company providing dialysis and immediately transferring the patients to a facility that does. Review of the Arizona Administration Code S R9-10-417, titled, Dialysis Services. If dialysis services are authorized to be provided on a nursing care institution's premises, an administrator shall ensure that the dialysis services are provided in compliance with the requirements in R9-10-1018.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure care and services related to a cervical collar was provided for one resident (#8). The deficient practice could result in resident needs not being met to attain and maintain the resident's highest practicable well-being. Findings include: Resident # 8 was admitted on [DATE] with diagnoses of unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture with routine healing, encephalopathy, acute kidney failure, and essential (primary) hypertension. Review of the Admission's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severe cognitive impairment. The hospital physician note dated June 12, 2024 included that the resident had the C-collar in place. Assessment included C2 cervical fracture. Per the documentation, the C-collar at all times except during showers and meals; and to follow-up in 8 weeks and reassess with new CT (computed tomography) scan of the cervical spine. The hospital discharge instruction dated June 12, 2024 included a discharge diagnosis of C2 cervical fracture. The documentation also included that the resident had repeat CT scan of the cervical spine without contrast. The admission note dated June 13, 2024 included that the resident arrived at the facility and was alert and oriented x1. The documentation did not include whether the resident had the C-collar on or not. The NP (nurse practitioner) progress note dated June 14, 2024 revealed that the resident was alert and oriented x 3, was frail and underweight. Assessment included C2 cervical fracture. Plan included for therapy evaluation and treatment and C-collar at all times x 8 except during showers and meals. The physician progress notes dated June 15 and 18, 2024 included a chief complaint of C2 cervical fracture; and that, the resident was to continue with C-collar at all times x 8 weeks except during showers and meals. Per the documentation, the C-collar was to be placed back on as the resident did not have it on when he came back from shower. However, clinical record revealed no care plan with goals and interventions in place to address the resident's primary diagnosis of displaced fracture of second cervical vertebra and use of the cervical collar. The care plan had a picture on the right lower corner of the page that showed a picture that the resident was wearing a collar on his neck. Despite documentation that the resident had cervical collar, there was no evidence of a physician order for the use cervical collar (C-collar) found in the clinical record; and that, the resident refused to wear the C-collar. The clinical record also revealed no evidence of a reason why the C-collar was not on; and that, the physician was notified. The Occupational Therapy (OT) note dated June 19, 2024 revealed that the resident was not able to maintain cervical and aspiration precautions while wearing cervical collar; and that, cervical collar was ill fitting and the resident's chin was tucking into collar when worn. The Physical Therapy (PT) services dated June 19, 2024 revealed that the resident's cervical brace had a poor fit; and that, cervical brace was not safe for wearing. The nursing note dated June 19, 2024 included that the resident was placed in the dayroom by therapy in eyesight of the nurse station dur to resident at risk of fall. Per the documentation, the staff last checked the resident at approximately 11:20 a.m. and was removed from the dayroom by his family at 12:00 p.m. via a wheelchair. The documentation also included that the resident's family called for assistance at 12:05 p.m. and the resident was found unresponsive and without a pulse. The recorded video footage from June 19, 2024 revealed that the resident was being wheeled in by a family member from the common room near the nursing station to his room and was not wearing the cervical collar. In an interview with Licensed Practical Nurse (LPN/staff #70) conducted on June 25, 2024 at 3:50 p.m., the LPN stated that in the morning of June 19, 2024, the resident appeared fine, had received medications in the room at about 8:00 a.m. and went to therapy after that. The LPN stated that after the therapy, the resident was brought and was left him in the common room sitting near the table. An interview was conducted on June 26, 2024 at 8:51 a.m. with an Occupational Therapist (OT/staff #33) who stated that he provided occupational therapy services to the resident twice i.e., the initial assessment and on the day of the resident's passing. The OT said that last OT session with the resident was on June 19, 2024, and after this session, the resident was left sitting in his wheelchair in the common room in front of nurses' station, and without his cervical collar. The OT said that he recalled the cervical collar was too big so resident's head rolled and ended up getting his chin tucked. The OT stated that the purpose of the cervical collar was to keep the resident's neck in alignment; however, there were no explicit orders regarding the use of the resident's cervical collar. Further, the OT said that other therapists had similarly noticed chin tucking. During the interview, the OT showed a screen shot of the recorded video footage from June 19, 2024 at 12:07 p.m. that showed that resident #8 was in his wheelchair being pushed by a female individual. The resident was wearing dark colored clothes, had a bonnet on but was not wearing a cervical collar. An interview was conducted on June 26, 2024 at 09:19 AM with Physical Therapist Assistant (PTA/staff # 42), who stated that she conducted the OT session for resident #8 with the OT on June 19, 2024. The PTA stated that the resident was not wearing his cervical collar when she arrived into the room to provide services; and that, the resident's cervical collar was on the resident's dresser. The PTA stated that the resident's cervical collar was poor fitting, too big, and if the resident moved his chin at all, his chin would tuck in. Further, the PTA said that she did not take any action on this issue because she assumed that staff knew the cervical collar was big for resident #8; and that, the purpose of the cervical collar was for the resident's comfort. In an interview with Physical Therapist (PT/Staff # 53) conducted on June 26, 2024 at 9:39 a.m., the PT stated that she provided physical therapy services to resident #8; and that, the cervical collar that the resident had was too big. The PT stated that she attempted and would attempt to put the cervical collar on resident #8, but the resident would often complain of discomfort; and, was likely the reason why the resident was refusing to wear the cervical collar. The PT said that in one instance when she arrived in the resident's room, the resident did not have the cervical collar which was observed laying on the resident's nightstand. During the interview, the PT showed a screen shot of the recorded video footage from June 19, 2024 at 12:07 p.m. that showed that resident #8 was in his wheelchair being pushed by a female individual. The resident was wearing dark colored clothes, had a bonnet on but was not wearing a cervical collar. An interview with Certified Nursing Assistant (CNA/staff #22) was conducted on June 26, 2024 at 11:14 a.m. The CNA stated that on June 19, 2024, the therapy staff had left the resident in front of the nurse's station; and that, the resident was not wearing the cervical collar. During an interview conducted with Director of Nursing (DON/staff #4) on June 27, 2024 at 8:22 a.m., the DON stated that regardless whether the cervical collar was needed, recommended, or used as needed, it should have been worn by resident #8. An interview was conducted on June 27, 2024 at 9:54 a.m. with Licensed Practical Nurse (LPN/staff #16) who stated that her role as an admission nurse was to assist with the admissions process of new residents that included obtaining orders, checking for devices like braces and looking for anything that residents were supposed to be wearing and to be added onto the resident's care plan. The LPN also said that medical records were reviewed and anything that was needed by residents will be brought up; and, the role of an admitting nurse was to input medications, care plan and goals, and interventions. In an interview with Medical Doctor (MD/staff #50) conducted on June 27, 2024. The MD stated that she would expect that a physician order and a care plan was in place for a resident who was admitted with a neck brace from a discharging facility. Review of the facility's policy titled, Specialized Rehabilitative Services (reviewed April 2024) revealed, it is the policy of this facility to provide rehabilitative services to residents as determined by their comprehensive plan or care to assist them to attain, maintain or restore their highest practicable level of physical, mental, functional and psycho-social well-being; specialized rehabilitative services include the following: physical therapy and occupational therapy. The facility's policy titled, Physician Orders reviewed in August 2023 included that admission orders are reviewed with the physician upon admission based on the discharge instruction from the discharging facility and are transcribed accordingly. The facility policy on Comprehensive Person-Centered Care Planning with a review date of February 2024 revealed that it is their policy that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical nursing, mental and psychosocial needs that are identified in the comprehensive assessment; within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instruction needed to provide effective and person-centered care.

Based on observations, resident interviews, clinical record review, staff interviews, and policy review, the facility failed to ensure staff did not leave medications with two residents (#351 and #354) who were not assessed and determined to be clinically appropriate for self-administration of medication. The deficient practice could result in medication not being taken as ordered by the physician. The findings include: -Resident #351 was admitted on [DATE] with diagnoses of periprosthetic fracture around internal prosthetic left hip joint, overactive bladder, and unspecified dementia. A nursing note dated December 9, 2022 revealed the resident was alert and oriented x 2 and had a history of Alzheimer's disease. The daily skilled note dated December 10, 2022 included the resident was alert and oriented x 2-3, and was forgetful and confused at times. A change of condition note dated December 10, 2022 included the resident was alert and oriented x 2, forgetful; and that, family needed to sign consents. An encounter note dated December 12, 2022 included that resident had a history of Alzheimer's disease, was alert and had mild confusion. Diagnosis included Dementia. The care plan dated December 12, 2022 revealed the resident was at risk for impaired cognitive function/dementia or impaired thought process and had alteration in neurological status related to dementia. Intervention included to administer medications as ordered and to give step by step instructions one at a time as needed to support cognitive function. The care plan did not include whether resident was appropriate for self-administration of medication. A nursing note dated December 12, 2022 included the resident was alert and oriented x 1-2, was anxious, verbally aggressive, requested pain medications and was redirected several times. The admission MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had an active diagnosis of non-Alzheimer's dementia. The daily skilled note dated December 17, 2022 revealed the resident was alert and oriented x 1. The physician order dated December 19, 2022 included an order for sodium chloride solution 0.9% to use 50 milliliters (mL) per hour intravenously (IV) every shift for one day. A nursing note dated December 19, 2022 revealed resident was alert, able to verbalize needs and needed IVF (intravenous fluid). According to the documentation, resident yelled at the staff and declined the IV. An encounter note dated December 20, 2022 included that resident was found to be hypotensive and an IV was ordered. However, per the note, the resident refused the IV. There was no evidence found in the clinical record that resident #351 was assessed and determined appropriate for self-administration of medications During an observation was conducted on December 19, 2022 at 10:08 a.m. resident #351 was in her room and had normal saline infusing through an IV. There were two tablets in a medication cup, one unopened 6 mL heparin flush syringe, and one saline flush syringe attached to an IV extension j-loop found on the window sill within the resident's reach. An interview was conducted with resident #351 immediately following the observation. Resident #351 stated the tablets in the medication cup were Tums (antacids). There were no staff present in the resident's room. A licensed practical nurse (LPN, #98) came in the room and stated she did not know why the the heparin flush was in the resident's room; and that, the night shift staff might have left it there. The LPN was then observed removing the items from the room. -Resident #354 was admitted on [DATE] with diagnoses of cirrhosis of the liver, alcohol abuse, and hypertension. The admission note dated December 9, 2022 included the resident was alert and oriented x 2-3. The daily skilled note dated December 9, 2022 revealed the resident was alert and oriented x 3. The care plan dated December 9, 2022 included resident was at risk for impaired cognitive function/dementia or impaired thought process related to alcohol. Interventions included to administer medications as ordered; engage in simple, structured activities that avoid overly demanding tasks; and give step by step instructions one at a time as needed to support cognitive function. The care plan did not include whether resident was appropriate for self-administration of medication. The admission MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 13 indicating resident had intact cognition. Active diagnoses included cirrhosis of the liver and alcohol abuse. An NP note dated December 14, 2022 included resident had a chief complaint of alcohol abuse, was awake, alert and oriented. Assessment was alcohol abuse and the resident consumed 3 vodkas daily. Review of the order summary report active as of December 21, 2022 revealed the resident had the the following medications: -Allopurinol (anti-gout); -Metoprolol Succinate (beta blocker); -Multivitamin- Minerals (supplement); -Omeprazole (proton-pump inhibitors); -Thiamine Hydrochloric (supplement); -Ipratropium- Albuterol Solution (bronchodilator); -Lactobacillus capsule (probiotic); and, -Sodium chloride (supplement). There was no evidence found in the clinical record that resident #354 was assessed and determined appropriate for self-administration of medications. An observation was conducted on December 19, 2022 at 9:58 a.m. Resident #354 was in her room and was in the middle of a breathing treatment. There was a medication cup that contained 7 pills on the bedside table that was in front of her. An interview was conducted immediately following the observation and resident #54 stated that the medications were left on the table by a staff so she can take it after her breathing treatment. There were no staff present inside the resident's room. Resident #354 stated she was going to take the medications. The LPN (staff #98) who was at the nurse's station immediately walked towards the resident's room when told of the medications left with resident #354. The LPN stated she left them in the room and planned to return to the room once the breathing treatment was done. She stated that she leaves the medications with a resident if the resident was having a breathing treatment; however, she said that resident #354 could not take the medications by herself. The LPN said that she had instructed resident #354 to call her once breathing treatment was done so she can administer it with the resident. The LPN then entered the resident's room and instructed the resident to take the medications. An interview was conducted on December 20, 2022 at 1:54 p.m. with another LPN (staff #6) who stated that nurses must watch residents swallow their medications to ensure residents are not hiding the medications in their cheek; and/or they do not drop the medications because most elderly drop their pills. Staff #6 said that residents are not allowed to have their medications in the room with them. Staff #6 also stated medications can not be left unattended with residents; and that, she would take the medications out of the room with her and instruct the resident to call her back when they are ready to take it. Staff #6 also stated that medications are not left with the residents to take on their own because the resident might forget to take it or they might waste it or save to take it at a later time. Regarding the heparin flush, staff #6 stated that it was the facility's policy to use the heparin flush on an IV to keep the line patent. However, she stated that the heparin flush can not be left at bedside because a resident can do something about it or administer it to themselves and bleed. In an interview conducted with the director of nursing (DON/staff #138) on December 21, 2022 at 1:32 p.m., the DON stated that the process of administering medications include watching the resident take their medications. The DON stated that residents can self-administer medications only if they were assessed for it; and that, currently there are no residents in the facility that were assessed to self-administer medications. She also said that medications cannot be left with a resident unattended without a staff present for any period of time. Regarding resident #354, the DON stated that her expectation was for a nurse to let the resident know that the nurse could not leave the medications during her breathing treatment. Further, the DON stated that the nurse needs to watch the entire process of the resident taking the medication. The DON also stated that if medications are left in the room for the resident to take on their own time then there is a risk that residents would take the medications incorrectly. Review of the facility's policy titled, Medication Administration with a revision date of May 2021 revealed that only licensed medical and nursing personnel or other lawfully authorized staff members may prepare, administer, and record the administration of medications. Medications may not be set up in advance. Review of the facility's policy titled, Self-Administration of Medication with a revision date of May 2021 stated, If a resident desire to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. If the resident is a candidate for self-administration of medications, this will be indicated in the chart.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the clinical record was accurate related to advance directives for one resident (#352). The deficient practice can lead to the advance directives being inconsistent with the resident's wishes. Findings include: Resident #352 was admitted on [DATE] with diagnoses of heart failure, shortness of breath, and atrial fibrillation. An advance directive signed by the resident and dated [DATE] revealed that the advance directive was reflective of the resident's values and wishes; and, it directed caregivers that if resident's heart or breathing stops, the resident had a code of do not resuscitation (DNR). It also included that the resident did not want any resuscitation measures, including but not limited to: CPR, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, and related emergency procedures. However, a physician order dated [DATE] revealed an order for a cardiopulmonary resuscitation (CPR)/full code. Despite the discrepancy, there was no evidence found in the clinical record that the advance directives were clarified, verified and changed to reflect resident's wishes. There was no evidence found the clinical record was updated to reflect resident's advance directive wishes until [DATE]. A physician order dated [DATE] revealed an order for a DNR. An interview was conducted on [DATE] at 12:27 p.m. with a licensed practical nurse (LPN, #98) who stated that in the event of a cardiac/respiratory arrest she would call rapid response, grab the crash cart, get the oxygen and the automated external defibrillator (AED). The LPN also stated that she will perform CPR if necessary; and that, she would check the report sheet, the electronic record and/or computer, or the code book. During the interview, a review of the code book was conducted with thee LPN who stated that resident #352's advance directive was in the book; and that, the resident had a code status of a DNR. The LPN also stated the code status of the resident will also be found in the medication administration record (MAR) and/or the electronic record. Further, the LPN stated there was a risk that staff will take the wrong step if the MAR or the electronic record was different from the advance directive signed by the resident and ordered by the physician. She stated that resuscitation to bring a resident back should not be performed on a a resident with a DNR status. In an interview with a certified nursing assistant (CNA/ staff #85) conducted on [DATE] at 12:39 p.m., the CNA stated that in the event of a cardiac/respiratory arrest she would notify the nurse and perform CPR if she needs to. The CNA stated the information for a resident's code status is located in a code book or in the main screen of the resident's profile in their charting system. The CNA said that the code book was easily accessible; however, if it is not available, she would check the electronic record. She further stated that if the code book and electronic record does not match, she would ask the unit manager. However, the CNA said that if a resident is in an active arrest she does not know what to do if the records do not match. An interview was conducted on [DATE] at 12:43 p.m. with another LPN (staff #6) who stated that in the event of a cardiac arrest she would call a code and the rapid response team will come and assist. She stated that one person will get the crash cart and one will grab the code book to verify the resident's code status. Staff #6 stated it was important to have an accurate record of the resident's code status because staff would not perform CPR on someone who has refused it. Staff #6 further stated that records are verified for accuracy daily; and that, someone was always verifying the information in the code book. An interview was conducted on [DATE] at 1:01 p.m. with the unit manager (staff #93) who stated that in the event of cardiac/pulmonary arrest, one staff will call a code blue, another staff will notify the respiratory therapist, one staff will grab the AED, one staff will call 911 and someone will start CPR. Staff #93 stated when residents are admitted , their code status are determined and placed in the code book. However, she stated that if the code status is not in the code book, she would then look in the electronic record. The unit manager said that the medical records staff checks the accuracy of the resident's code status; but, she does not know how often. Staff #93 also said that it was important to maintain accurate records to ensure residents get the appropriate care they want and need. The unit manager stated that she does not maintain the advance directives but medical records do. In an interview with medical records director (staff #43) conducted on [DATE] at 1:09 p.m., she stated medical records staff maintain the code status books; and that, every resident at the facility has a code status and an advance directive. She said that every Monday, Wednesday, and Friday, medical records staff conducts an audit to ensure all residents have a code status in the code book that matches the electronic record. Staff #43 sstated it was important to maintain accurate record to ensure facility meets the expectations of the resident, family and the facility. She also said that accurate record will ensure that code status of the resident was followed and updated accordingly when there are changes. Staff #43 said that the code status in the electronic record must match the resident's advance directive; and that, when there are changes made on the unit, the code book is updated by either the unit manager or the MDS (Minimum Data Set) nurse. During an interview with the director of nursing (DON/staff #138) conducted on [DATE] at 1:32 p.m., the DON stated that in the event of a cardiac or respiratory arrest staff are expected to check the resident's code status found in a code book located in every nurse station. She stated that resident's code status is also found in the electronic record; and that, resident records are maintained by medical records and the unit manager. The DON said that the CNA's were not able to see the resident's code status in the electronic record. She also said that the code status information in the code book should match with the electronic record. The DON said that since everything happens so quickly and changes occur often at the facility, the staff should look at the code book first. She stated the advance directive was usually completed on admission; and as soon as it is filled out, the expectation was that a physician order was put in place. During the interview, a review of the clinical record was conducted with the DON who stated that an advance directive was completed for resident #352 on admission; and that, the physician order did not reflect the resident's wishes until [DATE] which was approximately 12 days after the advance directive was completed. Review of the facility's policy titled, Content of Medical Record revision date of [DATE] revealed that it is their policy that a separate medical record shall be maintained for each resident admitted to the facility and the resident's name will be placed on all medical record forms. All physician, nursing staff and other health care professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the record. Procedures include: pertinent identification data to meet the facility's needs and accurately identify the resident is recorded on admission and updated periodically. Appropriate consents forms, authorizations and acknowledgements are signed by the resident or legal representative and entered in the medical record, these include acknowledgement of receipt of advance directive information.

Based on clinical record reviews, staff interviews, facility policy and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure the MDS (Minimum Data Set) assessments for 3 residents (#12, #79 and #81) were accurate. The sample size was 21. The deficient practice could result in the assessment not reflecting the resident's status. Findings include: -Resident #81 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the case manager progress note dated September 30, 2021 revealed that the resident was scheduled to be discharged to home on October 6, 2021. A physician order dated October 6, 2021 revealed an order to discharge to home with home health services. A nursing note dated October 6, 2021 included the resident was discharged and was following up with home health services. The nursing discharge summary note dated October 6, 2021 included the resident was being discharged to home. It also included that the resident health had improved sufficiently and the resident no longer needed the services of the facility. Despite documentation that the resident discharged to home, the discharge MDS assessment dated [DATE] was coded that the resident was discharged to an acute hospital. -Resident #79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP (nurse practitioner) progress note dated September 27, 2021 included the family wanted the resident to get a CT (computed tomography) scan of the abdomen and an evaluation of the wound when the resident presented to the ED (emergency department). The physician order dated September 27, 2021 included an order to send the resident to the hospital emergency room (ER) for a CT-scan for peg tube placement, and a bone scan related to wound infection. The nursing progress note dated September 27, 2021 included that the resident left for the hospital and that a report was provided to the hospital ER. However, the discharge MDS assessment dated [DATE] was coded that the resident was discharged to the community. An interview with the MDS assistant (staff #25) and MDS Coordinator (staff #171) was conducted on November 4, 2021 at 11:54 a.m. Both staffs stated that the discharge assessment is coded based on the information found in the resident's clinical record. Staff #25 stated that when a resident is discharged to the hospital and later discharged to home from the hospital, the facility will code that the resident was discharged to the hospital. Staff #171 stated that they code the discharge status of the MDS assessment based on where the facility discharged the resident to. The clinical records of resident #79 and #81 were reviewed with staffs #25 and #171 during the interview. Both staffs stated that based on the clinical record, resident #79 was discharged to the hospital. Staff #171 stated that the discharge MDS assessment was coded that resident was discharged to the community. Staff #171 stated that according to the clinical record, resident #81 was discharged to home but the discharge MDS assessment was coded that the resident was discharge to the hospital. Staff #171 further stated that these assessments were inaccurate and she will create a modification for these assessments. Staff #171 also stated that they use the RAI manual as their policy and guidance in coding for the MDS assessment The RAI manual included an instruction to review the medical record including the discharge plan and discharge orders for documentation of discharge location; and, to select the 2-digit code that corresponds to the resident's discharge status: -Code 01, community (private home/apt., board/care, assisted living, group home): if discharge location is a private home, apartment, board and care, assisted living facility, or group home; and, -Code 03, acute hospital: if discharge location is an institution that is engaged in providing, by or under the supervision of physicians for inpatients, diagnostic services, therapeutic services for medical diagnosis, and the treatment and care of injured, disabled, or sick persons. -Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse progress note dated August 17, 2021 revealed the Certified Nursing Assistant (CNA) found the resident on the floor and the nurse observed the patient lying face down on the floor next to the bed. The note included the resident was assisted back to bed and had re-opened skin tears to the left arm and left hand. Review of a Nurse Practitioner (NP) progress note dated August 17, 2021 revealed the resident was seen and examined at bedside and that the resident reportedly suffered a fall sometime last night. The note included that the resident had a bruise to the nose. However, review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a fall since admission with no injury. An interview was conducted on November 4, 2021 at 11:15 a.m. with a Registered Nurse/MDS coordinator (RN/staff #171). She stated that the MDS assessment was expected to be accurate and completed per the RAI manual guidelines for the lookback window. She stated that accuracy was important to give an accurate picture of the care of the resident and to assist in the development of the resident's care plan/plan of care. Staff #171 stated that the MDS assessment asked if the patient had a fall, if answer yes, the fall(s) would be documented as: no injury, minor injury, and/or major injury. She reviewed the August 17, 2021 progress notes and the August 19, 2021 MDS assessment for resident #12 and stated that the MDS assessment should have been coded as a fall with minor injury related to the fall resulting in re-opened skin tears and a bruise. Staff #171 stated that the MDS assessment had been coded as a fall with no injury and was incorrectly coded. An interview was conducted on November 4, 2021 at 11:33 a.m. with the Director of Nursing (DON/staff #16). She stated that she expected the MDS assessment to be complete and completed accurately per the RAI guidelines. The DON stated that it was important for the MDS assessment to be accurate as it gathers all of the information about the resident to formulate the care plan. The DON stated that the identified inaccurate MDS assessment did not meet her expectations. Review of the facility policy for Accuracy of Assessment (MDS 3.0) dated August 2018 revealed: It is the policy of this facility to ensure that the assessment accurately reflects the resident's status. Purpose: To assure that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident's status, needs, strengths, and areas of decline. Procedures included: -A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. -The physical, mental, and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medial social workers, dietitians, and other professionals in assessing the resident and in correcting resident assessments. -Involvement of other disciplines is dependent upon resident status and needs. -Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. Review of the RAI manual dated October 2019, included to review the nursing home incident reports and medical record for falls and level of injury. Determine the number of falls that occurred since admission/entry or reentry or prior assessment and code the level of fall related injury for each at No injury, Injury (except major), and/or Major Injury. The coding instructions included: -No injury: no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident behavior noted after the fall. -Injury (except major): skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes the resident to complain of pain. -Major injury: bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma.

Based on clinical record reviews, observation, staff interviews, and policy review, the facility failed to ensure medications were administered as ordered for two of five sampled residents (#13 and #31). The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include: -Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on August 8, 2021 revealed the resident had anti-anxiety medication use related to anxiety disorder as evidenced by restlessness. Interventions included to give anti-anxiety medications ordered by physician. The admission Minimum Data Set (MDS) assessment dated [DATE] included that resident received antianxiety medications during the 7 days look-back period. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No reason was documented why the medications were not administered. A review of the progress notes and eMAR notes did not reveal evidence why the medications were not given. Continued review of the MAR for October 2021 revealed [MEDICATION(S)] was not administered on October 16, 2021 and 2 was marked as the reason the medication was not given which meant Hold/See Nurses Note. However, review of the clinical record did not reveal a corresponding note as to why the medication was on hold that day. In an interview conducted with a Registered Nurse (RN/staff #173) on November 3, 2021 at 12:35 PM, the RN stated that if a medication is not administered the reason why the medication was not given should be documented in a nursing progress note or an e-MAR). The RN stated that when a medication is not given, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #173 stated medications highlighted in red meant that the medications were not given. The RN stated if a medication was not given, the physician should be notified. She stated the notification and the reason why the medication was not given should be documented in a progress note. An interview was conducted with the Director of Nursing (DON/staff #16) on November 3, 2021 at 1:34 PM, who stated her expectation is for nurses to administer medications as ordered. She stated if a medication is held or not given, the provider should be notified. Staff #16 stated it was weird that nothing was written in the progress note for the medications that were not administered. The DON stated that she expected the nurses to notify the provider and document the reasoning why the medications were held or not given. She stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The baseline care plan dated October 1, 2021 included that the resident required tube feeding related to dysphagia. The admission MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score was 6 which indicated the resident's cognition was severely impaired. The MDS assessment also revealed the resident had a feeding tube. A review of the therapy notes for November 1, 2021 stated the swallow evaluation was conducted by speech therapy and that the resident's swallow was within normal limits. The note further stated that the resident tolerated oral trials of regular textures and thin liquids without overt signs and symptoms of aspiration. During a medication administration observation conducted with a Licensed Practical Nurse (LPN/staff #176) on November 4, 2021 at 8:08 AM, the LPN was observed to administer the resident's medications by mouth except for [MEDICATION(S)] after the resident asked staff #176 to administer the supplement [MEDICATION(S)] via PEG (percutaneous endoscopic gastrostomy) tube and the rest of the medications by mouth. The medications staff #176 was observed to administered orally on November 4, 2021 at 8:08 AM were [MEDICATION(S)] (antacid) 20 milligrams (mg), [MEDICATION(S)] (anticonvulsant) 100 mg, Senna ([MEDICATION(S)]) 8.6 mg, [MEDICATION(S)] (antidepressant) 20 mg, [MEDICATION(S)] (antipsychotic) 25 mg, and Med Pass (supplement) 4 ounces. The LPN was observed to administer [MEDICATION(S)] (anticoagulant) subcutaneously and [MEDICATION(S)] (supplement) via PEG-tube. However, review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the LPN (staff #176) on November 4, 2021 at 1:03 PM. The LPN stated that it was her first-time taking care of resident #31 and the previous shift nurse gave report that resident #31 took medications whole by mouth. She stated that when administering a medication, the nurse has to make sure the medication to be administer is the right one, right dose, right route, within parameter and for the right resident. The LPN stated that she was aware the resident had a PEG tube and that she administered only the supplement via the PEG tube per the resident request. She stated resident #31 was alert and oriented and able to make needs known. The LPN stated when administering medications, nurses have to follow the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if the resident asks to be administered medications differently than what is ordered, the provider needs to be notified and the order should be changed after the provider agrees. An interview was conducted with another LPN (staff #126) on November 4, 2021 at 1:24 PM. She stated when administering medication, the process is to review the MAR, then the bubble card with the medication, to make sure the medication belongs to the right resident. The LPN stated the nurses have to follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if a resident refuse to take the medication via the ordered route then the physician needs to be notified. The LPN stated if the medication is ordered to be administered via PEG tube then the medication has to be given via PEG tube until the physician gives an order to administer the medication orally. She stated it is important to follow the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the DON (staff #16) on November 4, 2021 at 1:37 PM. She stated her expectation is for the nurses to follow the rights of medication administration during medication administration which includes the right medication, right dose, right resident, right frequency, right time, right route, etc. She stated if a resident is requesting medications to be administered orally instead of via PEG tube, her expectation is for the nurses to call the physician to get the order changed. The DON stated the staff should be following the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated it did not meet her expectation when the staff administered medication orally without notifying the physician. The facility policy titled Administration of Drugs revised on May 2021 stated that the facility policy is to administer medications as prescribed by the attending physician. The policy included that medications must be administered in accordance with the written orders of the attending physician and all current drugs and dosage schedules must be recorded on the resident's eMAR. The policy further stated if a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy also stated that the seven rights of medication administration are the right resident, right time, right medication, right dose, right route, right documentation and right diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure scheduled medications were obtained and available for one of five sampled residents (#13). The census was 93. The deficient practice could result in medications not being available for residents. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnosis that included [CONDITION(S)] disorder, [CONDITION(S)] disorder, history of suicidal behavior, anxiety, fluid overload, pulmonary embolism, [CONDITION(S)], pleural effusion, hypertension, [CONDITION(S)] and muscle weakness. The care plan initiated on August 8, 2021 revealed the resident was on [CONDITION(S)] medication use related to [CONDITION(S)]/[CONDITION(S)] disorder as evidenced by delusions, auditory hallucinations. Interventions included to administer medications as ordered. The admission Minimum Data Set (MDS) assessment dated [DATE] included that resident received antipsychotic and antianxiety medications during the 7 days lookback period. -Regarding [MEDICATION(S)]: A physician order dated September 10, 2021 included for [MEDICATION(S)] (antipsychotic) solution inject 100 milligrams (mg) intramuscularly one time a day every 14 days for [CONDITION(S)] as evidenced by delusions. Review of the October 2021 Medication Administration Record (MAR) revealed the resident did not receive the [MEDICATION(S)] injection on October 22, 2021. The MAR was marked as '2', a code that meant Hold/See Nurses Note. The corresponding nurse note for October 22, 2021 stated Awaiting arrival from Pharmacy. Provider Notified. Further review of progress notes did not reveal evidence if the medication was given after it was available, or any direction from the provider. -Regarding [MEDICATION(S)]: A physician order dated September 22, 2021 included for [MEDICATION(S)] (antipsychotic) suspension prefilled syringe 234 MG/1. 5ML (milliliter) inject 234 mg intramuscularly one time a day every 23 days for [CONDITION(S)] as evidenced by auditory hallucinations. Review of the September 2021 MAR revealed that the resident did not receive [MEDICATION(S)] injection on September 22, 2021. The MAR was marked as '2', Hold/See Nurses Note. The next dose was administered on October 15, 2021 as ordered. The corresponding nurse note for September 22, 2021 stated re-ordered. Further review of the progress note did not reveal whether the medication was received or given. An interview was conducted with a Registered Nurse (RN/staff #173) on November 3, 2021 at 10:17 AM. The RN stated when a medication is not available, the process is to check the pyxis, call the provider, call the pharmacy, place the unavailable medication order on hold, enter any changes in the resident while waiting for the medication arrival, and administer the medication after it arrives per provider order. Staff #173 stated she will mark the medication as not given when the medication is not available and enter a nurse note stating Pending delivery, provider aware. She stated the pharmacy usually delivers on the same day, same shift but if the medication is not delivered in the same shift then it is communicated to the oncoming shift. The RN stated normally medication refill is requested by faxing the medication label sticker and normally the medication is received the next day. A second interview was conducted with the RN (staff #173) on November 3, 2021 at 12:35 PM. She reviewed resident #13 chart and verified that the medications ([MEDICATION(S)] and [MEDICATION(S)]) were not given as they were not available. She stated when the medication is unavailable and the provider order is to give the medication as soon as one becomes available, normally the information is passed on to the next shift if the medication did not arrive on the same shift. The RN stated that if the nurse failed to notify the oncoming shift to administer the medication once it is available, the oncoming shift nurse will not know and will fail to administer the medication. Staff #173 stated they do what they can so that medications are available for the residents. She stated if a medication is not available, the provider is notified and they receive direction from the provider whether to hold the medication or skip that day and give the next day. The RN stated as per the provider direction, the nurses will change the order in PCC (Point Click Care). An interview was conducted with a Licensed Practical Nurse (LPN/staff #174) on November 3, 2021 at 12:57 PM. She stated when a medication is not available then the process is to check the emergency kit, if not available in emergency kit, call the pharmacy, contact the provider and let the provider know unless the medication will be available quickly. The LPN stated that if the provider states to give the medication once available, and the medication do not arrive on same shift then the information is passed on to the next shift. The LPN stated if the nurse failed to inform the next shift then the next shift will not know and the resident will not receive the medication. An interview was conducted with the Director of Nursing (DON/staff #16) on November 3, 2021 at 1:34 PM. The DON stated when a medication is not available, her expectation is for the staff to call the provider, call the pharmacy, get a hold order for the medication, let her know and work on getting the medication as soon as possible from the pharmacy. She stated then depending on the provider order, her expectation is for the staff to follow the provider direction. She stated most of the time the provider will order to administer the medication once available or skip the dose and give the medication the next schedule, if the medication is ordered daily. The DON further stated her expectation is for the nurses to document the reason either in a progress note or E-mar note. She stated it is hard to tell why the medications were reordered and not given. Staff #16 stated she will have to talk to the nurse. She stated the medications should be available to the resident and it did not meet her expectation. The facility policy titled Pharmaceutical Services revised on May 2021 stated that the policy of the facility is to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident. The facility policy titled Administration of Drugs revised on May 2021 stated if a medication is unavailable and is not administered at the scheduled time, the documentation will be reflected in the clinical record. The policy further included that physician notification and other information regarding unavailable medication will be documented accordingly.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure advanced directives were accurately documented for one of two sampled residents (#384). The census was 93. The deficient practice could result in residents receiving services which are not in accordance with their wishes. Findings include: Resident #384 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed an Advance Directive Statement form that the resident resuscitation status was DNR (Do Not Resuscitate), indicating the resident did not want cardiopulmonary resuscitation (CPR). The form also revealed verbal - pt was written in the space designated for the resident signature with the date [DATE] and that the form was signed by the facility representative on [DATE]. Continued review of the clinical record revealed a Prehospital Medical Care Directive (DO NOT RESUSCITATE) form that revealed verbal by pt was written in the space designated for the patient signature with the date [DATE]. The form also revealed the signature of a Licensed Healthcare Provider with the date [DATE]. The space designated for the signature and date of the signature of witness to the resident directive was blank. However, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician assistant progress note dated [DATE] stated that the resident chooses to be a DNR/DNI (Do Not Intubate). The note further stated that the resident does not want any heroic measures at resuscitation in the event of [CONDITION(S)]. This included CPR, chemical resuscitation, intubation, or ventilator support. Further review of the clinical record did not reveal the resident had changed the advance directive from DNR to full code. An interview was conducted with a Registered Nurse (RN/staff #173) on [DATE] at 10:17 AM, who stated advance directive is signed on admission and then is scanned into PCC (Point Click Care/electronic record). She stated each nursing station has a code book that contains advance directive for each resident on the unit. The RN stated PCC shows the resident's code status and the PCC should match with what the resident signed on the advance directive form. The RN stated when a resident wants to update their advance directive, the nurses go over the advance directive with the resident and updates any changes in PCC. An interview was conducted with a Licensed Practical Nurse (LPN/staff #174) on [DATE] at 12:57 PM. The LPN stated the advance directive is signed on admission. She stated the provider is contacted and the advance directive is updated when there are any changes. Staff #174 stated the signed advance directive form will be in the code book at the nursing station and the order will be in Point Click Care (PCC). She stated she will look at the code book first. The LPN further stated the code status in PCC and the advance directive paperwork signed should match. She stated all residents code status are entered as full code on admission until their advance directives paper is filled out. She stated the admission nurse or floor nurse can go over advance directive with the resident and should update it in PCC. The LPN stated advance directive form signed should match with the order in PCC so that there is no confusion. An interview was conducted with the Director of Nursing (DON/staff #16) on [DATE] at 1:34 PM. She stated her expectation is for the staff to obtain advance directive upon admission, place it in the code book and update the resident's record once completed. The DON stated nurses should be ultimately looking at the advance directive book but the form signed should eventually match with what is in the resident clinical record in PCC. The facility policy titled Advance Directive Documentation revised on [DATE] stated that the admission coordinator, or social service director shall provide the resident or responsible agent information regarding the right to formulate an advance directive, inquire whether he/she has completed an advance directive and document in the resident health record.

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one of four sampled residents (#384) had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Resident #384 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial Admission Record dated October 29, 2021 revealed the resident was receiving oxygen via nasal cannula at 2 liters per minute. The baseline Care Plan dated October 30, 2021 included that the resident had oxygen therapy related to heart failure, pleural effusions, and [CONDITION(S)]. The interventions included to give medications as ordered, monitor for signs/symptoms of respiratory distress, and oxygen settings per order. A review of the Weights and Vitals Summary revealed documentation that the resident's oxygen saturation was checked multiple times with the resident receiving oxygen via nasal cannula since admission. The summary included that on November 1, 2021 at 8:28 PM the resident oxygen saturation was 95% while on oxygen via nasal cannula. During an observation conducted of the resident on November 2, 2021 at 8:36 AM, the resident was observed receiving oxygen via nasal cannula at 3 liters per minute. Another observation was conducted of the resident on November 3, 2021 at 12:54 PM. The resident was observed receiving oxygen via nasal cannula at 3 liters. However, review of the clinical record did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with a Registered Nurse (RN/staff #173) on November 3, 2021 at 10:17 AM. She stated that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated oxygen is a medication therefore an order is needed to administer the oxygen. An interview was conducted with a Licensed Practical Nurse (LPN/staff #174) on November 3, 2021 at 12:57 PM. She stated the oxygen order in the resident's clinical record will let the nurse know how much oxygen a resident is on. She stated the clinical record has to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated the resident is on oxygen as the resident has CHF and that she does not know why there is not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated there should be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the Director of Nursing (DON/staff #16) on November 3, 2021 at 1:34 PM. The DON stated her expectation from nurses is to evaluate residents for any respiratory distress, check vitals two times a shift and look at PCC to make sure the resident is receiving oxygen as ordered. The DON stated an order is needed for oxygen if a resident needs oxygen administration. The facility's policy titled Oxygen Administration reviewed July 2019 revealed oxygen therapy is administered by the licensed nurse as ordered by the physician or as a nursing measure and an emergency measure until the order can be obtained. The policy included the resident's clinical record will include that oxygen is to be administered, when and how often oxygen is to be administered, the type of oxygen device to use, and charting and documentation related to oxygen use.

Based on observation, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure proper infection control protocols were being followed for one resident (#37). The census was 93. The deficient practice could result in the spread of infection. Findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The assessment included that the resident required extensive assistance of 2 staff with transfers and required the assistance of one staff for locomotion on unit. The results of a lab test completed 10/26/2021 revealed the resident was positive for [CONDITION(S)] (C. diff) toxin B gene. Review of a nursing note dated 10/26/2021 stated the results for stool sample received, Nurse Practitioner notified, new order for oral [MEDICATION(S)]. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 25 MG/ML (milligrams/milliliter) give 5 ml by mouth every 6 hours for C. diff until 11/9/2021. -Change of Condition for [MEDICATION(S)] for C. diff every shift until 11/9/2021. -Observed patient continued on isolation d/t (due to) diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on 10/27/2021 revealed that the resident was on antibiotic therapy related to C. diff, and on isolation for C. diff. Interventions included to administer medication as ordered, and contact isolation for C. diff. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record for bowel movements from 10/27/2021 through 10/30/2021 revealed that the resident had loose stools at least once a day. A review of the clinical record revealed the resident was at the hospital 10/30/21 through 10/31/2021. Continued review of the clinical record for the resident's bowel movements revealed that the resident had loose stools on 11/1/2021 and 11/3/2021. An observation was conducted on 11/1/2021 at 12:15 pm. The resident was observed sitting alone in the wheelchair next to the nursing station with a mask on. The resident remained in this area until a staff member took the resident back to her room at 12:30 pm. In an interview conducted with a Certified Nursing Assistant (CNA/staff #73) at 8:50 am on 11/4/2021, she stated that the residents in the unit are on isolation precautions because of COVID-19. The CNA stated that staff are required to put on isolation gowns, gloves, and masks before entering their rooms. Staff #73 stated that the residents on the unit are not able to leave their rooms unless they have an appointment. She stated that resident #37 is not able to leave her room due to the resident being on isolation precautions. An interview was conducted with a Licensed Practical Nurse (LPN/staff #113) on 11/4/2021 at 9:20 am. She stated the residents on isolation precautions are not allowed in the hallway. The LPN stated the only reason the resident would be able to come out of their room is if there was a fire. When asked about resident #37, she stated that the resident has C. diff and was being currently treated with antibiotics. The LPN also stated the resident still has the infection because that morning the resident had a loose bowel movement that had a foul odor to it. The LPN stated resident #37 is not allowed to leave her room. During an interview conducted with the Director of Nursing (DON/staff #16) on 11/4/2021 at 11:17 am, the DON stated residents who are on isolation precautions should not be coming out of their room unless it is for an important appointment. Another interview was conducted with the DON (staff #16) on 11/4/2021 at 12:44 pm. She stated that she did not know resident #37 had gone out of her room. She said that she asked staff about this and was told that the resident was taken out of the room because she was having anxiety/behaviors at that time. The DON stated staff told her the resident was taken out of her room to help her calm down. An interview conducted with the Infection Control Preventionist (ICP/#63) on 11/4/2021 at 1:16 pm, who stated that if a resident is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that if the resident did not have loose stools for 24 hours, then C. diff precautions can be lifted. The ICP stated the resident was still having loose stools and instead of taking the resident out of her room, nursing could have requested the activity staff to go into the resident's room to redirect the resident. Review of the facility's infection control policy regarding contact precautions for C. diff, reviewed 10/2015, revealed contact precautions will be used for specified patients known or suspected of being infected with C. diff. This microorganism may be transmitted to residents by the contaminated hands or clothing of healthcare workers or by contact with contaminated inanimate or environmental surfaces. The policy included that residents must remain in their room if active signs and symptoms are present. Therapies and activities will be performed in the resident's room. The policy included to limit the movement and transport of the resident from the room to essential purposes only. If the resident is transported, ensure precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environment surfaces or equipment. The policy also included that when transport is necessary, use appropriate barriers on the patient (e.g. gown, gloves).

Based on observations, clinical record review, staff interviews and review of policy and procedures, the facility failed to ensure that medication was administered in accordance with the physician's orders [REDACTED].#103). The deficient practice could result in residents experiencing complications from not receiving medications as ordered. Findings include: Resident #103 was admitted to the facility on (MONTH) 20, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 21, 2019 revealed the resident had [MEDICAL CONDITION]/SOB related to age, and [MEDICAL CONDITION] changes/spine curvature. A goal was that the resident would display optimal breathing pattern daily. Interventions were to give [MEDICATION NAME][MEDICATION NAME] as ordered and to monitor/document any side effects and effectiveness. Review of the Medication Administration Record (MAR) for (MONTH) 2019 revealed that the [MEDICATION NAME]-[MEDICATION NAME] Solution had not been administered on four occasions (September 21, 23, and 25 at midnight and (MONTH) 25 at 6:00 a.m.). The MAR included a code of 6, which indicated the resident was sleeping. Review of the nursing progress notes from (MONTH) 21 to (MONTH) 25 2019, revealed no documentation as to why the [MEDICATION NAME]-[MEDICATION NAME] Solution was not administered or of any communication with the provider regarding the omitted doses, until (MONTH) 25, at 9:56 a.m. The nursing note dated (MONTH) 25, 2019 at 9:56 a.m., now included that the nurse had spoken to the physician about the resident not receiving the midnight dose due to sleeping and that new orders were received to change the order to PRN (as needed). Review of the provider progress notes from (MONTH) 21 to (MONTH) 25, 2019 revealed no documentation that the [MEDICATION NAME]-[MEDICATION NAME] Solution was not administered or of communication regarding the omitted doses. An interview was conducted with a Licensed Practical Nurse (LPN/staff #27) on (MONTH) 25, 2019 at 9:10 a.m. She stated that the nurses need to follow the provider's orders as written. She stated if the MAR did not reflect a check mark, and instead contained a code of 6 (sleeping), the dose was not administered. She stated that if a resident was sleeping at the time a medication was scheduled to be given, the resident should have been woken up and the medication administered. She stated that if the medication was not given the nurse should notify the physician, and document an assessment of the resident and the communication with the physician. At this time, staff #27 reviewed the MAR and stated that the nurse did not follow the facility's expectations for following the provider's orders and for medication administration. She said the medication was a scheduled medication and it should have been given as ordered. She stated the omission of the medication would increase the resident's risk for shortness of breath. She stated that she followed the nurse who held the medication on (MONTH) 25, 2019 at midnight and 6:00 a.m., and the nurse did not communicate in report that the scheduled medication had not been given. An interview was conducted with the Director of Nursing (DON/staff #47) on (MONTH) 25, 2019 at 9:25 a.m. She stated the expectation is for nurses to follow the physician's orders [REDACTED]. She stated that a nurse may hold a medication based on nursing judgement, but the nurse would then be expected to notify the provider and document the reason why the medication was held, and document the provider communication in the medical record. She stated that if a medication is ordered to be given during the night or in the early morning hours, and there is no order for the medication to be given while awake, then the resident should be woken up and the medication administered. She stated that if the nurse is unable to administer the medication, there should be documentation that the provider was notified that the medication was held, and the nurse should obtain a clarification order if needed (obtain an order to give the medication while awake). On review of the MAR regarding the [MEDICATION NAME]-[MEDICATION NAME] Solution, she stated the nurse did not meet expectations for medication administration. Review of the policy on physician orders [REDACTED]. Review of the policy on medication administration revealed that medications shall be administered as prescribed by the attending physician and that medications must be administered in accordance with the written orders of the attending physician. The policy included that if the medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy stated that the seven rights of medication administration included that medications are administered according to the dose prescribed.

Based on observations, clinical record review, staff interviews and review of policy and procedures, the facility failed to ensure one resident (#102) was free from a significant medication error. The deficient practice could result in residents receiving the incorrect medication dose and possibly experiencing medical complications. Findings include: Resident #102 was admitted to the facility on (MONTH) 17, 2019, with [DIAGNOSES REDACTED]. A provider's initial progress note dated (MONTH) 18, 2019 at 8:30 a.m. included the resident was receiving [MEDICATION NAME] (corticosteriod) 45 milligrams (mg) for the treatment of [REDACTED]. The assessment and plan included a recent [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. During a medication administration observation conducted on (MONTH) 24, 2019 at 7:40 a.m., a Licensed Practical Nurse (LPN/staff #7) was observed preparing multiple medications for the resident. While preparing the medications, the LPN removed a 1/2 tablet (which equaled 5 mg) of [MEDICATION NAME] from the bubble pack. The LPN was then observed to administer the medications to resident #102, which included only 5 mg of [MEDICATION NAME]. However, review of the (MONTH) 2019 Medication Administration Record (MAR) revealed documentation that staff #7 had signed off that the resident had received [MEDICATION NAME] 4.5 tablets (10 mg tablets plus 1/2 tablet to equal 45 mg) at 8:00 a.m. on (MONTH) 24. Further review of the (MONTH) 2019 MAR revealed documentation by the nurses that the resident had received 4.5 tablets of [MEDICATION NAME] 10 mg tablets (to equal 45 mg) from (MONTH) 19, through (MONTH) 23. During an interview with staff #7 conducted at 8:55 a.m. on (MONTH) 24, 2019, staff #7 confirmed that she had only given 5 mg of [MEDICATION NAME] (one half tablet of a 10 mg tablet). She stated that the order was for 4.5 mg of [MEDICATION NAME] and that half of 10 is 4.5. The LPN then re-read the order and looked in the medication cart where she found a bubble pack card with whole tablets of [MEDICATION NAME] 10 mg. She stated that she had made an error in dosage, because of how the order was written. She stated the order needs to be written more clearly. The LPN then administered 4 tablets of [MEDICATION NAME] 10 mg tablets to the resident. On (MONTH) 24, 2019 at 1:17 p.m., the [MEDICATION NAME] bubble pack cards for the resident were reviewed. The bubble pack cards were provided to the facility by the pharmacy on (MONTH) 17, 2019, for a total of 56 whole tablets of [MEDICATION NAME] 10 mg and fourteen 5 mg tablets, which were divided onto three cards. The label directions were to administer 4.5 tablets (45 mg) by mouth every day. Card #1 contained 28 whole tablets of [MEDICATION NAME] 10 mg and none had been removed. Card #2 originally contained 28 whole tablets of [MEDICATION NAME] however; 17 tablets had been removed and 11 tablets remained. Card #3 originally contained 14 half tablets (5 mg) but 6 half tablets had been removed and 8 half tablets remained. If the 45 mg dose, (4 tablets of [MEDICATION NAME] 10 mg and 1/2 tablet of [MEDICATION NAME] 10 mg) had been given each day to the resident from (MONTH) 19, through (MONTH) 24, 2019 as documented on the MAR, there would have been 4 whole tablets remaining on card #2, instead of 11 tablets. During an interview conducted on (MONTH) 24, 2019 at 1:50 p.m., the Director of Nursing (DON/staff #47) stated that she had called the pharmacy when the LPN reported the error to her. She stated the pharmacy reported that they didn't have a 45 mg option for [MEDICATION NAME] so they sent what they had, which was 10 mg tablets of [MEDICATION NAME] and 1/2 tablets of [MEDICATION NAME] 10 mg. The DON said that she would expect the nurse to give four 10 mg tablets of [MEDICATION NAME] and one 1/2 tablet (5 mg) to make the 45 mg dose. She also stated that she was working with the pharmacy to write the order in such a way to prevent the error from being repeated in the future. Review of the policy on physician orders [REDACTED]. Review of the policy on medication administration revealed that medications shall be administered as prescribed by the attending physician and that medications must be administered, in accordance with the written orders of the attending physician. The policy included that if the medication is withheld, refused or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy stated the seven rights of medication administration included that medications are administered according to the dose prescribed.

Based on review of facility documentation, staff interviews, and policy review, the facility failed to ensure the daily staff postings were accurate on multiple occasions. Findings include: Review of the facility's staff posting forms and the staff sign in sheets revealed the following inconsistencies: -On (MONTH) 8, 2019, the staff posting form indicated that one Licensed Practical Nurse (LPN) would be working from 6:00 a.m. to 6:00 p.m. However, the staff sign in sheet reflected that one Registered Nurse (RN) worked from 6:00 a.m. to 6:00 p.m. -On (MONTH) 15, 2019, the staff posting form indicated that one LPN would be working from 6:00 a.m. to 6:00 p.m. and one LPN would be working from 6:00 p.m. to 6:00 a.m. However, the staff sign in sheet reflected that one RN worked from 6:00 a.m. to 6:00 p.m., a second RN worked from 2:00 p.m. to 10:00 p.m., and a LPN worked from 6:00 p.m. to 6:00 a.m. -On (MONTH) 21, 2019, the staff posting form indicated that one LPN would be working from 6:00 p.m. to 6:00 a.m. for 12 hours. However, the only staff who signed for this shift was an LPN from 6:00 p.m. to midnight. -On (MONTH) 23, 2019, the staff posting form indicated that one RN and one LPN would be working from 6:00 p.m. to 6:00 a.m. However, the staff sign in sheet reflected that two LPNs' worked from 6:00 p.m. to 6:00 a.m. -On (MONTH) 24, 2019, the staff posting form indicated that one LPN and one RN would be working from 6:00 p.m. to 6:00 a.m. However, the staff sign in sheet reflected that one LPN worked from 6:00 p.m. to 6:00 a.m. An interview was conducted with the Administrator (staff #8) on (MONTH) 25, 2019 at 10:16 a.m. He stated that the staff posting is required to include the number of nurses and CNA's that are on each shift. He stated that the staff posting should match/reflect the disciplines and hours actually worked that day. He acknowledged that the staff postings reviewed did not match the hours/disciplines that worked and therefore, did not meet his expectations for the staff postings. Review of the policy for posting staffing numbers revealed to post the number of staff working who are directly responsible for resident care and to post the number in Full Time Equivalence. The policy stated to include hours worked by Registered Nurses, Licensed Practical/Vocational Nurses, and Nursing Assistants for each shift.