Every finding on record at Tate Springs Health & Rehab

Based on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards regarding wound documentation for one of four residents in the survey sample (Resident #2). The findings include: Facility staff failed to document assessments for Resident #2 that included measurements, appearance, description and/or status of a wound. Resident #2 (R2) was admitted to the facility with diagnoses that included metabolic encephalopathy, diabetes, acute kidney failure, history of sepsis, ulcerative colitis, cognitive communication deficit, bipolar disorder and depression. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact. R2's clinical record documented a sacral wound on 11/29/24. A physician's progress note dated 11/29/24 documented, .Anorexia - continues to refuse to eat; frequently refuses meds [medications]. Developing sacral wound is due to worsening protein malnutrition due to poor dietary habits. Anticipate wound worsening and possibly additional wounds due to her meds and meals noncompliance . A physician's order dated 11/29/24 documented treatment of the sacrum with normal saline, honey fiber and foam dressing each day for wound care. Clinical notes on 11/29/23 documented no descriptive assessment of the sacrum wound indicating the type of wound, stage if pressure injury, wound measurements or any description of the wound's appearance. R2's treatment administration record (TAR) documented the treatments were administered as ordered. Nursing notes documented monitoring and treatment changes of the sacrum wound as follows: 12/2/23 - Physician's order to change wound treatment to zinc cream each day and evening shift for wound care. 12/11/23 - .Skin observation completed . 12/13/23 - .Skin observation completed .reddened area on sacral area - zinc was applied as ordered . 12/20/23 - .skin observation completed .With wound on her coccyx area measuring 1.5 cm in length and 0.5 cm in width. Zinc cream was applied as ordered . 12/27/23 - .skin observation completed .resident With wound on her coccyx area. Zinc cream applied as ordered . 1/3/24 - .skin observation completed. Open area to coccyx .coccyx area measuring 1.5 cm in length and 0.5 cm in width. Zinc cream applied as ordered . 1/6/24 - Physician's order to change wound treatment to normal saline, honey fiber and foam dressing each day A nursing note dated 1/10/24 documented R2's sacral wound had deteriorated rapidly and the resident was referred to the wound consultant for evaluation and treatment. The wound consultant diagnosed R2 with a Kennedy terminal ulcer and documented comprehensive assessments of the sacral ulcer weekly, until the resident's discharge on 1/24/24. Prior to referral to the wound consultant, R2's wound/skin observations were documented as done but notes did not include thorough assessments of the wound. There was no documented assessment associated with physician ordered treatment changes on 12/2/23 (honey fiber/foam dressing to zinc cream), nor on 1/6/24 (zinc cream to honey fiber/foam dressing). R2's clinical notes dated 11/29/23 and 12/27/23 indicated an open area on the sacrum but documented no measurements of the open area. R2's assessments captured on 11/29/23, 12/11/23, 12/20/23, 12/27/23, and 1/3/24 documented no description of the wound or length/width measurements, only noting open area. These assessments documented no appearance of the wound bed or surrounding skin, presence or absence of drainage, or if odor or pain was associated with the wound. On 9/3/24 at 2:20 p.m., the licensed practical nurse unit manager (LPN #2) was interviewed about assessment of R2's sacral wound. LPN #2 stated wound assessments were listed in the nursing notes or under the wound assessment tab in the clinical record. LPN #2 stated the wound consultant documented comprehensive wound assessments for wound tracked/treated by the consultant. LPN #2 stated nurses were expected to document the status of all wounds when assessed and with changes in treatment. LPN #2 stated assessments were supposed to provide a description of the wound. On 9/4/24 at 9:00 a.m., the director of nursing (DON) was interviewed about R2's documented assessments prior to the wound consultant care on 1/10/24. The DON stated she reviewed the clinical record and did not find complete assessments documented prior to 1/10/24. The DON stated that the unit managers were responsible for wound assessments. The DON stated if there was an open skin area, nurses were expected to document the measurements, appearance of surrounding tissue/skin, a description of the wound and presence of drainage, odor or pain. The DON stated prior to referral to the wound consultant, the physician/medical director provided care orders. The DON stated R2's wound was assessed, the physician notified, and treatments were implemented/changed based upon assessments. The DON stated the assessments completed by nurses prior to 1/10/24, were not thoroughly documented and did not include all required information. The facility's policy titled Documentation of Wound Treatments (undated) documented, .The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment . The following elements are documented as part of a complete wound assessment .Type of wound (pressure injury, surgical, etc.) and anatomical location . Stage of wound, if pressure injury .or the degree of skin loss if non-pressure .Measurements: height, width, depth . Description of wound characteristics .Color .Type of tissue .Condition of the peri-wound .wound drainage .Presence or absence of odor .Presence or absence of pain .Wound treatments are documented at the time of each treatment . These findings was reviewed with the administrator, DON, and nurse consultant during a meeting on 9/4/24 at 10:15 a.m. with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility failed to develop a care plan for one of 21 residents. Resident #43 did not have a care plan for fluid restrictions. The Findings Include: Diagnoses for Resident #43 included: Congestive heart failure, end stage renal disease (ESRD), hypertension with heart failure, and diabetes. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 2/17/23. Resident #43 was assessed with a cognitive score of 11 indicating moderately cognitively intact. On 4/17/23 Resident #43's active physician orders were reviewed and read in part: Fluid Restriction 1200 ML every shift for ESRD. Review of Resident #43's care plan did not evidence a care plan had been developed for fluid restrictions. On 4/18/23 at 11:59 AM registered nurse (RN # , unit manager) was asked to review Resident #43's care plan for fluid restrictions. RN # reviewed the care plan and verbalized that a care plan should have been developed. On 4/18/23 at 4:07 PM the above finding was presented to the director of nursing and administrator during an end of day meeting. No other information was presented prior to exit conference on 4/19/23.

Based on observation, interview and policy review, the facility failed to ensure a vial of insulin was not expired for one out of 18 residents who were prescribed insulin. This failure had the possibility of negatively impacting all 18 insulin dependent residents. Findings include: During a medication pass observation on 04/19/23 at 9:00 AM with Registered Nurse (RN) 3, a vial of Novolog insulin with an open date of 01/18/23 was in the top drawer of medication cart A. RN3 confirmed the written date on the insulin vial was 01/18/23. During an interview on 04/19/23 at 9:15 AM, Licensed Practical Nurse (LPN) 1, stated medications in the medication cart are checked randomly for expired medications. LPN1 stated that she did not know of a scheduled time/day for the expired medication check to be completed. During an interview on 04/19/23 at 9:45 AM, LPN2 stated the medication carts should be checked for expired medications daily during the night shift. During an interview on 04/19/23 at 11:40 AM, the Director of Nursing (DON) stated the medication carts should be checked daily for expired medications. A review of the facility's policy, Storage of Medications revised 08/2020 revealed, .Procedures III. Expiration Dating (Beyond-Use Dating) .3. Certain medication or package types, such as .multiple does injectable vials .require an expiration date shorter than the manufacturer's expiration date once opened to ensure medication purity and potency .5. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. A. The nurse shall place a date opened sticker on the medication and record the date opened on the new date of expiration. The expiration date of the vial or container will be 30 days from opening . No other information was presented prior to exit conference on 4/19/23.

Based on clinical record review and staff interview, the facility staff failed for one of 21 residents in the survey sample (Resident # 30) to ensure the resident's clinical record was complete and accurate. The circumstances of a fall sustained by the resident were not reflected in the clinical record. The findings were: Resident # 30 in the survey sample was admitted on [DATE] with diagnoses that included Type II Diabetes Mellitus, hypertension, renal insufficiency, hyperlipidemia, history of transient ischemic attacks and cerebral infarction, dysarthria and anarthria, muscle disorder, and hyperglycemia. According to a Quarterly review Minimum Data Set with an Assessment Reference Date of 2/28/2023, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Under Section G (Functional Status), the resident was assessed as independent with no set-up help needed for walking in the room and locomotion on the unit; as needing supervision with set-up help only for eating; as needing supervision with one person physical assist for dressing; as needing limited assistance with one person physical assist for personal hygiene; as needing extensive assistance with one person physical assist for bathing; and, as not walking in the unit corridor or having locomotion off the unit. Review of the Progress Notes in Resident # 30's Electronic Health Record (EHR) revealed the following entry: 2/22/2023 - 3:49 p.m. Resident had a fall yesterday with no apparent injury. She is alert and oriented. Vitals 132/76 (blood pressure), pulse 88, O2 (oxygen) sat (saturation) 96%, temp(erature) 98.6, respirations 18. She had not complained of any pain today. Further review of the Progress Notes revealed there were no other entries regarding the nature or cause of the resident's fall. At approximately 11:00 a.m. on 4/18/2023, the Director of Nursing (DON) was asked for any additional information regarding the resident's fall. At approximately 2:00 p.m. on 4/18/2023, the DON provided a copy of the incident report on the resident's fall which noted the following: Nursing Description: Resident found sitting in floor in the bathroom in front of the stool facing the stool. Resident Description: I was trying to get on the stool and my feet sled (sic) out from under me. Immediate Action Taken: Resident checked by nurse no injuries noted, resident not taken to hospital. No injuries observed at time of incident. Mental Status: Resident oriented to place, person, time, and what happened. At 2:30 p.m. on 4/18/2023, the DON was interviewed regarding the lack of documentation of the resident's fall. Asked if there should have been more documentation of the fall, the DON replied, There is an expectation that the fall would be documented in the Progress Notes. I don't know why the nurse didn't do it, she completed an incident report. The findings were discussed during a meeting at 3:45 p.m. on 4/18/2023 that included the Administrator, DON, Corporate Nurse Consultant, and the survey team.

Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy, titled OXYGEN ADMINISTRATION, updated 07/17, revealed .Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Review of R40's electronic medical record (EMR), under tab Clinical, revealed R40's initial admitted was 07/13/19. Review of the EMR under Med Diag (Medical Diagnoses) tab, revealed R40's diagnoses included [CONDITION(S)] ([CONDITION(S)] (lung disease that blocks airflow and makes it difficult to breath)), dated 07/13/19. Review of the EMR under the tab Care plans under the column Focus, created date of 07/13/19, revealed .Has respiratory impairment related to [CONDITION(S)], Under the column titled, Interventions/Tasks, revealed .Administer medications/treatments per physician, orders. Review of the EMR under the tab, TAR (treatment administration record), included .O2 [oxygen] @ [at] 2 liters per minute via [by way of] NC [nasal cannula]. dated 11/21. Review of the EMR under the tab Orders revealed, .O2 @ 2 liters per minute via NC., dated 10/21/21. Review of R40's quarterly, Minimum Data Set (MDS), with an assessment reference date (ARD) of 10/06/21, revealed the resident was assessed for respiratory diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed the facility answered yes to the question regarding use of oxygen while a resident at the facility. An observation conducted on 11/16/21 at 9:42 AM, revealed R40 had oxygen being administered at a flow rate of 5 liters per minute. A second observation conducted on 11/17/21 on 8:36 AM, revealed oxygen was not being administered to R40. A third observation conducted on 11/18/21 at 9:53 AM, revealed R40 had oxygen being administered at a flow rate of 5 liters per minute. During an interview on 11/18/21 at 3:01 PM, the Director of Nursing (DON) confirmed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/18/21 at 2:24 PM, the Medical Doctor confirmed the oxygen flow rate should be the same as the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of R32's EMR, under tab Clinical, revealed R32's initial admitted was 08/05/13. Review of EMR under Med Diag tab, revealed R32's diagnoses did not indicate a respiratory diagnosis, (dated 08/05/13). Review of the EMR under the tab, Care plans, revealed R32 did not have a care plan for oxygen treatment. Review of the EMR under the tab, TAR, included . O2 @ 4 liters per minute via NC every shift for chronic O2 use. dated November 2021. Review of the EMR under the tab, Orders revealed, .O2 @ 4 liters per minute via NC every shift for chronic O2 use O2 check @ shift, notify MD [Medical Doctor] below 90%., dated 09/23/21. Review of R32's quarterly MDS, with an ARD of 11/01/21 revealed the resident was assessed for respiratory diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation conducted on 11/15/21 at 3:46 PM, revealed R32 was receiving oxygen treatment with a flow rate of 5 liters via nasal cannula. A second observation conducted on 11/16/21 at 9:39 AM, revealed R32 was receiving oxygen treatment with a flow rate of 5 liters via nasal cannula. A third observation conducted on 11/17/21 at 8:32 AM, revealed R32 was receiving oxygen treatment with a flow rate of 5 liters via nasal cannula. During an interview and observation conducted on 11/17/21 at 2:36 PM, the Unit Manager (UM) verified R32 was receiving oxygen with a flow rate of 5 liters, administered by nasal cannula. During an interview on 11/18/21 at 3:01 PM, the DON confirmed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. During an observation on 11/15/21 at 1:10 PM, R44 was in his room with oxygen flowing at a rate of 4 liters per minute via nasal cannula. During subsequent observations on 11/15/21 at 1:20 PM and 4:58 PM, R44 was sleeping, and his oxygen continued at 4 liters per minute via nasal cannula. Review of R44's EMR, under tab Admission Record, revealed R44 was admitted to the facility on [DATE]. Review of the EMR under Med Diag tab, revealed R40's had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R44's EMR under the Orders tab revealed, R44 did not have orders for oxygen. Review of R44's EMR under the Care Plan tab revealed R44 was not care planned for care for oxygen therapy. A review of R44's most recent MDS with an ARD of 11/05/21, documented he did not receive oxygen therapy. During an interview on 11/16/21 at 2:34 PM, Licensed Practical Nurse (LPN) 2 confirmed she could not locate an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN2 checked R44's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN2 stated when she went into R44's room to give meds, she checked his oxygen to make sure tubing was dated, water bottle was full, and oxygen was running. When asked how she knew what rate the oxygen was to be running, LPN2 stated she would look at the order. LPN 2 admitted she did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN 2 stated she did not know how the order was missed but she would call the doctor right away to get the order. LPN2 stated nurses could administer oxygen at 2 liters per minute per nursing judgement and then get the order. LPN2 agreed this was not the case since R44 had been getting oxygen at 4 liters per minute. During an interview on 11/18/21 at 2:24 PM, the Medical Doctor confirmed oxygen should not be administered without a physician order. 4. Review of the admission MDS with an ARD of 10/12/21indicated that (R)47 was admitted to the facility on [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on 11/16/21 at 9:44 AM, 11/17/21 at 8:40 AM, and 11/18/21 at 9:40 AM revealed R47 was in bed, with oxygen being administered at a rate of 4 LPM via nasal canula. During an observation and interview on 11/18/21 at 1:20 PM LPN1 verified R47 was receiving oxygen per nasal canula at a rate of LPM. LPN1 verified R47 did not have a current order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on observation, resident interview, staff interview, and review of the facility policy, the facility failed to serve food that was palatable for three of 30 sample. Specifically, pureed food was unpalatable, pasta overcooked, and meat was tough. Findings include: Review of the facility's menu for 11/18/21 indicated the facility was served country fried steak with gravy, mashed potatoes, squash casserole, Texas toast, and strawberry [MEDICATION(S)] pie. The alternate choices were baked fish, orzo pilaf, and broccoli. Pureed foods included beef, mashed potatoes, the orzo, broccoli, squash casserole, bread, and pudding. Review of the facility's policy titled, Consistency Modified Foods-Level 4 Pureed, dated 11/2020, documented .pureed Level 4 diet requires foods that have a smooth texture with no lumps and are not sticky . 1. During an interview on 11/15/21 at 10:30 AM, R45 stated he did not like the food. 2. During an interview on 11/15/21 at 10:50 AM, R337 stated he did not like the food. 3. During an interview on 11/15/21 at 11:20 AM, R84 stated that a pig wouldn't eat the food. 4. During an observation and interview on 11/18/21 at 10:45 AM, the Dietary Cook (DC), Food Service Director (FSD), and the surveyor tasted the pureed orzo which was served as the alternative item on the menu. The DC gagged and stated, this tastes like pure paste. The FSD stated the pureed orzo was terrible, and he was taking it off the tray line so it would not be served. Both the DC and FSD stated they did not taste the prepared pureed foods. During observations on 11/18/21 from 12:43 PM to 1:11PM, five residents were served pureed trays on the second-floor units. These residents were not interviewable and were not able to answer questions regarding their meals. 5. On 11/18/21 at 12:59 PM, a test tray was tasted by the FSD and the surveyor. The FSD stated, the country fried steak was hard, dry, and the coating did not stay on the steak. It was extremely hard to chew, and I would not serve it again. The FSD stated the orzo was gummy and overcooked. The FSD stated the food texture was correct for the residents on the first floor served. However, for the last floor and unit served, the food was overcooked due to being on the steam table for so long. The FSD said he did not know how to prevent this. Observations on 11/18/21 at 1:23 PM of trays going back to the kitchen after being served to residents, revealed 14 trays with the country fried steak not eaten.

Based on observation, staff interview, and review of facility policy, the facility failed to ensure foods stored in the kitchen were labeled, dated when opened, and sealed closed. Also, pots and pans were not properly sanitized after washing and cups were not allowed to air dry before lids were reattached. These failures had the potential to affect all 90 residents in the facility who ate food from the kitchen. Findings include: Review of the facility's policy titled, Labeling Food and Date Marking, dated November 2020, documented .foods are labeled following preparation or opening to identify the item and to provide date, and time information .Use-by date is the last date recommended for the use of the product while at peak quality. Review of the facility's policy titled, Storage of Food, dated November 2020, documented . label opened foods as to contents and date. Review of the facility's policy titled, Food Storage and Date Marking, dated 2018, documented . Plastic containers with tight-fitting covers must be used for storing cereals, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legible and accurately labeled . 1. On 11/15/21 at 9:20 AM, the following observations were made with and verified by the Food Service Director (FSD). The dry storage room contained one bag of breadcrumbs, one bag of coconut flakes, one bag of cherry gelatin powder, and one bag of almonds that were opened and had not been labeled with a use by date. One bag of cherry gelatin powder that was open to air and not sealed closed. A plastic container of a powder food thickener was not labeled as to the contents of the container, nor did it have a use by date. The FSD confirmed open foods should be labeled with a use by date. 2. On 11/15/21 at 9:20 AM, four cups with lids on trays ready to go to the units that were still wet on the inside were observed with the FSD. The FSD stated the cups were still wet and could not air dry because the lids were on them. The FSD stated, there would be a potential for bacteria since the cups were closed and wet. 3. On 11/17/21 at 10:45 AM, an observation revealed there were no sanitizing buckets in the kitchen to wipe off workstations. The FSD located two sanitizing buckets in the dish washroom that did not contain sanitizer and one bucket had broken glass in it. The FSD stated they did not use spray disinfectants in the kitchen. The FSD stated, the buckets were being washed and they should have one in the kitchen to be used at all times. 4. On 11/17/21 at 11:14 AM, the wash, rinse, and sanitizer sinks were cold and contained food products. The sanitizer was tested by the FSD and did not register any sanitizer. All three sinks were emptied and refilled, and the sanitizer level was then adequate per manufacturer recommendation.

Based on record review, review of facility policy, and interview, the facility failed to refer one resident of three residents (Resident (R) 40) reviewed for Preadmission Screening and Resident Review (PASARR) to the appropriate State-designated authority for a Level II PASARR evaluation and determination. Findings include: Review of the facility's policy titled, Social Services Guidelines Documentation dated August 2021 revealed, .complete the new PASARR screen for patients if the PASARR received is incorrect., and .Social service staff are required to coordinate the PASARR assessment. Review of R40's electronic medical record (EMR), under tab Clinical, revealed R40's initial admitted was 07/13/19. Review of R40's EMR under Med Diag (Medical Diagnoses) tab, revealed R40's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R40's paper medical record, under the tab Legal Documents, revealed a PASARR I dated 09/03/19, which documented R40 did not have a serious mental illness. Review of R40's paper medical record, under the tab, Legal Documents, revealed there was not a PASARR II form. Review of R40's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 10/06/21, located in the resident's EMR under the MDS tab revealed the resident was assessed to have the active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/18/21 at 5:35 PM, the Director of Nursing (DON) verified neither R40's electronic nor paper medical record included a Level II PASARR. The DON confirmed R40 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . DON confirmed SW was responsible to refer R40 to the department of community health, for a Level II PASARR screening and determination.

Based on interview, medical record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed and implemented for two of 30 sampled residents (Resident (R) 32, R47, and R186). Specifically, the facility failed to develop a care plans for R32's and R47's oxygen therapy; and an incontinence care plan for R186. Findings include: Review of the facility's policy titled, INTERDISPLINARY CARE PLANNING, updated March 2018 revealed, .The facility must develop and implement a baseline person-centered care plan for each patient that includes the instructions needed to provide effective and person-centered care that meets professional standards of quality care. 1. Review of R32's electronic medical record (EMR), under tab Clinical, revealed R32's initial admitted was 08/05/13. Review of EMR under Med Diag (Medical Diagnoses) tab, revealed R32's diagnoses did not indicate a respiratory diagnosis (dated 08/05/13). Review of the EMR under the tab, Care plans, revealed R32 did not have a care plan for oxygen treatment. Review of the EMR under the tab, TAR (treatment administration record), included . O2 [oxygen] @ [at] 4 liters per minute via [by way of] NC [nasal canula] every shift for chronic O2 use. dated November 2021. Review of the EMR under the tab, Orders revealed, .O2 @ 4 liters per minute via NC every shift for chronic O2 use O2 check @ shift, notify MD [Medical Doctor] below 90%., dated 09/23/21. Review of R32's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 11/01/21 revealed the resident was assessed for respiratory diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation conducted on 11/15/21 at 3:46 PM, revealed R32 was receiving oxygen treatment with a flow rate of 5 liters via nasal cannula. A second observation conducted on 11/16/21 at 9:39 AM, revealed R32 was receiving oxygen treatment with a flow rate of 5 liters via nasal cannula. A third observation conducted on 11/17/21 at 8:32 AM, revealed R32 was receiving oxygen treatment with a flow rate of 5 liters via nasal cannula. During an interview and observation conducted on 11/17/21 at 2:36 PM, the Unit Manager (UM) verified R32 was receiving oxygen with a flow rate of 5 liters via nasal cannula. During an interview on 11/18/21 at 3:01 PM, the Director of Nursing (DON) confirmed R32's care plan should have included oxygen therapy. 2. Review of the admission MDS with an ARD of 10/12/21 indicated R47 was admitted to the facility on [DATE] with diagnoses including [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EMR under the Care Plan tab, the care plan dated 10/11/21 did not include a plan for the use of oxygen. During observation on 11/16/21 at 9:44 AM, 11/17/21 at 8:40 AM, and 11/18/21 at 9:40 AM, R47 was in bed with oxygen being administered via nasal canula at 4 liters per minute (LPM). During an observation and interview on 11/18/21 at 1:20 PM, Licensed Practical Nurse (LPN)1 verified that R47 was receiving oxygen per nasal canula and that it was set at a rate of 4 LPM. LPN1 also verified the resident did not have a care plan for the use of oxygen. 3. Review of the MDS dated [DATE] located in the EMR indicated R186 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R186's Care Plan under the Care Plan tab dated 01/25/21 revealed no evidence of a care plan to address the resident's incontinence. Review of the Kardex dated 01/25/21 revealed no evidence of incontinence care. In an interview with LPN1 on 11/18/21 at 1:20 PM confirmed R186 did not have a care plan to address her incontinence.

Based on interview, medical record review, and facility policy review, the facility failed to include one resident of 25 sampled residents (Resident (R) 25) in the discharge planning process. Findings include: Review of the facility's policy, titled Social Services Guidelines, dated 8/21, revealed . Discharge planning is a person-center interdisciplinary process driven by the patient . It is important that patients make informed choices in the course of discharge planning. During an interview conducted on 11/15/21 at 12:45 PM, R25 indicated he would like a discharge plan from the facility and Social Worker (SW) would not help. Review of R25's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/15/21 revealed the facility assessed R25 to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R25 was cognitively intact. Review of R25's electronic medical record (EMR), under the Profile tab, revealed a facility initial admitted [DATE] with multiple medical diagnoses. Review of R25's EMR, under the tab, Progress Note, a note dated 11/01/21, revealed a note documented by the Social Worker (SW). The note further revealed, the SW informed R25 his option for discharge was Against Medical Advice (AMA) per the Interdisciplinary Team (IDT) meeting's decision. An interview conducted with Medical Doctor on 11/18/21 at 4:35 PM, revealed AMA was not R25's only discharge option. An interview conducted with the SW on 11/18/21 at 5:05 PM, revealed R25 was not included in his discharge plan. The SW stated R25 was not part of the IDT meeting. The SW stated because the IDT decided the discharge was AMA, she was unable to assist R25 with discharge options. The SW confirmed including R25 in his discharge plan and IDT meeting would be beneficial. During an interview on 11/18/21 at 5:26 PM, the Director of Nursing (DON) stated the facility should begin discharge planning, with the resident, on the day of the resident's admission.

Based on observation, interview, policy review and record review, the facility failed to ensure professional standards of practice were maintained for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff failed to perform hand hygiene and ensure a clean environment prior to performing wound treatments. Findings include: Review of the admission ''Minimum Data Set (MDS) found in the electronic medical record (EMR) revealed R47 was admitted to the facility on [DATE] and had a ''Brief Interview for Mental Status (BIMS)'' of 15 which indicated that resident was cognitively intact. The assessment revealed that R47 had a Stage 3 Sacral wound, a surgical wound to her right lower quadrant and a peri-stoma. Review of R47's EMR under, the ''Orders'' tab and Treatment Administration Record, (TAR) dated 11/11/21 revealed, R47 had three wounds with three different treatments. An abdominal right lower quadrant (RLQ) peristomal wound, a RLQ (boil) and a Sacral Stage 3 wound. Observation on 11/16/21 at 4:15 PM revealed Nursing Supervisor Registered Nurse (NSRN) was completing wound care to R47's three wounds. NSRN did not clean and disinfect or drape the area for clean supplies and did not perform hand hygiene after doffing and prior to donning gloves in between treatments to the resident's three wounds. During an interview on 11/18/21 at 4:15 PM, NSRN verified that she did not clean the table, did not put down a barrier and did not perform hand hygiene between dirty to clean glove changes during the wound care performed on 11/16/21. Review of the facilities policy titled, ''Dressing change: nonsterile (clean)'', dated 12/09 indicated, '' .disinfect over bed table using an EPA (environmental protective agent) approved disinfectant .Place a clean barrier on the over bed table .Perform hand hygiene when going from clean to dirty.''

Based on observation, interview, record review, and review of facility policies, the facility failed to provide assistive devices to prevent accidents for one of five (Resident (R) 23) residents reviewed for accidents out of 30 sample residents. Findings include: Review of R23's Admission Record, located under the Profile tab of the electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. Review of R23's diagnoses, located under the Diagnosis tab of his EMR revealed unspecified dementia without behavioral disturbance, type 2 Diabetes mellitus with diabetic [CONDITION(S)] (Weakness, numbness, and pain from nerve damage, usually in the hands and feet), and cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it). Review of R23's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 09/13/21, revealed a Brief Interview of Mental Status (BIMS) score of 13 out of 15, indicting intact cognition. R23 was assessed as being total dependent on two persons for transfers with mechanical lift. Review of R23's care plan located in the EMR under the Care Plan tab, dated 02/18/20 revealed a Focus area of risk for falls. Review of the Interventions revealed the facility planned to keep his bed in the low position; encourage to transfer and change positions slowly; have commonly used articles within easy reach; and staff education. Further review of R23's care plan revealed an additional intervention for therapy evaluation on his wheelchair beginning 09/20/21. Review of a Falls report provided by the facility revealed R23 had a fall on 09/20/21 at 1:12 PM. R23 had an outside appointment and was transported by a transport company arranged by the facility. Upon return to the facility and while still inside of the transport van, R23 slid out of his wheelchair to the floor of the transport vehicle. R23 had no visible injuries noted at that time. Review of a Witness Statement report provided by the facility, dated 09/20/21 at 1:30 PM, revealed the van driver stated R23 was properly secured when leaving the dental appointment. When the driver turned around and realized the resident was sliding out of his wheelchair, he pulled over to a safe area to reposition the resident. He could not reposition the resident successfully and returned to the facility that was five minutes away. By that time, the resident had slid all the way to the floor. The driver of the transport van was not available for interview. Interview on 11/17/21 at 3:22 PM with R23 revealed that the resident did not remember having a fall during transport. Observation of R23's room on 11/17/21 at 3:22 PM revealed the resident's wheelchair folded between the wall and the bed. Leg/footrest were not on the wheelchair. Interview on 11/17/21 at 3:25 PM with Nurse Aide (NA) 2 revealed that the footrest was usually taken off the wheelchair and stored when not in use. NA2 stated the footrest kept the resident from sliding out of his chair. On 11/17/21 at 2:09 PM, interview with the Director of Nursing (DON) revealed that R23 did not self-propel, and his wheelchair should have leg/footrests. DON stated footrests should have been in place on R23's wheelchair when he left for his appointment. At the time of the incident, his wheelchair did not have that assistive device. The DON stated the resident's wheelchair was used for transport and was strapped into the van. No other facility staff assisted the resident during transportation. At 2:13 PM on 11/17/21, an interview with the Corporate Quality Assurance Consultant-RN (CQAC-RN) stated that the root cause of the fall incident was due to R23 not having a leg/footrest on his wheelchair and that was the contributing factor for him sliding out of his wheelchair. On 11/17/21 at 3:29 PM an interview with the Administrator revealed that she went out to the transport van as soon as the facility was notified of the incident. R23 was on the floor of the van and his wheelchair did not have leg/footrests attached to the chair. The Administrator believed they were taken off to help the resident and stated that the leg rest were on the floor of the van. Review of the Rehabilitation Screening for R23 on 9/20/21 revealed that the R23 stated that the wheelchair did not have leg rests on at the time of his fall. Rehabilitation services documented that the resident has no issues sitting in his chair when leg rests were used. Staff documented the resident reported he did not have his leg rests when he left the facility. Review of the facility Falls Practice Guide dated 12/11, indicated that this is what the facility provided as the Fall Policy. The CQAC-RN stated that this is the Fall Policy. This Practice Guide indicated . that this booklet is considered a practice guide . this guide is intended to support clinical practice .the purpose is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls .the information included within this guide does not relieve a business unit ore center of the obligation to comply with all applicable HCR ManorCare policies as well as federal and state regulations.

Based on observation and interview it was determined the facility failed to ensure the resident receiving enteral feeding received appropriate care and services to prevent complications for one of one resident (Resident (R)17) reviewed for tube feeding cares. Findings include: Review of R17's face sheet located under the Admissions Record tab in the electronic medical record (EMR) revealed R17 was admitted to the facility on [DATE] following a [CONDITION(S)] ([CONDITION(S)], loss of blood flow to the brain resulting in damage to brain tissue). R17's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 11/17/21 at 12:50 PM, Licensed Practical Nurse (LPN) 2 administered one medication to R17 by way of (via) the enteral tube. LPN2 did not place a barrier down on the overbed table or the bed prior to placing her supplies on it. LPN2 aspirated for residual volume from the feeding tube without opening the clamp proximal to R17's body. LPN2 placed the syringe on the bed while she was getting her supplies ready. LPN2 flushed to tube with 30 cubic centimeters (cc) of water, gave the crushed medication with 15 cc of water and then flushed the tube with 30 cc of water. LPN2 used the plunger on the syringe to push the fluids in as opposed to attempting a gravity feed. During an interview on 11/18/21 at 9:05AM, the Family Nurse Practitioner (FNP), referring to how medications were to be given via enteral tube stated, Always gravity-that is how we were taught to do it-always. During an interview on 11/18/21 at 9:17AM, the Medical Director, referring to how medications were to be given via an enteral tube stated, Always gravity is the preferred method. During an interview on 11/18/21 at 1:54 PM, LPN 2 stated she was not sure why she did it (used the plunger, opposed to allowing to gravity feed) that way on that day. LPN 2 stated she was aware of the need to use a barrier and to do attempt a gravity feed prior to using the syringe plunger. During an interview on 11/18/21 at 6:50 PM, when asked how the nurse would know to give medications by gravity feed, the Director of Nursing (DON) stated there was a procedure manual on each nurses' station for the nurses to review. The DON added that their policy did not indicate to give medication by gravity feed but acknowledged it was a Standard of Practice and should be done by gravity feed.

Based on interview, medical record review, and facility policy review, the facility failed to ensure there was a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy, titled Agreement for Outpatient [CONDITION(S)], dated 07/01/16, revealed .G. Prescription for treatment by any other physician. Review of R25's electronic medical record (EMR), under the Profile tab, revealed a facility initial admitted [DATE] with multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R25's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 08/15/21 revealed the facility assessed R25 to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated R25 was cognitively intact. The facility assessed R25 for Active Diagnosis, and confirmed R25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R25's EMR, under the Orders tab, revealed there was not a physician's order for [CONDITION(S)] treatment. Review of R25's paper chart, under Physician Orders tab, revealed there was not a physician's order for [CONDITION(S)] treatment. Review of R25's EMR under the Care Plan tab, under the column Focus, created date of 08/04/21, revealed .resident needs [CONDITION(S)] hemo. During an interview on 11/18/21 at 10:26 AM, the Unit Manager (UM) verified and confirmed no physician order was included on R25's EMR for [CONDITION(S)] treatment. UM confirmed the facility should include a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/18/21 at 2:50 PM, the Director of Nursing (DON) verified and confirmed R25's EMR did not include a physician's order for [CONDITION(S)] treatment. DON confirmed R25 was transported to [CONDITION(S)] outpatient treatment center on 11/16/21 without physician orders on the R25's EMR or paper chart. During an interview on 11/18/21 at 2:24 PM, the Medical Doctor (MD) confirmed R25's paper chart did not include a physician's order for [CONDITION(S)] treatment. MD confirmed a physician's order was required for hemodialysis treatment for facility's residents.

Based on observation, interview, and review of the facility's policy, the facility failed to remove expired medication from their medication room. This failure to remove expired medication had the potential to place the resident at an increased risk of receiving expired medications. Findings include: During an observation of the Third Floor Medication Room on 11/18/21 at 10:50 AM, the following items were found to be expired: one opened stock vial of [MEDICATION(S)], [MEDICATION(S)] (Mantoux) solution dated as opened on 10/11/21 and 30 packets of stock ProSource with manufacturer expiration dates of 04/03/21 and 06/02/21. Licensed Practical Nurse (LPN) 2 verified the items in question had expired at the time of the observation. Interview with the Director of Nursing (DON) on 11/18/21 at 6:30PM, revealed the medication rooms were to be checked weekly by the central supply staff for expired medications. The DON did not have a reason for the medications to have remained in the medication room and agreed they should have been removed. Review of the facility policy titled Disposal/Destruction of Expired or Discontinued Medication dated 12/01/07 revealed . 4. Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.

Based on observation, staff interview, family interview, clinical record review and complaint investigation, the facility staff failed to assess and monitor a skin rash for one of eight residents in the survey sample. There were no documented assessments or monitoring of a skin rash on Resident #7's face. The findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #7 with severely impaired cognitive skills. On 12/3/19 at 10:40 a.m., Resident #7 was observed in bed accompanied by a family member. The resident had a visible skin rash on her face in the area under her nose and around her mouth. The rash had scattered small bumps with white colored flaky skin. There were several small scabbed areas on the resident's chin below the corner of the left lower lip. The resident's family member was interviewed at this time about the skin rash. The family member stated the skin rash had been present for months and the nurses applied some type of cream each day as treatment. The family member stated the cream was stopped once and the rash became worse so they restarted the cream. Resident #7's clinical record documented a physician's orders [REDACTED]. Resident #7's treatment records documented the [MEDICATION NAME] gel was applied daily as ordered from 9/7/19 through 12/2/19. The clinical record documented no assessment or ongoing monitoring of Resident #7's facial skin rash. Weekly skin assessments from (MONTH) 2019 through 11/27/19 listed no skin impairments with the exception of a red area on the right ankle on 10/12/19 and on 11/17/19 a moisture-associated [MEDICAL CONDITION] on the sacrum. A nursing note dated 9/6/19 documented, Nurse discussed the previous treatment to patients face with her husband, the DON (director of nursing) and (physician) and the fact that this is the only treatment that is effective. (Physician) gave order to re-instate this treatment . (Sic) A note on the resident's (MONTH) 2019 treatment record documented the [MEDICATION NAME] gel was discontinued on 8/31/19 and re-ordered by the physician on 9/7/19. There was no assessment providing any description of the rash. There was no documentation of the rash's appearance, size, color or exact location in order to determine improvement or deterioration in the skin condition. Resident #7's plan of care (revised 11/25/19) listed the resident was at risk for altered skin integrity due to contractures, incontinence, impaired mobility and decreased sensation due to history of stroke. Interventions to prevent or minimize skin breakdown included, repositioning, monitoring of skin conditions and report abnormalities and provide preventive skin care and treatments as ordered. The care plan made no mention of the skin rash on the resident's face/mouth. On 12/4/19 at 8:50 a.m., the licensed practical nurse (LPN #2) caring for Resident #7 was interviewed about the facial skin rash. LPN #2 stated Resident #7 had the rash on her face and mouth area for months and [MEDICATION NAME] gel was ordered and applied as treatment. LPN #2 stated the rash had improved last week but was present again when he returned to work on Monday (12/2/19). LPN #2 stated the [MEDICATION NAME] gel was previously used on the rash; was discontinued at the end of (MONTH) (2019) and then restarted because the rash became worse. LPN #2 stated floor nurses performed weekly skin assessments. LPN #2 did not know why the face rash was not listed on the skin assessments or mentioned in notes. LPN #2 stated the scabbed areas on the resident's chin were caused by the resident occasionally picking at the bumps on her face. On 12/4/19 at 10:00 a.m., the director of nursing (DON) was interviewed about any assessment and monitoring of Resident #7's observed facial skin rash. The DON stated she reviewed the clinical record and the last documentation about the rash was the nursing note dated 9/6/19. The DON stated LPN #2 routinely cared for Resident #7 and reported the rash at one time was over much of the resident's face and was now just around the mouth. The DON stated the [MEDICATION NAME] gel was re-ordered in (MONTH) 2019. The DON stated skin assessments were documented in the nursing notes. The DON presented no assessments and/or documented monitoring of Resident 7's facial rash. This finding was reviewed with the administrator and DON on 12/4/19 at 11:15 a.m.

Based on observation, resident interview, staff interview, and clinical record review the facility staff failed to obtain dental services for Resident # 55. Resident # 55 had broken, carious bottom teeth, and had no dental care since admission. Findings include: Resident # 55 was admitted to the facility 3/17/18 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 1/15/19. Resident # 55 was coded as cognitively intact with a total summary score of 13 out of 15. The clinical record was reviewed 2/20/19 beginning at 10:30 a.m. Nurses' notes documented the following: 11/30/18 Complaint of tooth pain. Tylenol 325 mg 2 tabs administered. Effective 12/5/18 .tooth pain. 2 Tylenol 325 mg administered with effectiveness. 12/17/18 (name of practice) called regarding an appointment for tooth extraction .daughter aware and will transport . 1/14/19 scheduled for oral surgery 1/23/19 . 1/18/19 complain of tooth pain .Tylenol 325 mg 2 tabs administered. Effective. 1/20/19 tooth pain .Tylenol administered with relief 1/23/19 Dental appt. canceled by daughter. She states she will let us know when appt. (appointment) is rescheduled. 1/25/19 .complaint of tooth pain .given Tylenol daughter canceled dental appt. in (city) stating she could not drive her car that far .spoke with unit manager concerning this . 1/28/19 Tylenol for tooth pain 2/6/19 Tylenol for tooth pain . 2/8/19 Tylenol for tooth pain .pain rated at 6 . On 2/20/19 the unit manager, RN (registered nurse) # 2 was interviewed about the resident's tooth pain, and if there was any further information about the appointment that was to have been rescheduled by the daughter. RN # 2 was read the entry from 1/25/19 that he was made aware of the canceled appointment. He stated Who made that note? I do know that the daughter was supposed to call back when the appointment was rescheduled .she has not called yet. No one locally will see our patient's, they have to go out of the area. RN # 2 was then asked since the daughter had voiced an issue with her car, why the facility ahd not gotten the appointment rescheduled and transportation arranged? RN # 2 stated The social worker should have been involved to help with those arrangements. On 2/20/19 at 11:30 a.m. the facility social worker was interviewed. She stated Well, I know I had quite a time to get that first appointment scheduled; I had arranged transportation but then the daughter said she would take her .I was not made aware the appointment did not happen .the unit manager is the one who would have reported to me so I could get everything rescheduled . On 2/20/19 at 1:50 p.m. during an interview Resident # 55 she stated Yes, these bottom teeth have been bothering me quite a while .do you think you can help me get a ride to get them taken care of? They're (teeth) in a bad fix. The resident was then asked if the bottom teeth could be observed. She stated yes and of the 4 remaining teeth on the bottom, one was broken, two were blackened, and two other teeth were in poor condition overall. On 2/21/19 at 7:45 a.m. the care plan was reviewed. A care plan for dental problems was dated as initiated on 1/30/19. The care plan included focus/goals and interventions related to the resident's tooth pain. The care plan did not include any information about the canceled appointment. There were few interventions other than to refer to dentist/hygienist for evaluation/recommendations re: denture realignment, new fitting, teeth pulled, repair of carious teeth. Other interventions included administering medication for tooth pain and reporting any changes in oral cavity. On 2/21/19 at 8:09 a.m. RN # 3, who was an MDS coordinator, was asked about the care plan, and the date initiated as the resident began complaining of tooth pain in (MONTH) (YEAR). RN # 3 stated In (MONTH) when the tooth pain was identified they could have/should have initiated the care plan at that time. On previous assessments, there had not been any dental issues identified. When the most recent quarterly review was done, that's when the tooth pain and issues were identified so that's when I initiated the care plan . On 2/21/19 at approximately 9:00 a.m. the social worker informed this surveyor a dentist appt. for Resident # 55 had been made for in the morning. On 2/21/19 during a meeting with facility staff the administrator, DON (director of nursing), and regional nurse consultant were made aware of the above findings. No further information was provided prior to the exit conference.

Based on resident interview, staff interview and clinical record review, the facility staff failed to ensure a CCP (comprehensive care plan) was developed and implemented for one of 23 residents in the survey sample, Resident #24. Findings include: Resident #24 was admitted to the facility originally on 05/27/18. The resident was readmitted on [DATE] and again on 08/17/18, with the most recent readmission being on 01/31/19. [DIAGNOSES REDACTED]. A quarterly MDS (minimum data set) assessment dated [DATE] was reviewed. The MDS assessed the resident with a cognitive score of 15, indicating the resident was cognitively intact for daily decision making skills. The resident was assessed as requiring extensive assistance for toileting with at least one person physical assistance. The resident was also assessed as always continent of bowel. This MDS additionally assessed the resident as receiving a diuretic during the previous, 7 day look back period, and as receiving [MEDICAL TREATMENT] while a resident. The most recent full MDS assessment with CAAS (care area assessment summary), was a 5 day admission assessment dated [DATE]. This MDS was reviewed for CAAS information. The resident triggered on this MDS for, but not limited to: urinary, nutrition and dehydration. Further review of this MDS for dehydration, documented that the resident had vomiting on 05/29/18 per nursing notes and this was a causative trigger. An interview was conducted on 02/19/19 at 2:52 PM with Resident #24. The resident stated that she went to the hospital (MONTH) 28th because she was sick and stated that she was vomiting and couldn't stop. The resident stated that she was eventually sent to the hospital, where she was admitted and was told (by hospital staff) that she was impacted. The resident stated that this isn't the first time that she has had problems with her bowels and it seems to be an ongoing problem. The resident was readmitted to the facility on [DATE]. Resident #24's clinical record documented that the resident had a new [DIAGNOSES REDACTED]. The resident's hospital records were reviewed and documented that it was originally thought that the resident had a [MEDICAL CONDITION] (nausea/vomiting), but after further evaluation, concluded the resident was impacted. A GI ([MEDICATION NAME]) consult dated 01/18/19 was reviewed and documented that the resident was examined and the resident had complained of constipation and associated nausea with abdominal cramping. The GI consult documented, .patient previously doing well on Linzess, but (was) discontinued in 08/2018-unsure why this was done .Constipation- will restart Linzess 290 mcg (micrograms) daily after [MEDICAL TREATMENT] continue [MEDICATION NAME] as well after [MEDICAL TREATMENT] .Nausea - feel this is secondary to constipation . A review of Resident 24's medical record revealed the resident went to hospital on [DATE] for chest pain while at [MEDICAL TREATMENT]. The resident was admitted to the hospital and then readmitted to the facility on [DATE]. On 08/08/18 the resident's hand written POS (physician's orders [REDACTED]. A nursing note documented the resident was trying to have a BM (bowel movement) on 08/11/18, but was having difficulty. On 08/14/18 the resident was at [MEDICAL TREATMENT] and complained of a headache with slurred speech per documentation. The resident was again sent to ER. The resident was readmitted to the facility on [DATE]. The Linzess was not on the POS dated 08/17/18. The resident was discharged to the hospital and upon return the medication was not restarted. There was no discontinuation order and no documentation regarding the discontinuation of the Linzess. The physician's orders [REDACTED]. Further review of the resident's record revealed that the resident was administered Linzess, [MEDICATION NAME] and [MEDICATION NAME] daily from 01/18/19 through 01/28/19. It was documented that the resident had bowel movements during this time. The resident's current CCP (comprehensive care plan) was reviewed. The CCP documented, .Pain medication .Monitor for altered mental status .constipation . No other information was found regarding the resident's constipation, gastroparesis, nausea/vomiting, medications used for constipation or any information regarding this resident's history of bowel problems. On 02/20/19 at 3:37 PM, an end of day meeting was held with the DON (director of nursing), administrator, corporate nurse and regional director. They were asked for the most current CCP on Resident #24. On 02/21/19 at 8:08 AM, the DON presented a CCP for Resident #24 and stated that this was the most current care plan. The DON stated that the resident did not have a care plan for constipation, and agreed that the resident should have triggered and should have a care plan for constipation. The DON then stated, that she updated the care plan this morning, but not for constipation. The DON was asked why this resident's medication (Linzess) for constipation had been discontinued in (MONTH) of (YEAR). On 02/21/19 at 8:20 AM, the DON returned and stated that the resident had constipation listed under the pain section of the CCP. The DON then stated that the resident doesn't actually have a [DIAGNOSES REDACTED]. The DON was made aware that the resident did have a current [DIAGNOSES REDACTED]. No further information and/or documentation was presented prior to the exit conference on 02/21/19 at 10:45 AM, to evidence the facility staff developed and implemented a CCP for this resident for constipation and gastroparesis.

Based on observation, and staff interview, the facility staff failed to ensure a date was placed on opened medication and was readily available for use on one of 2 units. An opened multidose vial of [MEDICATION NAME] (insulin) without a date was readily available for use on the second floor unit. The Findings Include: On 02/20/19 at 2:39 PM, storage of medications and biological's was observed on the second floor. A multidose vial of [MEDICATION NAME] was observed opened and without an open date in the refrigerator available for distribution. There was a sticker on the bottle to indicate that the [MEDICATION NAME] would expire after 28 days of being opened. The Director of nursing (DON) was in the medication room at the time of the observation. When asked about the medication without an open date, the DON verbalized that the [MEDICATION NAME] should have been dated with an open date and should not be in the refrigerator. On 02/20/19 at 3:35 PM, the above information was brought to the attention of the director of nursing (DON) and administrator during an end of day staff meeting. The administrator was asked for a policy regarding storing medications. On 02/21/19 the facility presented a policy regarding storage and expiration dates of drugs and biological's and read in part ( .) Nursing staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. No other information regarding this concern was provided prior to exit conference on 2/21/19.

Based on staff interview and clinical record review the facility staff failed to provide written notification of a hospital transfer for two of 23 residents in the survey sample: Residents #76 and # 93. 1. Resident #76 was discharged to hospital and the facility did not notify the Ombudsman or the responsible party (RP) in writing. 2. Resident #93 was discharged to hospital and the facility did not notify the Ombudsman or the responsible party (RP) in writing. The Findings Include: 1. Resident #76 was admitted to the facility on [DATE] with the most readmission on 1/24/19. [DIAGNOSES REDACTED]. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/27/19. Resident #76 was assessed as being cognitively intact with a score of 15 of 15. Resident #76 was her own responsible person (RP). On 2/20/19 Resident #76's medical record indicated that Resident #76 was admitted to the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. On 02/20/19 at 10:56 AM, the social worker (SW) was interviewed concerning notifying the Ombudsman and Resident #76 in writing of the discharges in (MONTH) 2019. The SW verbalized that she had not been sending written notification to Ombudsman or Representative regarding being discharged to the hospital. The SW verbalized that she does send notification to the Ombudsman of someone's discharge if the Resident is not going to return to the facility, but was unaware that she had to notify in writing if a Resident was being discharged to a hospital. On 02/20/19 03:35 PM the above information was presented to the director of nursing and the administrator. No other information was presented prior to exit conference on 2/21/19. 2. Resident #93 was admitted to the facility on [DATE] with a readmission on 1/30/19. [DIAGNOSES REDACTED]. The most recent minimum data set ((MDS) dated [DATE] assessed Resident #93 as being cognitively intact with a score of 15 for daily decision making. Resident #93 was interviewed on 02/19/19 regarding her stay at the facility. Resident #93 stated she was doing better and making slow progress since her hospital stay last month. Resident #93 stated she originally was admitted to the facility for therapy after falling and breaking her hip at home, however she had a small stroke and was admitted to the hospital where she had surgery for [REDACTED]. Resident #93's clinical record was reviewed on 02/19/19 at 2:15 p.m. A nursing progress note dated 01/23/19 with a timestamp of 14:53 p.m. (2:53 p.m.) documented Patient admitted to hospital. On 02/20/19 at 10:56 a.m., the social worker (OS #1) was interviewed concerning notifying the State Ombudsman's office regarding Resident #93 being discharged to the hospital on [DATE]. OS #1 stated she did not notify the State Ombudsman's office of Resident #93's discharge to the hospital because she was not aware she was supposed to. OS #1 stated she had not been notifying the State Ombudsman's office when any resident was discharged to the hospital. These findings were reviewed with the administrator, director of nursing and corporate staff during a meeting on 02/20/19 at 3:34 p.m.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation; the facility staff failed to follow professional standards of nursing practices for three of 9 residents in the survey sample, Residents #7, #8 and #9. 1. Resident #8 was administered another resident's medication ([MEDICATION NAME] 200 mcg (micrograms), which resulted in harm to the resident and the resident had to receive an injection of [MEDICATION NAME] 0.4 mg (milligrams) IM (intramuscularly) to reverse the harm caused by the [MEDICATION NAME]. 2. Resident #7's order for D 5 ,[DATE] NS ([MEDICATION NAME] with one half percent of Normal Saline) was transcribed incorrectly and a clarification was not obtained regarding the order. 3. Resident #9's [MEDICATION NAME] was not verified by the nurse prior to administration and the wrong dose was administered to the resident. The order was for [MEDICATION NAME] 10 milligrams (mg) and the resident received [MEDICATION NAME] 20 milligrams on [DATE] and twice on [DATE]. The error was noted by the facility on [DATE] during the abbreviated survey. The findings include: 1. Resident #8 was administered another resident's medication ([MEDICATION NAME] 200 mcg (micrograms), which resulted in harm to the resident and the resident had to receive an injection of [MEDICATION NAME] 0.4 mg (milligrams) IM (intramuscularly) to reverse the harm caused by the [MEDICATION NAME]. According to Drug Information Handbook for Nursing (2007) page 860... "[MEDICATION NAME] ([MEDICATION NAME]) is used for the complete or partial reversal of opiod depression, including respiratory depression, induced by natural and synthetic opiods...[DIAGNOSES REDACTED]. Caution: [MEDICATION NAME]'s effects are due to its action on narcotic reversal, not due to any direct effect upon opiate receptors..." (1). According to Nursing Drug Handbook (2012) pages ,[DATE], "[MEDICATION NAME] is defined as a narcotic and opiod [MEDICATION NAME] used to treat [DIAGNOSES REDACTED]. According to Drug Information Handbook for Nursing (2007) pages 506..."[MEDICATION NAME]: ...Warning/Precautions: An opiod-containing [MEDICATION NAME] regimen should be tailored to each patient's needs and based upon the type of pain being treated (acute versus chronic), the route of administration, degree of tolerance for opiods (naive versus chronic user), age, weight, and medical condition. The optimal [MEDICATION NAME] dose varies widely among patients..." (3). Resident # 8 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] was a quarterly assessment; the resident was assessed as a fourteen (14) for cognitive skills. On [DATE] at approximately 11:00 a.m., a complaint investigation was conducted to include the allegation that Resident #8 received another resident's medication and became unresponsive and was administered [MEDICATION NAME]. Resident #8's clinical record was reviewed to include the following nursing note: Nursing Note: "[DATE] 13:11 (1:11 p.m.) New order: Nalaxone HCL 0.4 mg/ml. Give 1 ml IM in deltoid stat...(sic)." "[DATE] 14:56 (2:56 p.m.) (Resident named) very drowsy, slightly confused this am. Respirations regular and non-labored, MD (doctor) NP (nurse practitioner) and RP (responsible party/person) notified of change in condition, medications resident has received in the last 24 hours. New order for one time dose of [MEDICATION NAME] administered this shift. (Resident named) is now awake and alert, back at her baseline. Spoke with RP (named) to update him on her improvement..." There were no other nursing notes in the clinical record, of the resident's status or vital signs after the [MEDICATION NAME]es were found, until the [MEDICATION NAME] was ordered and started at 13:11 p.m. On [DATE] at approximately 11:30 a.m., a copy of the facility's "Incident Report" was reviewed to include the following: Incident Report: "Incident Description and Investigation: Date of Incident: [DATE] 8p (8:00 p.m.)...Location of Incident: Patient's Room...Type: Medication error without harm...Description of Incident: Resident received medication intended for another resident...Center Action: Physician Notification: Was physician notified? Yes...If yes, Date: [DATE] 12:00 pm...Center Action: Patient's Care: Describe care and medications, if any, provided to patient following incident, and by whom provided: resident assessed and monitored for adverse side effects. [MEDICATION NAME] administered for sedation..." On [DATE] at approximately 2:00 p.m., during the meeting with the administrator and the director of nursing, who will be identified as Administrator #2, this Surveyor interviewed Admin #2 regarding the above incident. Admin #2 stated, "Her respirations remained stable at eighteen (18) and her sats (oxygen saturation) was ninety-eight (98). She was given [MEDICATION NAME] because she was sleepy; the resident stated she felt fuzzy, she was aware of the error." When interviewed and asked the reason for [MEDICATION NAME] due to the resident just being "sleepy", Admin #2 stated, "The NP (nurse practitioner) decided to do the [MEDICATION NAME] because she felt it was an easy solution to reverse the drowsiness and she, the NP, was acting in her, the resident's, best interest." Admin #2 further stated that "because it was a patch, the absorption can be different from individual to individual and she, the NP, felt the medication was still in her, the resident's, tissues and it was no way to determine how much was absorbed she (NP) felt that it was better to be overly cautious and reverse the medication." On [DATE] at approximately 2:10 p.m., Admin #2 was made aware that the resident received [MEDICATION NAME] 200 mcg, which was a high dose of a medication that was not prescribed to the resident but to a resident with end [MEDICAL CONDITION], who was opiod tolerant. Admin #2 stated, "We did not see any significant life threatening consequences; we educated the nurse, the nurse had to look at a medication training video. Admin #2 stated, "The mentor watched the nurse pull the medication and she (the mentor) allowed the nurse to go in and administer the medication. She (the mentor) was also educated on not allowing a new nurse to administer meds (medicines) until orientation is complete." Admin #2 also stated to this Surveyor, "the nurse, who allowed the new nurse to administer the medication, felt she (new nurse) had ten years experience and she should have given the meds to the right person. On [DATE] at approximately 2:17 p.m., Admin #2 was interviewed regarding the time frame the MD was made aware that the resident received the wrong medication. Admin #2 stated, "It, the medication error, happened on [DATE] at eight o'clock, she (Resident named) wore the patch for twelve hours. The nurse on first shift discovered it the next morning due to her sleepiness; she found both patches on her (Resident #8). The NP was in the building and she was immediately made aware." According to Potter and Perry's, Fundamentals of Nursing, 7th edition, 2009, pages ,[DATE], documents the following information: "medication Errors. A medication error can cause or lead to inappropriate medication use or harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication...Steps to Take to Prevent Medication Errors...Follow the six rights of medication administration, be sure to read the label at least three times (comparing Medication Administration Record [REDACTED]...1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, 6. The right documentation...(3)." (1) (3) Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2007. (2) Lippincott,Williams and Wilkins. Nursing Drug Handbook. Columbia, Ohio: 2012. (3) Potter Patricia A. and Perry Anne Griffin. Fundamentals of Nursing. 7th Edition. St. Louis, Missouri: Mosby Elsevier, Inc, 2009. 2. Resident #7's order for D 5 ,[DATE] NS ( 5% [MEDICATION NAME] with one half percent of Normal Saline) was transcribed incorrectly and a clarification was not obtained regarding the order. D5 ,[DATE] Normal Saline- Hypertonic pH 4.4 hypertonic fluid replacement; replace sodium, chloride and some calories. D5W- [MEDICATION NAME] pH 5.0 [MEDICATION NAME] hydration; provides some calories. Resident #7 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] was an admission assessment. The resident was assessed as a fourteen (14) for cognitive skills, independent in decision-making skills and able to make needs known. On [DATE] at approximately 11:00 a.m. a complaint investigation was conducted to include the allegation that Resident #7 was administered the wrong medication and subsequently died . Resident #7's clinical record was reviewed to include the following Physician's Telephone Order: Physician's Telephone Order: "[DATE] ...Start D5W ( 5% [MEDICATION NAME] in Water) @ 75 cc/hr x1..." Further review of the clinical record evidenced a nursing note to include the following: Nursing Note: "[DATE] 22:16 (10:16 p.m.) Resident found vomiting with pain from vomiting. Vitals were as follows: Temp 101.1, Pulse: 93, BP ,[DATE] Resp 30, SpO2 78. Call (Dr. named) and family. New Orders: (1) Start Oxygen 2 LPM (liters per minute) NC (nasal canula) PRN (as needed/necessary) (2) Start D5W @75 cc/hr one time order (Follow up with (Dr. named upon completion for new orders.)... "[DATE] 11:20 a.m. Note Text: in with pt (patient) this am pt was cold and clammy and sweatty (sp) pts bs (blood sugar) was 39 order obtained for [MEDICATION NAME] im (intramuscular) x's 1 dose prn (as needed/necessary) pt was given im injection 3rd shift nurse had started iv (intravenous) on pt per dr (doctor) orders and labs were drawn per order spoke with son about pts care and explain to him of pts decline and discussed pts care and went over palliative care/comfort care orders with him (RP responsible person/party) named (son) in agreeance in making the pt palliative/comfort care son stated he did not want her to suffer anymore and he did not want her sent to the hospital that she had fought long enough and she just needs to be comfortable explain to him that if she pulls out iv for the 2nd time that since we made pt palliative/comfort care that we would not attempt to put iv back in son (named) stated he did not want anymore iv's as well as... [DATE] 16:05 (4:05 p.m.) Resident observed pulseless and without breath sounds... On [DATE] at approximately On [DATE] at approximately 11:30 a.m., a copy of the facility's "Incident Report" was reviewed to include the following: Incident Report: "Incident Description and Investigation: Date of Incident: [DATE] 9:30 p.m...Description of Incident: On [DATE] nurse received a start IV fluids on resident. MD ordered via T.O. (telephone order) D5 ,[DATE] NS. Nurse wrote order for D5W. D5 ,[DATE] NS was given. Transcription error, no resident harm. Center Action: Physician Notification: Was physician notified? Yes...If yes, Date: [DATE] 1 pm...Center Action: Patient's Care: Describe care and medications, if any, provided to patient following incident, and by whom provided: ,[DATE] labs did not show any adverse effect r/t IV fluids..." An "Investigation Report" was reviewed to include the following: Investigation Report: Date of Investigation: [DATE] Date of Incident: [DATE] Summary of alleged incident: On [DATE], it is alleged that (resident named) nurse hung the incorrect IV fluids..." Statement: Did you care for resident (named) on [DATE]? Yes. I worked second and third that day...Was anything unusual happening with her? She couldn't tolerate po intake. She had some vomiting...I talked to her son who is her emergency contact and he didn't want her sent to the hospital. I told the son she was uncomfortable from the vomiting and appeared dehydrated...I suggested some IV fluids might make her more comfortable and the son was in agreement...I called (Dr. named) and let him know what her condition was and what the son's care wishes were. He was ok starting the IV fluids. I was at the nurse's station and I had the IV start box on the desk. I told (Dr. named) the three different IV fluids you had available, and he told me to start the D5...(sic). Do you remember whether he specified D5 and ,[DATE] NS or D5W? He just said D5. But I had told him what was in the box, which was NS, NS with 20K and D% and ,[DATE] NS. So he knew what D5 was available. You wrote the order for D5W? Yes. What did you hang? D5 ,[DATE] NS @ 75 an hour. That is what (Dr. named) told me to hang. There is no D5W in the start box. I just made a mistake when I wrote the order. I hung what he ordered..." On [DATE] at approximately 5:15 p.m., the nurse involved in the above incident, who was a licensed practical nurse and will be identified as LPN #1 was interviewed regarding the above allegation. LPN #1 stated, "When she came in she was doing well, she later developed periods of nausea and vomiting and she was not able to keep anything down. I talked with the family about starting IV fluids due to vomiting and dry heaving and they agreed; they did not want any hospitalization so I called (Dr. named) and explained to him what was going on. I read all the fluids that we had in house and he said hang D5." LPN #1 was asked if he clarified with the doctor, which IV he wanted to be hung. LPN #1 stated, "No. prior to being here I was in the Army and when you hear D5 you automatically wrote D5W. I wrote the order and faxed the pharmacy. I did not hang the D5W. I hung D5 ,[DATE] NS @ 75 cc/hr." LPN #1 was asked how did he know which D5 to hang if he did not get clarification and if there were three in the start box. LPN #1 stated, "I just hung the D5 ,[DATE] NS." (1). LPN #1 further stated, ",[DATE] cc's infused before the IV came out at shift change. I bandaged the arm and called the family. The family did not want to restart the fluids. She (resident named) passed the next day." On [DATE] at approximately 2:00 p.m., during the meeting with the administrator and the director of nursing, the above findings were mentioned. The director of nursing, who will be identified as Administrator (Admin) #2 stated, "We educated the nurse on transcribing orders. He gave the right medication because we do not have D5W in the building." According to Potter and Perry's, Basic Nursing Essential for Practice, 6th edition, 2007, pages ,[DATE], documents the following information: "The best way to avoid being liable for negligence is to follow standards of care, to give competent health care, and to communicate with other health care providers. The physician or health care provider is responsible for directing the medical treatment of [REDACTED]." Potter and Perry's Fundamentals of Nursing 7th edition 2009, page 336 documents the following information: "physician's orders [REDACTED]. Nurse's follow physician's orders [REDACTED]. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary... (2)." (1) Potter Patricia A. and Perry Anne Griffin. Fundamentals of Nursing. 6th Edition. St. Louis, Missouri: Mosby Elsevier, Inc, 2005. (2) Potter Patricia A. and Perry Anne Griffin. Fundamentals of Nursing. 7th Edition. St. Louis, Missouri: Mosby Elsevier, Inc, 2009. 3. Resident #9's [MEDICATION NAME] was not verified by the nurse prior to administration and the wrong dose was administered to the resident. The order was for [MEDICATION NAME] 10 mg and the resident received [MEDICATION NAME] 20 milligrams on [DATE] and twice on [DATE]. The error was noted by the facility on [DATE] during the abbreviated survey. According to Drug Information Handbook for Nursing pages 927 -928 [MEDICATION NAME] is used for the management of moderate to severe pain, normally used in combination with non-narcotic [MEDICATION NAME]. Warning/Precautions: ...Use caution in elderly...(1)." Resident #9 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] was a thirty (30) day assessment. The resident was assessed as a fourteen (14) for cognitive skills, independent in decision-making and able to make needs known. On [DATE] at approximately 11:15 a.m., Resident #9 was observed during tour, in bed tossing and turning. This Surveyor knocked on the door to speak to the resident but the resident did not acknowledge this Surveyor; the resident was talking incoherently and raising her hands in a swinging motion, as if something was there. Incident Report "Date of Incident: [DATE] 1:40 p.m. ...Type: Medication error without harm...Description of Incident: On ,[DATE] @ 2200 (10:00 p.m.), ,[DATE] @ 1 AM, ,[DATE] @ 6:45 AM resident received 20 mg of [MEDICATION NAME] order only 10 mg of [MEDICATION NAME] Action: Patient's Care: Educated staff that resident is on 10 mg of [MEDICATION NAME] not 20 mg and only one tablet needed for pain when she needs pain..." Attached to the back of the "Incident Report" was a "Controlled Medication Utilization Record" the form was reviewed to include the following: "[MEDICATION NAME] HCL 10 MG TABLET EA...TAKE 1 TAB BY MOUTH EVERY 4 HOURS AS NEEDED FOR PAIN...Date received: [DATE]...Qty (quantity) received: 20..XXX[DATE] 2200 ii (2) tablets (dose given)... On [DATE] at 4:00 p.m., the resident's "Controlled Medication sheet" was documented as having eleven (11) tablets left. On [DATE] 0100 ii (2) tablets and [DATE] 0645 ii (2) tablets were given leaving a total of seven tablets in the pack." According to the above physician's orders [REDACTED]. On [DATE] at approximately 9:00 a.m., this Surveyor went to the unit where the resident was residing to view the resident's clinical record. A licensed practical nurse, who will be identified as LPN #1 stated, "She is in the hospital, I sent her out last night." When interviewed and asked the reason, LPN #1 stated, "she had a change in her condition." On [DATE] at 9:05 a.m., Resident #9's clinical record was reviewed to include the following nursing note: Nursing Note: "[DATE] 17:40 (5:40) Resident observed in room on edge of bed trying to get out of bed. Resident fell out of bed onto padded mats before staff could get to resident. Resident did hit her head on mat during the fall. Bed was in low position and call bell in reach. 2 staff members got resident back into center of bed and assessed vital...asked resident what she was doing, resident stated "There is always animals around me and always on my feet..." [DATE] 19:14 (7:14) Resident has increase confusion, nausea and head trauma. After referring with doctor and family. New orders: Transfer to (hospital named) ED (emergency department) for evaluation of head and decline in status..." On [DATE] at approximately 1:04 p.m. during the meeting with the administrator and the director of nursing (DON). The DON was interviewed regarding the resident receiving the incorrect dose of [MEDICATION NAME]. The DON stated, "We found this on the twenty first (21st) when we were reviewing the medication card. We, again, educated the nurses. We recognize that medication error is a problem but how can we prevent this from continuing to happen. I mean we educate the nurses whenever we find there is a problem. How do you fix it?" The DON further stated, "The mistake was made because the order was changed. She, the resident, was getting five (5) milligrams two (2) tablets. The nurse was so accustomed to pulling the medication and giving the two (2) tablets, she was not aware that the order had changed." When interviewed and asked if the nurse, who made the error was in the facility, the DON stated, "No, she has not worked since the incident happened, she is scheduled to come in tonight; she we will have to do the training and look at the medication video before she is allowed to administer medications again." According to Potter and Perry's, Fundamentals of Nursing, 7th edition, 2009, pages ,[DATE], documents the following information: "medication Errors. A medication error can cause or lead to inappropriate medication use or harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication...Steps to Take to Prevent Medication Errors...Follow the six rights of medication administration, be sure to read the label at least three times (comparing Medication Administration Record [REDACTED]...1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, 6. The right documentation...(2)." (1) Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2007. (2) Potter Patricia A. and Perry Anne Griffin. Fundamentals of Nursing. 7th Edition. St. Louis, Missouri: Mosby Elsevier, Inc, 2009. This is a complaint deficiency.

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation; the facility staff failed to ensure two of 9 residents in the survey sample were from free of unnecessary medications. Resident #8 received two [MEDICATION NAME] 100 micrograms (mcg) patches (which were prescribed for another resident). Resident #8 had to be administered [MEDICATION NAME] to reverse the effects of the [MEDICATION NAME]es resulting in harm. Resident #9 was administered the wrong dose of [MEDICATION NAME]. 1. Resident #8 was administered another resident's medication. Resident #8 received two [MEDICATION NAME] 100 micrograms (mcg) patches, which resulted in harm to the resident and the resident had to receive an injection of [MEDICATION NAME] 0.4 mg (milligrams) IM (intramuscularly) to reverse the harm caused by the [MEDICATION NAME]. 2. Resident #9 was administered the wrong dose of [MEDICATION NAME]. The order was for [MEDICATION NAME] 10 milligrams (mg) and the resident received [MEDICATION NAME] 20 milligrams on 4/13/15 and twice on 4/16/15. The error was noted by the facility on 4/21/15 during the abbreviated survey. The findings include: 1. Resident #8 was administered another resident's medication. Resident #8 received two [MEDICATION NAME] 100 micrograms (mcg) patches, which resulted in harm to the resident and the resident had to receive an injection of [MEDICATION NAME] 0.4 mg (milligrams) IM (intramuscularly) to reverse the harm caused by the [MEDICATION NAME]. According to Drug Information Handbook for Nursing (2007) page 860... "[MEDICATION NAME] ([MEDICATION NAME]) is used for the complete or partial reversal of opiod depression, including respiratory depression, induced by natural and synthetic opiods...[DIAGNOSES REDACTED]. Caution: [MEDICATION NAME]'s effects are due to its action on narcotic reversal, not due to any direct effect upon opiate receptors..." (1). According to Nursing Drug Handbook (2012) pages 576-580, "[MEDICATION NAME] is defined as a narcotic and opiod [MEDICATION NAME] used to treat [DIAGNOSES REDACTED]. According to Drug Information Handbook for Nursing (2007) pages 506..."[MEDICATION NAME]: ...Warning/Precautions: An opiod-containing [MEDICATION NAME] regimen should be tailored to each patient's needs and based upon the type of pain being treated (acute versus chronic), the route of administration, degree of tolerance for opiods (naive versus chronic user), age, weight, and medical condition. The optimal [MEDICATION NAME] dose varies widely among patients..." (3). Resident # 8 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/6/15 was a quarterly assessment; the resident was assessed as a fourteen (14) for cognitive skills. On 4/21/15 at approximately 11:00 a.m., a complaint investigation was conducted to include the allegation that Resident #8 received another resident's medication and became unresponsive and was administered [MEDICATION NAME]. Resident #8's clinical record was reviewed to include the following nursing note: Nursing Note: "11/14/14 13:11 (1:11 p.m.) New order: Nalaxone HCL 0.4 mg/ml. Give 1 ml IM in deltoid stat...(sic)." "11/14/14 14:56 (2:56 p.m.) (Resident named) very drowsy, slightly confused this am. Respirations regular and non-labored, MD (doctor) NP (nurse practitioner) and RP (responsible party/person) notified of change in condition, medications resident has received in the last 24 hours. New order for one time dose of [MEDICATION NAME] administered this shift. (Resident named) is now awake and alert, back at her baseline. Spoke with RP (named) to update him on her improvement..." There were no other nursing notes in the clinical record, of the resident's status or vital signs after the [MEDICATION NAME]es were found, until the [MEDICATION NAME] was ordered and started at 13:11 p.m. On 4/21/15 at approximately 11:30 a.m., a copy of the facility's "Incident Report" was reviewed to include the following: Incident Report: "Incident Description and Investigation: Date of Incident: 11/13/14 8p (8:00 p.m.)...Location of Incident: Patient's Room...Type: Medication error without harm...Description of Incident: Resident received medication intended for another resident...Center Action: Physician Notification: Was physician notified? Yes...If yes, Date: 11/14/14 12:00 pm...Center Action: Patient's Care: Describe care and medications, if any, provided to patient following incident, and by whom provided: resident assessed and monitored for adverse side effects. [MEDICATION NAME] administered for sedation..." On 4/22/15 at approximately 2:00 p.m., during the meeting with the administrator and the director of nursing, who will be identified as Administrator #2, this Surveyor interviewed Admin #2 regarding the above incident. Admin #2 stated, "Her respirations remained stable at eighteen (18) and her sats (oxygen saturation) was ninety-eight (98). She was given [MEDICATION NAME] because she was sleepy; the resident stated she felt fuzzy, she was aware of the error." When interviewed and asked the reason for [MEDICATION NAME] due to the resident just being "sleepy", Admin #2 stated, "The NP (nurse practitioner) decided to do the [MEDICATION NAME] because she felt it was an easy solution to reverse the drowsiness and she, the NP, was acting in her, the resident's, best interest." Admin #2 further stated that "because it was a patch, the absorption can be different from individual to individual and she, the NP, felt the medication was still in her, the resident's, tissues and it was no way to determine how much was absorbed she (NP) felt that it was better to be overly cautious and reverse the medication." On 4/22/15 at approximately 2:10 p.m., Admin #2 was made aware that the resident received [MEDICATION NAME] 200 mcg, which was a high dose of a medication that was not prescribed to the resident but to a resident with end [MEDICAL CONDITION], who was opiod tolerant. Admin #2 stated, "We did not see any significant life threatening consequences; we educated the nurse, the nurse had to look at a medication training video. Admin #2 stated, "The mentor watched the nurse pull the medication and she (the mentor) allowed the nurse to go in and administer the medication. She (the mentor) was also educated on not allowing a new nurse to administer meds (medicines) until orientation is complete." Admin #2 also stated to this Surveyor, "the nurse, who allowed the new nurse to administer the medication, felt she (new nurse) had ten years experience and she should have given the meds to the right person. On 4/22/15 at approximately 2:17 p.m., Admin #2 was interviewed regarding the time frame the MD was made aware that the resident received the wrong medication. Admin #2 stated, "It, the medication error, happened on 11/13/14 at eight o'clock, she (Resident named) wore the patch for twelve hours. The nurse on first shift discovered it the next morning due to her sleepiness; she found both patches on her (Resident #8). The NP was in the building and she was immediately made aware." (1) (3) Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2007. (2) Lippincott,Williams and Wilkins. Nursing Drug Handbook. Columbia, Ohio: 2012. This is a complaint deficiency. 2. Resident #9 was administered the wrong dose of [MEDICATION NAME]. The order was for [MEDICATION NAME] 10 milligrams (mg) and the resident received [MEDICATION NAME] 20 milligrams on 4/13/15 and twice on 4/16/15. The error was noted by the facility on 4/21/15 during the abbreviated survey. According to Drug Information Handbook for Nursing pages 927 -928 [MEDICATION NAME] is used for the management of moderate to severe pain, normally used in combination with non-narcotic [MEDICATION NAME]. Warning/Precautions: ...Use caution in elderly...(1)." Resident #9 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/20/15 was a thirty (30) day assessment. The resident was assessed as a fourteen (14) for cognitive skills, independent in decision-making and able to make needs known. On 4/21/15 at approximately 11:15 a.m., Resident #9 was observed during tour, in bed tossing and turning. This Surveyor knocked on the door to speak to the resident but the resident did not acknowledge this Surveyor; the resident was talking incoherently and raising her hands in a swinging motion, as if something was there. Incident Report "Date of Incident: 4/21/15 1:40 p.m. ...Type: Medication error without harm...Description of Incident: On 4/13 @ 2200 (10:00 p.m.), 4/16 @ 1 AM, 4/16 @ 6:45 AM resident received 20 mg of [MEDICATION NAME] order only 10 mg of [MEDICATION NAME] Action: Patient's Care: Educated staff that resident is on 10 mg of [MEDICATION NAME] not 20 mg and only one tablet needed for pain when she needs pain..." Attached to the back of the "Incident Report" was a "Controlled Medication Utilization Record" the form was reviewed to include the following: "[MEDICATION NAME] HCL 10 MG TABLET EA...TAKE 1 TAB BY MOUTH EVERY 4 HOURS AS NEEDED FOR PAIN...Date received: 4/12/15...Qty (quantity) received: 20...4/13/15 2200 ii (2) tablets (dose given)... On 4/15/15 at 4:00 p.m., the resident's "Controlled Medication sheet" was documented as having eleven (11) tablets left. On 4/16/15 0100 ii (2) tablets and 4/16/15 0645 ii (2) tablets were given leaving a total of seven tablets in the pack." According to the above physician's orders [REDACTED]. On 4/22/15 at approximately 9:00 a.m., this Surveyor went to the unit where the resident was residing to view the resident's clinical record. A licensed practical nurse, who will be identified as LPN #1 stated, "She is in the hospital, I sent her out last night." When interviewed and asked the reason, LPN #1 stated, "she had a change in her condition." On 4/22/15 at 9:05 a.m., Resident #9's clinical record was reviewed to include the following nursing note: Nursing Note: "4/21/15 17:40 (5:40) Resident observed in room on edge of bed trying to get out of bed. Resident fell out of bed onto padded mats before staff could get to resident. Resident did hit her head on mat during the fall. Bed was in low position and call bell in reach. 2 staff members got resident back into center of bed and assessed vital...asked resident what she was doing, resident stated "There is always animals around me and always on my feet..." 4/21/15 19:14 (7:14) Resident has increase confusion, nausea and head trauma. After referring with doctor and family. New orders: Transfer to (hospital named) ED (emergency department) for evaluation of head and decline in status..." On 4/22/15 at approximately 1:04 p.m. during the meeting with the administrator and the director of nursing (DON). The DON was interviewed regarding the resident receiving the incorrect dose of [MEDICATION NAME]. The DON stated, "We found this on the twenty first (21st) when we were reviewing the medication card. We, again, educated the nurses. We recognize that medication error is a problem but how can we prevent this from continuing to happen. I mean we educate the nurses whenever we find there is a problem. How do you fix it?" The DON further stated, "The mistake was made because the order was changed. She, the resident, was getting five (5) milligrams two (2) tablets. The nurse was so accustomed to pulling the medication and giving the two (2) tablets, she was not aware that the order had changed." When interviewed and asked if the nurse, who made the error was in the facility, the DON stated, "No, she has not worked since the incident happened, she is scheduled to come in tonight; she we will have to do the training and look at the medication video before she is allowed to administer medications again." According to Potter and Perry's, Fundamentals of Nursing, 7th edition, 2009, pages 704-705, documents the following information: "medication Errors. A medication error can cause or lead to inappropriate medication use or harm. Medication errors include inaccurate prescribing, administration of the wrong medication, giving the medication using the wrong route or time interval, and administering extra doses or failing to administer a medication...Steps to Take to Prevent Medication Errors...Follow the six rights of medication administration, be sure to read the label at least three times (comparing Medication Administration Record [REDACTED]...1. The right medication, 2. The right dose, 3. The right client, 4. The right route, 5. The right time, 6. The right documentation...(2)." (1) Turkoski, Beatrice B., Brenda R. Lance and Mark F. Bonfiglio. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2007. (2) Potter Patricia A. and Perry Anne Griffin. Fundamentals of Nursing. 7th Edition. St. Louis, Missouri: Mosby Elsevier, Inc, 2009. This is a complaint deficiency.

Based on observation, staff interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide supervision and safety devices to prevent an accident for two of 27 Residents, Resident #'s 16 and 15. 1. Resident #16 was left unattended and suffered a laceration to the head. 2. Resident #15 did not have physician ordered fall mats placed. Findings include: This was a closed record review. 1. Resident #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A initial MDS (minimum data set) with an assessment reference date of 3/15/11 assessed Resident #16 with a score of 7 under cognitive/decision making skills. Review of Resident #16's clinical record conducted on 9/29/11, and revealed the following nursing notes: 3/9/11 "Pt (patient) got up this a.m. to go to bathroom & ran into the door..." 3/14/11 "Resident was sitting on floor beside of bed. States she had slid off of bed trying to slide up in bed..." 3/16/11 "0420 Notified by CNA (certified nursing assistant) that pt had fell in the bathroom floor. Assessed pt observed a large hematoma on right side temple, moderate blood called 911..." 3/16/11 "11A (a.m.) Returned from (name of hospital) per W/C (wheel chair)... DSG (dressing) in place on forehead- No active bleeding noted. States she has 3 stitches in area..." Further review of the clinical record revealed hospital records dated 3/16/11 documenting, Resident #16 had suffered a laceration to the scalp requiring sutures. This surveyor then collected information through documentation to examine contributing factors in regards to prevention of falls for Resident #16. The following information was observed: Physician admission orders Ambulate with assist." A "Tinetti Balance Assessment Tool" of which six assessments were documented, each 1 week apart, starting upon admission to the facility. All six assessments deemed Resident #16 a high risk for falls. A "Physical Therapy Evaluation" dated 3/8/11, which documented "...balance issues..." An "Occupational Therapy Summary" dated 3/9/11, which documented "... Toileting, SBA (stand by assistance)..." A Fall risk care plan dated 3/8/11 "Provide assist to transfer and ambulate as needed." An Minimal Data set (MDS) with assessment reference date of 3/15/11 was observed. Under "Section G Functional Status" subsection I. Toilet use, column 1 was coded 3, column 2 was coded 2. Coding directory deemed Resident #16 as extensive assistance with one person assist. Under MDS section "G0300. Balance... subsection "D. titled Moving on and off toilet" Resident #16 was coded as a "2", which is defined as "NOT steady, only able to stabilize with human assistance." After reviewing the above documentation this surveyor then reviewed the incident report pertaining to Resident #16's fall on 3/16/11. The following information was a hand written documentation by the Certified Nursing Assistant (CNA #2) who was taking care of Resident #10 at the time of the fall: "help assist resident to bathroom, sat her on commode, as I walking out her room to see who was ringing (call light) heard noise went back into bathroom found resident laying on floor under sink face down on R (right) side...Picked up sat back onto commode. Not wanting to leave resident alone I put bathroom light on while holding her up on commode (due to her head bleed) (she was wobbly). Nurse came in, cleaned blood off face hands & legs assisted back to bed. Asked resident what happened she stated I fell my head hurts." CNA #2 was not available for interview during the survey. On 9/29/11 at 3:40 p.m. this surveyor interviewed the director of nursing (DON) concerning the above finding. The DON verbalized that Resident #16 was fairly alert when first admitted , but then had gotten weaker. The DON also verbalized the CNA had partially closed Resident #16's bathroom door to provide privacy, while on toilet. At this time this surveyor pointed out according to CNA #2 's documentation, CNA #2 was leaving the room to answer another call bell when CNA#2 heard a noise and went back into Resident #16's bathroom. This surveyor then asked the DON what the expectation is, if a resident is assessed as needing extensive assistance with one person assist while toileting and with a balance assessed as unsteady without assistance. The DON verbalized that the resident should not have been left alone. No other information was provided concerning the above finding prior to exit conference on 9/29/11. This is a complaint deficiency. 2. The facility staff failed to ensure fall mats were placed on each side of Resident # 15's bed. Resident # 15 was admitted to the facility 2/13/03 with a readmission date of [DATE] with [DIAGNOSES REDACTED]. The most recent full MDS (minimum data set) was an annual assessment dated [DATE]. Resident # 15 was scored as being severely impaired in cognition with a total summary score of 07. On 9/28/11 at approximately 4:15 p.m. the clinical record was reviewed. The current POS (physician order [REDACTED]. in bed." The treatment sheet for September 2011 was then reviewed. From September 1st through September 28 th staff had initialed on all three shifts that the mats were in place. On the same above date at approximately 4:50 p.m. Resident # 15 was observed lying in bed. There were no mats observed down on either side of the bed. A certified nursing assistant (CNA # 3) was observed in the room providing care for the resident. The surveyor asked CNA # 3 about the mats that were to be placed on each side of the bed. CNA # 3 stated "I haven't seen them down for a while." CNA # 3 then proceeded to look around Resident # 15's room for the mats. CNA # 3 then stated "I don't see any in here." On 9/29/11 at approximately 7:45 a.m. Resident # 15 was observed lying in bed with eyes closed. There were no mats down on either side of the bed. These findings were shared 9/29/11 at approximately 2:15 p.m. with the administrator, DON (director of nursing) and ADON (assistant director of nursing).