Every finding on record at The Encore Healthcare and Rehabilitation Center

Based on record review and interview, the facility failed to develop a person-centered comprehensive plan of care for 3 (#9, #73, #75) out of a final sample of 37 residents as evidenced by:1. Failing to develop a plan of care for Resident #9's hospice status, and;2. Failing to develop a resident centered comprehensive care plan for Resident #73 and #75.On 07/23/2025, a review of the facility's policy titled, Care Plan Policy and Procedure with a last reviewed date of 02/09/2025 read in part; A comprehensive person-centered care plan will be completed according to the RAI (Resident Assessment Instrument) manual upon admission, significant change, annual and as needed. Resident #9A review of Resident #9's EMR (Electronic Medical Record) revealed an admission date of 07/23/2020 with diagnoses that included, Hemiplegia and Hemiparesis Following Cerebral Infarction, Acute Kidney Failure, and Hypertensive Heart Disease. Review of Resident #9's MDS (Minimal Data Assessments) assessments revealed a comprehensive assessment indicating hospice services completed on 06/05/2025.Review of Resident #9's physician's orders revealed an order to admit to hospice services. Review of Resident #9's person-centered care plan failed to reveal the resident had a plan of care to reflect the Resident's hospice status. Resident #73Review of Resident #73's EMR revealed an admission date of 05/19/2025 with diagnoses that included, Pneumonitis, Paroxysmal Atrial Fibrillation, and Anxiety Disorder. Review of Resident #73's MDS assessments revealed an admission MDS assessment was complete on 05/30/2025.Review of Resident #73's person-centered care plan revealed it was incomplete.Resident #75Review of Resident #75's EMR revealed an admission date of 06/16/2025 with diagnoses that included, Pneumonia, Sepsis, and Paroxysmal Atrial Fibrillation. Review of Resident #75's MDS assessments revealed an admission MDS assessment was complete on 06/22/2025.Review of Resident #75's person-centered care plan revealed it was incomplete. On 07/23/2025 at 10:35 a.m., a concurrent records review and interview was conducted with S6MDS. S6MDS stated person-centered care plans should be updated and/or completed according to the RAI manual which is no later than 7 days after the completion of a comprehensive assessment. Resident #7's records reviewed at this time. S6MDS confirmed the resident had been admitted to hospice services and her last MDS comprehensive assessment was on 06/05/2025 making the current plan of care, which failed to include a hospice plan, overdue. Interview and records review continued for Resident #73. S6MDS viewed and confirmed Resident #73 admission MDS assessment was completed 05/30/2025. S6MDS viewed Resident #73's person-centered care plan and confirmed it was not complete and was overdue. Further interview and records review done with S6MDS for Resident #75. S6MDS viewed Resident #75's admission MDS assessment and confirmed it was completed on 06/22/2025. She then viewed Resident #75's person-centered care plan and confirmed it was not complete and was overdue.

Based on observation, interviews, and record review, the facility failed to ensure a residents were safe to perform self-administration of medication for 1 (#61) out of 4 residents observed for medication administration. Findings:A review of the facility's policy titled Meds-Self Administration Policy and Procedure which was last reviewed on 02/09/2025, read in part, Policy: To maintain the residents' high level of independence, residents who desire self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the residents and other residents of the facility and there is a prescriber's order to self-administer. 1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility during the care planning process. 2. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of an assessment conducted on a quarterly basis or when there is a significant change in condition. Review of Resident #61's health record revealed he was admitted to the facility on [DATE] with diagnosis which included, but were not limited to allergic rhinitis. Review of Resident #61's MDS (Minimum Date Set) assessment with an ARD (Assessment Reference Date) of 05/15/2025, revealed he had a BIMS (Brief Interview for Mental Status) score of 15, indicating his cognition was intact. Review of Resident #61's physician orders revealed an order dated 09/03/2024, for Ipratropium Bromide Nasal Soln (Solution) 0.03% (21 mcg (micrograms)/spray) 1 spray in both nostrils two times a day related to Other allergic rhinitis. On 07/22/2025 at 8:22 a.m., an observation was made of S8LPN (Licensed Practical Nurse) administering medications to Resident #61. S8LPN handed Resident #61 his bottle of Ipratropium nasal spray. The resident then asked S8LPN if he was supposed to administer two sprays in each nostril. S8LPN replied, indicating that one spray in each nostril should be administered. She also responded to the resident stating, I know you like to cheat. Resident #61 was observed spraying two sprays of Ipratropium in each nostril. On 07/22/2025 at 2:10 p.m., an interview was conducted with S8LPN. She confirmed that Resident #61 did administer Ipratropium two sprays in each nostril and should not have. She stated that Resident #61 would not allow her to administer the nasal spray herself and confirmed that the resident was noncompliant with administering the correct dose. She stated that she was not aware of the facility's policy on self-administration of medication by residents. On 07/22/2025 at 2:15 p.m., an interview was conducted with S2DON (Director of Nursing) and S1CN (Corporate Nurse). S1CN confirmed that Resident #61 should have been assessed and care planned for the ability to self-administer his nasal spray and was not. S1CN further confirmed that Resident #61 should have had a physician's order to self-administer his nasal spray and he did not.

Based on observations, record review and interview, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming for 1 (#25) out of 37 sampled residents. Findings:Review of Resident #25's electronic medical record revealed she was admitted on [DATE] with diagnosis included, but not limited to, Vascular Dementia, Psychotic Disturbance, Cognitive Communication Deficit, Anxiety and Major Depression.Review of Resident #25's quarterly MDS (Minimum Data Set) dated 06/24/2025 revealed her BIMS (Brief Interview for Mental Status) score was 5, indicating her cognition was severely impaired. Review of Resident #25's current Care Plan Report read in part, I require staff assistance for ADL's (Activities of Daily Living) due to Impaired Cognition. Assist me with hygiene and grooming tasks. On 07/22/2025 at 8:57 a.m., Resident #25 was observed in the Beauty Shop. She had multiple hairs growing on her chin approximately 1/2 inch long. On 07/22/2025 8:58 a.m., S7HairDresser observed Resident #25's hair on her chin and she confirmed the resident's hair on her chin was long and should have been cut. On 07/22/2025 at 9:05 a.m., an interview with S4CNASupervisor (Certified Nursing Assistant Supervisor) confirmed Resident #25's hairs on her chin were long and needed to be cut. She stated the residents get a shower on Mondays, Wednesdays and Fridays and staff should have ensured that the residents were groomed on these days. On 07/22/2025 at 9:10 a.m., S1CN (Corp Nurse) confirmed the resident had poor cognition and the staff were to groom the residents that required assistance with grooming. She stated S4 C.N.A. Supervisor should have ensured Resident #25 did not have overgrown facial hair on her chin.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including accurate administration of all drugs and accurately documenting controlled medication reconciliation as evidenced by:1 (#9) of 4 (#9, #36, #41, and #61) residents observed for administration of drugs, the facility failed to ensure Resident #9's Nifedipine was administered per manufacturer's recommendations, andin Med Cart C the facility failed to ensure Resident #79's controlled medication reconciliation was accurately maintained.Findings: Resident #9: A review of the facility's policy titled Medication Administration-General Guidelines which was last reviewed on 02/09/2025, read in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. vi. Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order. 1. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought. Review of Resident #9's health record revealed she was admitted to the facility on [DATE] with a diagnosis which included, but were not limited to essential (primary) hypertension and hypertensive heart disease without heart failure. Review of Resident #9's physician orders revealed an order dated 04/30/2025 for Procardia XL oral tablet extended release 24 hour 90 mg (milligrams) (Nifedipine) Give 1 tablet by mouth one time a day. Reference: https://labeling.pfizer.com/showlabeling.aspx?id=542 On 07/22/2025 at 7:46 a.m., an observation was made of S9LPN (Licensed Practical Nurse) administering medications to Resident #9. S9LPN was observed administering Nifedipine extended release to Resident #9 after crushing it. On 07/22/2025 at 1:51 p.m., an interview was conducted with S9LPN. She confirmed that she had administered Nifedipine extended release to Resident #9 crushed and should not have. On 07/22/2025 at 2:15 p.m., an interview was conducted with S2DON (Director of Nursing) and S1CN (Corporate Nurse). S1CN confirmed that Nifedipine Extended Release should not have been administered crushed to Resident #9. Resident #79: A review of the facility's policy titled, Medication – Controlled Substances Policy and Procedure with a last review date of 02/09/2025, read in part, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. The policy also indicated general guidelines, When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): a. date and time of administration (MAR, Narcotic Record); b. amount administered (Narcotic Record); c. remaining quantity (Narcotic Record); and d. initials of the nurse administering the dose, completed after the medication is administered (MAR, Narcotic Record). A review of Resident #79's electronic medical record revealed she was admitted to the facility on [DATE] with diagnoses that included in part, Malignant Neoplasm of Colon and Secondary Malignant Neoplasm Liver and Intrahepatic Bile Duct. A review of Resident #79's physician's orders revealed a start date of 07/22/2025: Oxycodone-Acetaminophen Tablet 7.5-325 mg (milligram) Controlled Drug Give 1 tablet by mouth four times a day for pain. A review of Resident #79's Oxycodone-Acetaminophen Tablet 7.5-325 mg administration details in the EHR (electronic health record) revealed the controlled drug was administered on 07/23/2025 at 12:09 p.m. A review of the facility's form labeled, Individual Patient's Narcotic Record, for Resident #79 failed to reveal the administration of Oxycodone-Acetaminophen Tablet 7.5-325 mg on 07/23/2025 at 12:09 p.m. On 07/23/2025 at 1:21 p.m., a controlled drug count and interview was conducted with S10LPN (Licensed Practical Nurse). A review of Resident #79's Individual Patient's Narcotic Record, for Oxycodone-Acetaminophen Tablet 7.5-325 mg give 1 tablet by mouth 4 times per day stated that 6 tablets were supposed to be in the Oxycodone-Acetaminophen Tablet 7.5-325 mg medication card. Medication card reviewed with S10LPN for Resident #79's Oxycodone-Acetaminophen Tablet 7.5-325 mg which revealed 5 tablets. S10LPN stated she just administered Resident #79's Oxycodone-Acetaminophen Tablet 7.5-325 mg, and forgot to sign it off on the resident's Individual Patient's Narcotic Record, because she got busy doing other things. She confirmed that she should have documented on Resident #79's Individual Patient's Narcotic Record, before administering the medication and she did not. On 07/23/2025 at 1:30 p.m. a record review and interview was conducted with S3ADON (Assistant Director of Nursing). She stated in the EHR under administration details for Resident #79's Oxycodone-Acetaminophen Tablet 7.5-325 mg it was administered on 07/23/2025 at 12:09 p.m. by S10LPN. S10LPN reviewed Resident #79's Individual Patient's Narcotic Record for Oxycodone-Acetaminophen Tablet 7.5-325 mg and confirmed the 12:09 p.m. dose on 07/23/2025 was not documented and it should have been.

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5%. A total of 33 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 6.06%. FindingsA review of the facility's policy titled Medication Administration-General Guidelines which was last reviewed on 02/09/2025, read in part, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. vi. Tablet Crushing/Capsule Opening: Crushing tablets may require a physician's order. 1. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought. 2. Administration: b. Medications are administered in accordance with written orders of the prescriber. Review of Pfizer Medical.com (Procardia XL Manufacture website), in part: Dosage and Administration. Procardia XL extended release tablets should be swallowed whole and should not ne bitten or divided.Resident #9Review of Resident #9's health record revealed she was admitted to the facility on [DATE] with a diagnosis which included, but were not limited to essential (primary) hypertension and hypertensive heart disease without heart failure.Review of Resident #9's physician orders revealed an order dated 04/30/2025 for Procardia XL oral table extended release 24 hour 90 mg (milligrams) (Nifedipine) Give 1 tablet by mouth one time a day. On 07/22/2025 at 7:46 a.m., an observation was made of S9LPN (Licensed Practical Nurse) administering medications to Resident #9. S9LPN was observed administering Nifedipine extended release to Resident #9 after crushing it. On 07/22/2025 at 1:51 p.m., an interview was conducted with S9LPN. She confirmed that she had administered Nifedipine extended release to Resident #9 crushed and should not have.On 07/22/2025 at 2:15 p.m., an interview was conducted with S2DON (Director of Nursing) and S1CN (Corporate Nurse). S1CN confirmed that Nifedipine Extended Release should not have been administered crushed to Resident #9.Resident #61 Review of Resident #61's health record revealed he was admitted to the facility on [DATE] with a diagnosis of allergic rhinitis. Review of Resident #61's physician orders revealed an order dated 09/03/2024, for Ipratropium Bromide Nasal Soln (Solution) 0.03% (21 mcg (micrograms)/spray) 1 spray in both nostrils two times a day related to Other allergic rhinitis. On 07/22/2025 at 8:22 a.m., an observation was made of S8LPN (Licensed Practical Nurse) administering medications to Resident #61. S8LPN handed Resident #61 his bottle of Ipratropium nasal spray. Resident #61 was observed spraying two sprays of Ipratropium in each nostril.On 7/22/2025 at 2:10 p.m., an interview was conducted with S8LPN. She confirmed that Resident #61 did administer Ipratropium two sprays which was not the correct dose. The facility failed to ensure the medication error rate was less than 5%. A total of 33 opportunities were observed with 2 medication errors, which resulted in a medication error rate of 6.06%.

Based on observations and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles by failing to discard an expired medication in 1 (Med Cart C) of 2 (Med Cart B and Med Cart C) medication carts sampled for medication storage. Findings:On 07/23/2025 at 1:15 p.m., observation was conducted of Med Cart C with S10LPN (Licensed Practical Nurse) which revealed the following: 1 Aspirin 325 mg (milligram) bottle with an expiration date of 06/2025On 07/23/2025 at 1:21 p.m., an observation and interview was conducted with S10LPN who confirmed the expiration date on the Aspirin 325 mg bottle was 06/2025, and it should have been discarded and not in the med cart.On 07/23/2025 1:24 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing). She confirmed that no expired medications should be in any med carts.

Based on record review, observation, and interviews, the facility failed to promote resident's dignity during dining by standing over residents while assisting them to eat for 1 (Resident #67) of 37 sampled residents.Findings: A review of the facility's policy titled, Dining and Meal Service Policy and Procedure with a last review date of 02/09/2025, read in part, The dining experience will be person centered with the purpose of enhancing each individual resident's quality of life and being supportive of each individual's needs during dining. The policy also indicated general guidelines, Appropriate staff will assist as needed to assure adequate intake of food and fluids at the meal while maintain the resident's dignity (staff to sit eye level with resident while assisting to feed).A review of Resident #67's electronic medical record revealed he was admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's Disease, Dysphagia, and Gastro-Esophageal Reflux Disease,A review of Resident #67's MDS (Minimum Data Set) dated 05/20/2025 revealed she had a BIMS (Brief Interview for Mental Status) of 04, indicating her cognition was severely impaired.A review of Resident #67's comprehensive care plan read, I require assistance for ADL's (Activity of Daily Living) impaired cognition with interventions that read in part, I require assistance with feeding.On 07/21/2025 between 12:10 p.m. - 12:20 p.m. an observation was conducted of S9LPN (Licensed Practical Nurse) standing up and feeding Resident #67 while in the dining room for lunch. Resident #67 was seated on her geri-chair. On 07/21/2025 at 12:42 p.m., an interview was conducted with S9LPN. She stated she was feeding Resident #67 in the dining room for lunch. She stated she was standing up while feeding the resident who was sitting down in her geri-chair. She confirmed she should have been sitting next to the resident while feeding her, and not standing over her. 07/22/2025 at 3:11 p.m. an interview was conduct with S3ADON (Assistant Director of Nursing) who confirmed that while feeding residents, the staff should be sitting down in front of the resident and at eye level with the resident.

Based on record review, policy review, and interviews, the facility failed to implement its policy for incident investigation and reporting when staff failed to immediately report alleged staff-to-resident physicall abuse to administrative staff and failed to notify the resident's responsible party (RP) for 1 (#3) out of 7(#1, #2, #3, #R1, #R2, #R3 and #R4) sampled residents. Findings: On 09/16/2024 at 1:45 p.m., a review of the facility's undated policy, Abuse and Neglect Policy and Procedure revealed, in part, the following: To provide a safe environment for all residents free of abuse .Administrator or designee will complete a thorough investigation .If the resident is not interviewable, the resident's family may be questioned. 7. Reporting/Response- The facility employee or agent, who becomes aware of abuse .shall immediately report the matter to the facility administrator or Director of Nurses .The administrator or designee will notify the resident's representative of the matter. Follow up contact must be made with the resident and the resident representative regarding outcome, prevention, and resolution .All employees are required by law to report any suspected abuse . Review of Resident #3's electronic health record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Malignant Neoplasm of Endometrium, Unspecified Dementia, Aphasia, Other Schizoaffective Disorders, Other Specified Anxiety Disorders, Other Cerebrovascular Disease, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Left Dominant Side and Parkinson's disease. Review of Resident #3's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to participate in the Brief Interview for Mental Status due to the resident being rarely/never understood. Resident #3 had severely impaired cognitive skills for daily decision making. Review of SIMS (Statewide Incident Management System) report provided by the facility revealed the event occurred on 08/26/2024 at 9:00 a.m., was discovered on 08/27/2024 at 11:00 a.m. and was entered on 09/06/2024 at 11:45 a.m. Resident #3 was the victim of alleged physical abuse from the accused staff (S5CNA-Certified Nursing Assistant) and witnessed by S4CNA. Review of S4CNA's witness statement revealed in part, Resident #3 was involved in the incident of abuse on 08/26/2024 at 12:30 p.m. S4CNA wrote she was helping S5CNA get the resident ready for a doctor's appointment and S5CNA was combing the residents hair ruff and slapping resident very hard because she said the resident was getting on her nerves. Then S4CNA reported the incident of abuse the next day to the S3LPN (Licensed Practical Nurse). Review of Resident #3's electronic health record failed to include documentation that the Resident's RP was notified of the abuse allegation that occurred on 08/26/2024. Review of S3LPN's statement made on 09/10/2024 at 3:05 p.m. revealed in part that she was doing treatments when S4CNA came to her and wanted to tell her something. S4CNA told S3LPN that the day prior, she was helping S5CNA with Resident #3 and the resident was reaching and S5CNA slapped the resident's hand down and was rough with combing the resident's hair. S3LPN stated she asked S4CNA if she thought this was intentional and she stated yes. S3LPN then stated she went to S2CNASupervisor and reported the incident of abuse to her. On 09/06/2024 during a meeting with S1ADM (Administrator), S2CNASupervisor, and Resident #3's family, S3LPN stated that she reported the alleged abuse immediately after becoming aware, but did not call the resident's family because she thought the family would be notified after the investigation. On 09/16/2024 at 2:05 p.m., Resident #3's RP was interviewed via phone call. The RP stated she found out about the allegation of physical abuse involving Resident #3 and S5CNA through a social media post. The RP further stated some of her other siblings also saw the social media post the week of 09/02/2024, and they went to the facility on [DATE] for a meeting with S1ADM (Administrator). On 09/17/2024 at 9:25 a.m., an interview was conducted with S3LPN. S3LPN confirmed S4CNA informed her on 08/27/2024 regarding an allegation of physical abuse by S5CNA to Resident #3. S3LPN reported S4CNA told her that S5CNA was observed picking the resident's hair roughly and slapping the resident's hands. S3LPN stated she did not notify the resident's family and should have. On 09/17/2024 at 10:42 a.m., a phone interview was conducted with S4CNA. S4CNA stated she observed the alleged physical abuse involving Resident #3 and S5CNA on 08/26/2024 around 12:30 p.m. S4CNA verified she had not reported the allegation until the next morning on 08/27/2024. S4CNA confirmed she had not notified the facility staff immediately and should have. On 09/17/2024 at 4:15 p.m., an interview was conducted with S1ADM. S1ADM verified S4CNA had not reported the allegation immediately and should have. S1ADM confirmed Resident #3's family had a group meeting on 09/06/2024 and voiced their concern that they had not been notified by the facility of the alleged abuse.

Based on policy review, record review and interviews, the facility failed to ensure reportable incidents of an allegation of staff to resident physical abuse was reported to the State Survey Agency within 2 hours after the allegation was made for 1 (#3) of 7 (#1, #2, #3, #R1, #R2, #R3 and #R4) sampled residents. Findings: On 09/16/2024 at 1:45 p.m., a review of the facility's undated policy, Abuse and Neglect Policy and Procedure revealed, in part, the following: The facility administrator or designee shall complete a report to be made to the mandated state agency according to state guidelines upon notification of alleged abuse .Immediately means as soon as possible .but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Review of Resident #3's electronic health record revealed the resident was admitted to the facility on [DATE] with the following pertinent diagnoses: Malignant Neoplasm of Endometrium, Unspecified Dementia, Aphasia, Other Schizoaffective Disorders, Other Specified Anxiety Disorders, Other Cerebrovascular Disease, Hemiplegia and Hemiparesis Following Cerebrovascular Disease Affecting Left Dominant Side and Parkinson's disease. Review of Resident #3's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to participate in the Brief Interview for Mental Status due to the resident being rarely/never understood. Resident #3 had severely impaired cognitive skills for daily decision making. Review of SIMS (Statewide Incident Management System) report provided by the facility revealed an incident of alleged physical abuse occurred involving Resident #3. The event occurred on 08/26/2024 at 9:00 a.m. and was discovered on 08/27/2024 at 11:00 a.m. Further review revealed the event was entered into the SIMS on 09/06/2024 at 11:45 a.m., which was 10 days later before the facility reported the incident. On 09/17/2024 at 9:25 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). S3LPN confirmed S4CNA informed her on 08/27/2024 regarding an allegation of physical abuse by S5CNA to Resident #3. S3LPN reported S4CNA told her that S5CNA was observed picking the resident's hair roughly and slapping the resident's hands. S3LPN stated she immediately reported the allegation to S2CNASupervisor. On 09/17/2024 at 10:42 a.m., a phone interview was conducted with S4CNA. S4CNA stated she reported the alleged physical abuse involving Resident #3 and S5CNA to S3LPN on the morning of 08/27/2024, which was the day after the incident occurred. On 09/17/2024 at 3:45 p.m., an interview was conducted with S2CNASupervisor. S2CNASupervisor confirmed that S3LPN reported to her early in the morning on 08/27/2024 an allegation of physical abuse involving Resident #3. S2CNASupervisor stated she immediately informed S1ADM (Administrator). An interview was conducted with S1ADM on 09/17/2024 at 4:15 p.m. S1ADM confirmed S2CNASupervisor had informed him on 08/27/2024 that S4CNA reported an allegation of physical abuse involving Resident #3 and S5CNA. S1ADM then confirmed he reported the allegation to the state agency on 09/06/2024, which was outside of the 2 hour requirement.

Based on record review and interview, the facility failed to ensure a Discharge Minimum Data Set (MDS) assessment was completed timely for 1(Resident #38) out of 35 sampled residents investigated. Findings: Resident #38 was admitted to the facility on [DATE] with diagnoses including Cord Compression, Aural Vertigo, Spinal Stenosis, Diabetes Mellitus, Hypertension, and Displaced Fracture of Right Femur. Review of Resident #38's medical record, revealed Resident #38 was admitted on [DATE] and discharged from the facility on 02/19/2024. Review of Resident #38's Discharge MDS assessment dated [DATE], revealed a transmission date of 06/20/2024. On 06/20/2024 at 12:30 p.m., an interview was conducted with S9MDSLPN. S9MDSLPN reviewed Resident #38's record and confirmed that an MDS discharge assessment should have been completed and transmitted within the 120 days after the resident was discharged from the facility and was not.

Based on record review and interview, the facility failed to ensure accuracy of the documentation entered into the resident's record for 2 (#35, #71) residents in a final sample of 35 residents evidenced by: 1. inaccurately documenting a presence of a PEG (Percutaneous Endoscopic Gastrostomy) tube for Resident #35; 2. the nurse failing to document the correct reason as to why Resident #71 did not receive a scheduled medication, and another nurse failing to document that Resident #71 received an antibiotic injection immediately after administration per the facility's policy for medication administration. Findings: 1. Resident #35 Resident #35 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Urinary Incontinence, Edema, Depression, Anxiety Disorder, Congestive Heart Failure, Allergic Rhinitis, Insomnia, Restless Leg Syndrome, and Pain. A review of the physician's orders for Resident #35 revealed 03/04/2024: Regular Diet, Meat Finely Cut, no rice. Review of Resident #35's electronic records nursing progress notes revealed on 06/17/2024 at 5:45 a.m., residual check on PEG with 125cc (cubic centimeter) noted. On 06/17/2024 at 2:30 p.m., an interview was conducted with Resident #35, she stated she does not have a PEG tube. On 06/17/2024 at 2:45 p.m., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN reviewed the resident's record and confirmed Resident #35 did not have a PEG tube. 06/17/2024 at 2:55 PM an interview was conducted with S2DON (Director of Nursing). S2DON reviewed the resident's record and confirmed Resident #35 did not have a PEG tube and that the nurse who documented incorrectly would need to retract that entry error. 41824 2. Resident #71 Review of the facility's policy titled, Medication Administration- General Guidelines reviewed and approved by the facility on 08/26/2022 revealed in part: 4. Documentation: a. The individual who administers the medication dose records the administration on the resident's eMAR (Electronic Medication Administration Record) directly after the medication is given .v. If a dose of regularly scheduled medication is withheld, refused, not available, or given a time other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time .), the medication is documented as not given and an explanatory note is entered in the electronic document. Review of the resident's record revealed she was admitted to the facility on [DATE]. The resident's diagnoses included Urinary tract infection (UTI). Review of the resident's urine culture lab report revealed: collection date 06/06/2024; resulted and reviewed on 06/08/2024 .urine culture positive for Escherichia coli. Review of the resident's physician telephone orders for June 2024 revealed the following: 06/06/2024 Rocephin 1g (gram) IM (intramuscularly) QD (every day) x3 days pending C&S (urine culture and sensitivity) results. 06/08/2024 continue Rocephin 1g IM q (every) day for 4 more days. 06/13/2024 Rocephin 1 GM (gram) IM x3 days Review of the resident's eMAR for June 2024 revealed Ceftriaxone (Rocephin) 1 gm IM was marked as not administered 06/14/2024. On 06/18/2024 at 3:30 p.m., an interview was conducted with Resdient #71's nurse, S11LPN (Licensed Practical Nurse). She stated Resident #71 had a UTI and was prescribed the antibiotic Rocephin for treatment. She reviewed the resident's eMAR but could not find documentation that the resident received all 7 doses of the antibiotic as prescribed. On 06/18/2024 at 3:54 p.m., an interview and review of Resident #71's medication administration was reviewed with S7RCE (Regional Clinical Educator) who confirmed the resident did not receive a dose of Rocephin on 06/14/2024 as prescribed. Review of the medication administration history report revealed a note entered by S8LPN that read ceftriaxone 1gm vial give 3cc IM x 3 doses scheduled for 6/14/24 5:00 pm was not administered - other. cbg wnl (capillary blood glucose within normal limits) 6/14/24 5:31 p.m. S7RCE stated S8LPN charted in error and that the reason the resident did not receive the antibiotic was not accurately documented. S2DON (Director of Nursing) was present at this time and reviewed the resident's record in question. S2DON and S7RCE stated they were unsure if S8LPN administered the dose of Rocehpin and confirmed the resident's medication administration record was inaccurate. On 06/18/2024 at 4:21 p.m., an interview was conducted with S8LPLN who stated she did not administer Resident #71's dose of Rocephin on 06/14/2024 because the resident was transferred to the emergency room (ER) for evaluation. The resident did not return to the nursing home until after 6:00 p.m., after her shift ended. S8LPN reviewed the note she entered in the resident's medication administration record and confirmed she charted in error and did not enter the correct reason the resident did not receive the dose on her shift. S8LPN further reviewed the resident's record and progress notes and confirmed there was no documentation the resident received the dose of Rocephin upon return from the hospital. On 06/18/2024 at 4:31 p.m., S2DON stated Resident #71 returned from the hospital on 06/14/2024, but she was not sure of what time. A review of Resident #71's progress notes and skilled nursing notes for 06/14/2024 were conducted with S2DON and S7RCE which failed to reveal documentation of the exact time the resident returned from the hospital. Review of the resident's skilled notes revealed an assessment dated [DATE] at 9:37 p.m. There was no documentation the night nurse administered the dose of Rocephin on 06/14/2024. On 06/18/2024 at 4:51 p.m., S2DON and S7RCE stated S12LPN was Resident #71's nurse on the night shift on 06/14/2024. S12LPN reported to them that she administered Resident #71's dose of Rocephin on 06/14/2024 when the resident returned to the nursing home, but confirmed she failed to document it the resident's record. On 06/20/2024 at 9:11 a.m., a phone interview was conducted with S12LPN who stated she administered Resident #71's dose of Rocephin on 06/14/2024 upon the resident's return from the hospital. She stated that she failed to document the administration in the resident's record immediately after administering the drug to the resident per the facility's policy.

Based on record review and interview, the facility failed to accurately code all applicable diagnoses on two consecutive comprehensive MDS (Minimum Data Set) assessments for 1 (#41) of 35 final sampled residents. Findings: Review of Resident #41's record revealed she was admitted to the facility on [DATE] with diagnoses including Dementia. Review of Resident #41's Psychiatric Evaluation by the psychiatrist dated 09/15/2020 revealed the resident was diagnosed with Depression, Dementia without behavior disturbances, and Schizoaffective Disorder. According to the resident's updated billing diagnosis code report, the resident's diagnoses of Dementia had a documented onset date of 09/11/2020; Schizoaffective Disorder had a documented onset date of 09/30/2020. Review of Section I-Active Diagnoses of the resident's admission MDS assessment dated [DATE] revealed the listed diagnoses of Non-Alzheimer's Dementia and Schizophrenia (Schizoaffective disorders) were unchecked. Review of Section I-Active Diagnoses of the resident's following quarterly MDS assessment dated [DATE] revealed the listed diagnoses of Schizophrenia (Schizoaffective disorders) was unchecked. On 06/18/2024 at 1:25 p.m., an interview and record review was conducted with S7RCE (Regional Clinical Educator). She explained that according to Resident #41's records, the resident was admitted to the nursing home on 09/11/2020. The resident was diagnosed with Schizoaffective Disorder on 09/15/2020 when the psychiatrist evaluated the resident and documented the diagnosis on 09/15/2020. On 06/18/2024 at 2:03 p.m., an interview and review of Resident #41's records was conducted with S10MDSLPN (Minimum Data Set, Licensed Practical Nurse). She reviewed the dates of the resident's diagnoses in comparison with the resident's admission MDS assessment dated [DATE] and the resident's subsequent quarterly MDS assessment dated [DATE]. S10MDSLPN confirmed the resident's admission assessment failed to include the resident's Dementia and Schizoaffective Disorder diagnoses. She further confirmed the following quarterly assessment dated [DATE] failed to include the resident's diagnosis of Schizoaffective Disorder. S10MDSLPN confirmed two of the resident's MDS assessments were inaccurate.

Based on interview, observations and record review the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice as evidenced by failing to ensure medication was labeled as per physician orders for 1 (#20) resident. The deficiency had the potential to affect a census of 69 residents. Findings: Review of the facility's policy titled, Medication Administration-General Guidelines, read in part: Procedure: 1. Preparation: d. eight rights - right resident, right drug, right dose .A triple check of these rights is recommended at three steps in the process of preparation of medication administration: .3. Check #3: complete the preparation of the dose and re-verify the label against the MAR .e. prior to administration, the medication dosage schedule on the resident's electronic medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change on the direction or ., the physician's orders are checked for the correct dosage schedule. On 06/18/2024 at 8:37a.m., during an observation of medication administration to residents, Resident #20, S6LPN, observed the medication card for Potassium Chloride 20meq (Milliequivalents) was labeled take 1 &1/2 tablets (30meq) by mouth once now then resume 1 tablet by mouth once daily. S6LPN reviewed the EMR (Electronic Medical Record) physicians' orders and MAR (Medication Administration Record) and stated the physicians' orders and MAR read to give 20meq, give 2 tablets, confirming the medication card was labeled wrong. On 06/18/2024 at 09:10 a.m., a review of the physician orders and MAR was conducted with S6LPN, and S2DON (Director of Nursing). S6LPN confirmed the physician's order dated 05/17/2024 was for Potassium Chloride 20meq to give 2 tablets po (by mouth) daily, and the medication label on the card was incorrect. She also confirmed there was not another medication card with the correct label in the medication storage bin for the resident.

Based on observations and interviews, the facility failed to ensure medications were labeled to reflect medication adjustments as the physician ordered for 1 (#55) resident. The deficiency had the potential to affect a census of 69 residents. Findings: On 06/20/2024 a review of the facility's policy titled, Medication Storage with a last reviewed date of 09/28/2023, read in part, Policy: . 5. Medications will be labeled in accordance with currently accepted professional principles including expiration dated .Procedure: 1. Designated personnel will perform weekly and as needed review of medication storage areas and carts for compliance of policy Review of Resident #55's electronic health record revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, Hypertensive Heart Disease with Heart Failure, Cognitive Communication Deficits and Unspecified Pain. On 06/20/2024, a review of Resident #55's Physician Orders for June 2024 revealed the following order: Order date: 05/17/2023, start date: 05/24/2023 - Tramadol ER (extended release) 100mg (milligrams) take one tablet by mouth (po) every 12 hours (Q12H) as needed (PRN) for pain. A review of Resident #55's individual narcotics record with a date of 05/2023 revealed medication/dosage/method of administration: Tramadol i (one) po Q12H PRN. Further review revealed on 05/26/2023 at 3:40 a.m., 06/01/2023 at 4:40 p.m., 06/05/2023 at 3:07 p.m., 09/15/2023 at 7:14 p.m., 09/16/2023 at 6:00 p.m., and 09/ /2023 quantity given was i. On 06/04/2023 and 07/28/2023 at 11:30 p.m., quantity given was ii (two). Further review of Resident #55's individual patient's narcotics record with a date of 12/26/2023 revealed medication/dosage/method of administration: Tramadol 50mg ii po Q12H PRN. On 03/13/2024 at 7:30 p.m., 03/22/2024 at 7:25 a.m., 05/17/2024 at 8:00 p.m., 05/28/2024, and 06/16/2024 at 5:30 a.m., quantity given was i. Review of Resident #55's Medication card with a date of 12/26/2023 was labeled: Tramadol HCL (Hydrochloride) tab 50mg; take one tablet by mouth every 12 hours as needed for pain. On 06/20/2024 at 12:15 p.m., while conducting a CartB narcotic review with S8LPN (Licensed Practical Nurse), she confirmed the card dated 12/26/2023 for Resident #55's Tramadol read: Medication/Dosage/Method of Administration: Tramadol 50mg ii by mouth every 12 hours as needed. Amount received: 30. S8LPN also confirmed the resident was given ii Tramadol 50mg tablets for the following dates 03/16/2024 at 7:30 p.m., 03/22/2024 at 7:25 a.m., 05/17/2024 at 8:00 p.m., 05/28/2024 at 2:00 p.m. and 06/16/2024. The resident was given i Tramadol tablet on the following dates: 03/23/2024 at 7:37 a.m., 03/24/2024 at 8:33 a.m., 04/21/2024 at 8:00 p.m., 04/22/2024 at 6:00 p.m., 05/10/2024 at 10:39 a.m., 05/14/2024 at 6:00 a.m., and 05/24/2024 at 6:59 p.m. S8LPN confirmed the resident should have received ii tablets, to equal 100mg, each time the medication was administered. On 06/20/2024 at 3:30 p.m., an interview was conducted with S17RCS (Regional Clinical Specialist), she confirmed the physicians order for Resident #55 was changed on 05/17/2023 to Tramadol 100mg po Q12H po PRN for pain. S17RCS also, confirmed Resident #55 only received Tramadol 50mg on 05/26/2023 at 3:40 a.m., 06/01/2023 at 4:40 p.m., 06/05/2023 at 3:07 p.m., 09/15 at 7:14 p.m., 09/16 at 6:00 p.m., 03/23/2024 at 7:37 a.m., 03/24/2024 at 8:33 a.m., 04/21/2024 at 8:00 p.m., 04/22/2024 at 6:00 p.m., 05/10/2024 at 10:39 a.m., 05/14/2024 at 6:00 a.m., and 05/24/2024 at 6:59 p.m. S17RCS also confirmed the resident should have received Tramadol 100mg on those dates as the physician ordered.

Based on observation, record review and interview, the facility failed to provide necessary care and services that is in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered rate for 1 (#42) out of 3 (#12, #42, #71) resident reviewed for respiratory care out of a total sample of 35 residents. Findings: Resident #42 was admitted on [DATE], with diagnoses not limited to Chronic Respiratory failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Aphasia and Cognitive Communication Deficits. Review of the Resident #42's physician's orders for June 2024 revealed on 10/19/2023 an order for Oxygen (O2) at 2 L/NC (Liters per Nasal Cannula) continuous to relieve hypoxia; document oxygen saturation every shift. On 06/17/2024 at 9:18 a.m., an observation of resident lying in bed, with contractures to bilateral arms and hands, with O2 resting on resident's shoulder, a knot/kink in O2 tubing, midway between concentrator and end of nasal cannula tubing. On 06/17/2024 at 10:28 a.m., an observation of Resident #42 with S5LPN was conducted. S5LPN confirmed the O2 at 2 L/NC was in place to resident's nose. S5LPN then observed the N/C tubing and confirmed the oxygen tubing had a knot/kink in the tubing, midway between resident and concentrator. She removed the knot/kink from the tubing and confirmed the knot/kink was obstructing the oxygen flow.

Based on observations, record review and interview, the facility failed to develop a comprehensive resident centered care plan for 1 (#324) of 35 final sampled residents by failing to develop nursing interventions to address edema to both lower extremities present upon Resident #324's nursing admission assessment. Findings: Review of the facility's policy titled, Care Plan Policy and Procedure reviewed and approved by the facility on 09/28/2023, read in part: a comprehensive person-center care plan will be completed .upon admission .and as needed. It is the policy of this facility to utilize an advanced care planning approach to review and determine patient centered care plans based on the following areas .active disease process .services furnished to attain or maintain the resident's highest practicable physician, mental, and psychosocial well-being; the resident individual goals. Review of Resident #324's record revealed she was admitted to the facility on [DATE] for skilled services. The resident had diagnoses including: Chronic Obstructive Pulmonary Disease (COPD), Chronic Diastolic Congestive Heart Failure (CHF), Atrial Fibrillation and Hypertensive Heart Disease with Heart Failure. Review of the resident's progress notes for June 2024 read in part: entry dated 06/04/2024 3:01 p.m., Resident admitted to facility .swelling noted to lower extremities. Swelling to left foot and leg greater than right. Pedal pulses difficult to palpate. entry dated 06/09/2024 11:55 p.m., swelling noted to BLE (bilateral lower extremities); Legs elevated. entry dated 06/09/2024 2:22 p.m., .+3 pitting edema to BLE. Review of the resident's eMAR (electronic Medication Administration Record) with physician orders for June 2024 revealed the following: 06/04/2024 Lasix 20 mg (milligrams) po (by mouth) daily for Hypertensive Heart Disease with Heart Failure; 06/07/2024 notify NP (nurse practitioner) of wt (weight) gain greater than 2lbs (pounds); 06/14/2024 increase Lasix to 40 mg po x3 days then resume 20mg po qd (every day) 06/10/2024 increase Lasix 40 mg x3 days then resume 20 mg q day wt mwf (Monday, Wednesday, Friday) notify if >2 # (pounds) gain Further review of the eMAR revealed the severity of the resident's pitting edema was assessed by nursing staff and graded (grade 1+ indicating 2 millimeters of depression that rebounds immediately; grade 2+ indicating 3-4 millimeters of depression that rebounds in 15 seconds or less; grade 3+ indicating 5-6 millimeters of depression that rebounds in 60 seconds; and grade 4+ indicating 8 millimeters of depression or deeper that rebounds in 2-3 minutes). The resident's edema was documented as follows: +1 on 06/05/2024 - 06/06/2024; +2 on 06/07/2024 -06/08/2024; +3 on 06/09/2024 and 06/10/2024; +2 on 06/11/2024; +3 on 06/12/2024 -06/13/2024; and +4 on 06/15/2024, 06/16/2024 and 06/17/2024. Review of the CNA (Certified Nursing Assistant) Fixed Task Care Plan, which listed resident specific tasks to be completed by the CNAs, failed to reveal a task to elevate the resident's legs. Further review of the resident's record revealed no documentation present that indicated staff elevated the resident's legs daily or implemented any interventions to address the edema. Review of the resident's comprehensive care plan failed to reveal a care plan was developed with interventions to address the resident's lower extremity edema. Review of the resident's AM5 MDS (Admission Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12, indicating the resident's cognition was moderately intact. On 06/17/2024 at 11:47 a.m., Resident #324 was observed sitting in her wheelchair inside her room wearing non-skid socks with her feet planted on the wheelchair foot rests. Closer observations revealed both of the resident's feet were swollen. The resident stated her feet and ankles were always swollen even prior to her admission into the facility. She stated the swelling worsened since she'd been in the facility, in part because she did not elevate her legs as she should. She stated to help with the edema, they increased her Lasix (a diuretic) which helped a little, but swelling to her legs increased again. She further stated the current swelling was more than she was used to having in the past. When asked what else besides Lasix the facility had tried to address her edema, the resident replied, nothing that she was aware of. The resident was asked if staff elevated her legs when she was in bed or when in her wheelchair and she stated no. She stated she would elevate her legs at home and it would help with the swelling. She tried to elevate them herself while in the facility, but sometimes she forgets to do so. She stated the swelling was a little worse today because she forgot to elevate her feet last night. The resident denied that the night nursing staff would elevate or assist her with elevating her legs at night when in bed. At this time, the resident's daughter/RP (responsible party) was visiting the resident and sitting at the bedside. The resident's RP confirmed the resident always had swelling to both feet and voiced concern making the statement, maybe if they would put some pillows to elevate her legs at night it would help. At this time observations of the resident's room did not reveal any positioning aides or extra pillows in the room. There was no special attachment to the wheelchair foot rests to elevate the legs or lift the feet higher. On 06/18/2024 at 9:54 a.m., an interview was conducted with Resident #324's nurse, S15LPN (Licensed Practical Nurse) who confirmed the resident currently had swelling to both lower extremities. S15LPN reviewed the resident's record and stated there were no orders or interventions to elevate the resident's legs. She further stated she was not aware of any other interventions that specifically addressed the resident's edema. On 06/18/2024 at 10:01 a.m., an interview was conducted with S6NP (Nurse Practitioner) who stated she was the resident's provider. S6NP stated the resident had COPD/CHF and chronic edema to the bilateral lower extremities upon admission to the facility. S6NP stated she and the physician had been titrating the resident's Lasix to decrease the resident's cardiac/respiratory congestion due to her heart condition. She stated the resident's edema was chronic and did not expect it to resolve due to her diagnoses. S6NP stated nursing staff should ensure the resident's legs were elevated due to the swelling, but she was not sure if elevating the legs were included in the resident's plan of care. On 06/18/2024 at 10:11 a.m., an interview was conducted with S10MDSLPN who stated she was responsible for Resident #324's care plan. She reviewed the comprehensive care plan in full and confirmed interventions were not developed to address the resident's bilateral lower extremities edema. She further confirmed the care plan did not indicate the resident had edema to both lower extremities. On 06/18/2024 at 10:14 a.m., an interview was conducted with Resident #324's CNAs (Certified Nursing Assistant), S13CNA and S14CNA who stated Resident #324 required limited assistance and could elevate her own legs. The CNAs further stated the resident knew she needed to elevate her own legs and that they were not required to remind, prompt, or ensure the resident elevated her legs. They were not told to elevate the resident's legs nor aware of any other interventions to address the resident's edema. On 06/18/2024 at 10:32 a.m., an interview was conducted with S2DON (Director of Nursing) who stated the nurses should use nursing judgement regarding when to elevate a resident's legs and was not sure if this needed to be documented in the care plan. S2DON stated the resident could elevate her legs herself, but confirmed staff were not instructed to monitor to ensure the resident's legs were elevated. A review of the resident's progress notes was conducted with S2DON at this time. S2DON confirmed the resident was assessed by the nurse upon admission on 06/04/2024, where the nurse who assessed the resident, documented the resident had edema to both lower extremities. She reviewed the resident's comprehensive care plan and confirmed the edema to the resident's lower extremities was not addressed. On 06/18/2024 at 11:07 a.m., an interview and review of resident #324's record was conducted with S2DON and S7RCE (Regional Clinical Educator) who reviewed the resident's admission assessment dated [DATE] and confirmed the resident was admitted with edema to both lower extremities. S7RCE stated based on the nurses' assessment, a physician's order was not needed for the facility to care plan the resident for nursing interventions to address the edema. S2DON and S7RCE confirmed a care plan was not developed to address the edema and that the intervention to elevate the resident's legs should have been implemented since the resident's admission.

Based on record review and interview, the facility failed to refer a resident with a newly evident serious mental disorder to the appropriate state designated authority for Level II PASARR (Pre-Admission Screening and Resident Review) evaluation and determination for 1 of 1 (#41) residents investigated for PASARR review in a final sample of 35 residents. Findings: Review of the facility's policy titled, Pre-Admission Screening and Resident Review (PASRR) Policy and Procedure reviewed and approved by the facility on 04/12/2023 revealed in part: The purpose of the policy was to ensure completion of Pre-Admission Screening and Resident Review Level II evaluations to assess the need for .and facilitation of behavioral health services. Policy: The facility is to review the resident diagnosis and medications upon admission and throughout the resident stay to determine if a Level II request for resident review is to be completed .2. Referring all residents with newly evident or possibly serious mental disorder .5. A resident review for Level II evaluation should be considered for the following residents: Residents with tier one diagnosis Schizophrenia .is to have a completed resident review form according to OBH (Office of Behavioral Health) guidance .The resident has a new mental health diagnosis, which will not normally resolve itself once the condition stabilizes. 6. Completed forms are to be filed/scanned in the resident chart. Review of Resident #41's record revealed she was admitted to the facility on [DATE]. Review of Resident #41's pre-admission Level I PASARR application dated 08/12/2020 revealed the resident was not diagnosed with a serious mental disorder prior to her nursing home admission. Review of Resident #41's Psychiatric Evaluation by the psychiatrist dated 09/15/2020 revealed resident was diagnosed with Depression, Dementia without behavior disturbances, and Schizoaffective Disorder. Review of Resident #41's updated billable diagnoses code report revealed the resident's diagnosis of Schizoaffective Disorder had an onset date of 09/30/2020. Review of the resident's physician orders for June 2024 revealed an order dated 01/23/2023 Risperidone 0.25 mg (milligram) tab (tablet), 1 tab PO (by mouth) .look for target behaviors (getting in other resident's bed, eat my own scabs, refuse to get dressed, take water pitcher off nursing cart, take food out of trash, try to drink sanitizer, refuses to open mouth .dx (diagnosis) schizoaffective disorder. On 06/18/2024 at 8:45 a.m., an interview and review of Resident #41's PASARR records was conducted with S3SSD (Social Services Director). S3SSD stated Resident #41's pre-admission Level I PASARR was completed by the hospital the resident was admitted from on 8/12/2020. The nursing home received the Level I determination letter from the State (Form 142) on 09/10/2020 stating the resident did not qualify for Level II services. On 06/18/2024 at 1:25 p.m., an interview and record review was conducted with S7RCE (Regional Clinical Educator). She explained that according to Resident #41's records, the resident was admitted to the nursing home on 09/11/2020. The resident was diagnosed with Schizoaffective Disorder on 09/15/2020 when the psychiatrist evaluated the resident and documented the diagnosis on 09/15/2020. Another review of the resident's record failed to reveal evidence that a Level II request was submitted to OBH after the resident was diagnosed with Schizoaffective Disorder. On 06/18/2024 at 2:13 p.m., a review of the facility's PASARR policy and another review of Resident #41's record was conducted with S3SSD. S3SSD confirmed the resident was diagnosed with Schizoaffective Disorder on 09/15/2020 by the psychiatrist and with a documented onset date of 09/30/2020. She stated she was not sure if a Level II evaluation was sent at that time and confirmed according to the facility's policy, the paperwork should have been submitted to OBH. On 06/18/2024 at 4:59 p.m., a follow-up interview was conducted with S3SSD who stated she contacted OBH who informed her that due to the resident's newly identified Tier 1 diagnosis of Schizophrenia Disorder, the facility was required to submit a request for Level II since 2020. She further confirmed a Level II request had not been submitted for the resident and the resident currently required evaluation for services.

Based on record review and interview, the facility failed to ensure the resident and/or resident's representative (RP) exercised the right to appropriately make informed decisions regarding the right to choose a provider of their preference for hospice services for 1 (#28) of 4 (#5, #7, #28, #42) residents investigated for hospice services in a final sample of 35 residents. Findings: Review of the facility's policy titled, Resident Rights and Quality of Life Policy and Procedure reviewed and approved by the facility on 08/22/2022 revealed in part: Resident's rights will be explained to the responsible party or legal guardian as appropriate. The resident has the right to .be informed in advance about care and treatment .freedom of choice of providers. Resident #28 Review of the resident's record revealed she was originally admitted to the facility on [DATE], then readmitted to the facility on [DATE]. The resident's diagnoses included Heart failure, Chronic obstructive pulmonary disease (COPD), Respiratory failure, Presence of cardiac pacemaker, Dementia, and Cognitive communication deficit. Review of the resident's significant change MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 7, indicating severe cognitive impairment. Further review of the resident's record revealed the resident received hospice services elected by the resident's daughter/RP with the facility's contracted hospice provider for a terminal diagnosis of COPD from 2/12/2024 until 5/29/2024. The resident was placed on palliative care with another hospice provider not contracted with the facility on 05/30/2024. Review of the resident's physician orders revealed: 02/12/2024 admit to (the facility's contracted hospice provider name) for a terminal diagnoses of COPD; 05/10/2024 d/c (discharge) from (the facility's contracted hospice provider name); 05/29/2024 consult with (hospice provider name of which the facility did not have an existing contract agreement). Review of the facility's grievances in the last 120 days revealed Resident #28's daughter/responsible party (RP) filed a complaint on 05/23/2024. Subject: Do not want (the facility's contracted hospice provider name) services. Review of the resident's grievance report dated 05/23/2024 revealed Resident #28's RP reported to S3SSD (Social Services Director) that she did not want (the facility's contracted hospice provider name) to follow-up with her mother's care when her mother returned to the facility. On 06/20/2024 at 9:45 a.m., a phone interview was conducted with Resident #28's RP who stated her mother had Dementia, was confused at times and was not able to answer appropriately nor make sound decisions for herself. She confirmed she made decisions on the resident's behalf including signing paperwork on the resident's behalf. She stated her mother had a decline in functioning and was ill therefore she elected to hospice services after consultation with the medical provider. The RP stated at the time she was made aware her mom was a hospice candidate, she initially met with an employee of the nursing home for consultation. She stated the nursing home only presented their contracted hospice provider. She was not informed of any other hospice agency providers nor that she had the right to choose the hospice provider of her choice. Because her mom needed the hospice services, she signed up to have the facility's contracted provider admit her mom to hospice. She stated the facility's contacted hospice provider staff rushed through the paperwork, did not explain anything to her fully, and also did not make her aware of the right to choose other providers. She was just told to sign all these papers with not fully understanding what any of the paperwork meant. The RP stated on 05/11/2024 around 4:15 p.m., she became dissatisfied with the hospice provider's nurse and revoked hospice services to allow her mother to be transfer to the ER evaluation and further treatment. It was then that a personal friend of hers informed her she had a right to choose which hospice provider she wanted. The RP expressed that she was upset finding this out from her friend and that had the nursing home informed her of rights she never would have elected to hospice from their contracted provider. She proceeded to file a grievance with S2DON (Director of Nursing) which led to the nursing home informing her at that she was able to obtain an individual contract with the hospice provider of her choice. The RP further stated that had she been aware of her rights, she would have researched other hospice providers before making a decision. Further review of Resident #28's record was conducted with review of the progress notes and social services notes for January 2024 - February 2024 which revealed in part: 02/08/2024 1:53 p.m., entry by S3SSD- Resident's RP has a conference with (the facility's contracted hospice provider name) on Monday. She will decide if she needs to be a hospice patient. 02/12/2024 entry by S3SSD- Resident #28 was admitted under (the facility's contracted hospice provider name) hospice services today. Further review of the notes failed to reveal any evidence the nursing home informed the resident's RP of her right to choose other hospice providers. 06/20/2024 at 3:07 p.m., an interview was conducted with S3SSD who was the facility's designated staff to provide initial hospice education and set up hospice consults for the families. During her meeting with the family, she informs them they have a right to choose hospice providers and are provided information of other hospice providers available to them. She further stated the facility had an agreement with one hospice agency, but the resident/RP could choose another provider if they opted to do so. S3SSD stated she did not document the details of the family meetings and could not provide any evidence that the resident/RP was notified of the right to choose a provider of their choice. On 06/20/2024 at 3:48 p.m., an interview was conducted with S1ADM (Administrator) who stated the family/resident/RP should be informed of their right to choose a hospice provider upon the education consult with S3SSD. 06/20/2024 04:58 p.m., S2DON confirmed resident should be informed of right to choose hospice providers including being made aware of a list of companies in which to choose during their educational consult with S3SSD. She was informed there was no documented evidence in the records to show Resident #28's RP was informed of their right to choose a provider of their choice for hospice services.

Based on observation, record review and interview, the facility failed to ensure its medication rate was not 5 percent or greater as evidenced by a calculated medication error rate of 41.68%. Findings: Review of the facility's policy titled, Medication Administration: General Guidelines. The policy read in part: d. Eight Rights--right resident, right drug, right dose, right route, right time, right reason, right documentation and right response are applied for each medication being administered . f. Tablet splitting: if breaking tablets is necessary to administer the proper dosage .the following guidelines are followed: . iv. since un-scored tablets may not be accurately broken, their use is discouraged if a suitable alternative is available. v. Where possible, the provider pharmacy is requested to package half tablets or the prescriber is contacted for an alternative dosage form (e.g. liquid) or therapeutic equivalent that does not require splitting k. A scheduled of routine dose administration times is established by the facility and utilized on the administration record . i. Medications are administered between one (1) hour before and one (1) hour after scheduled time, except before, with or after meal orders . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. Review of the facility's medication administration schedule reveled the following scheduled times: QD (every day)-8 a.m.; BID (twice a day)-8 a.m./8 p.m.; TID (three times a day)---8 a.m./12p.m./4p.m or 8a.m./4p.m./12p.m.; QID (four times a day)-8a.m./12p.m./4p.m./8p.m.; Pril (Prilosec)/Syn (Synthroid)-6a.m.; HS (hour of sleep)-9p.m.; AC (before meals)-7a.m./11a.m./4p.m Resident # 18 Resident #18 was admitted to the facility on [DATE] with the following diagnoses in part: Type 2 Diabetes Mellitus, Angina Pectoris, GERD, Rheumatoid Arthritis, Essential Hypertension and Generalized Anxiety Disorder. Review of Resident #18's May 2023 physician's orders revealed the following orders: Accucheck (finger stick for blood sugar) BID, Levemir (insulin) 100 unit/ml vial-Give 20 units Subq (subcutaneous) QD; Azelastine HCL 0.05% drops-give one drop in each eye; Review of Resident #18's May 2023 eMAR (Electronic Medication Administration Record) revealed the following medications orders and administration schedule (Time code): accuchecks-Q127 ( every 12 hours-7 a.m. and 7 p.m.), Levemire-QD7 ( every day at 7 a.m.) and Azelastine-Q128 (every day at 8 a.m.) Review of the Resident #18's medication administration history for 05/23/2023 revealed the following: accucheck was conducted at 9:43 a.m. and Levemir was administered at 9:43 a.m. by S2DON. Resident #45 Resident #45 was admitted to the facility on [DATE] with the following diagnoses in part: Essential Hypertension, Dry Eye Syndrome Of Bilateral Lacrimal Glands and Injury Of Conjunctiva And Corneal Abrasion. Review of Resident #45's May 2023 physician's orders revealed the following medications orders and administration schedule (Time code): Simbrinza 1%-0.2% eye drop-1 gtt (drop) to eft eye TID-TID 848 (three times a day at 8 a.m., 4 p.m. and 8 p.m.) Review of Resident #45's May eMAR revealed that her Simbrinza eye drops were scheduled for 8:00 a.m., 4:00 p.m. and 8:00 p.m. Review of the Resident #45's medication administration history for 05/23/2023 revealed the following: Simbrinza eye drops were not administered until 9:25 a.m. Resident #51 Resident #51 was admitted to the facility on [DATE] with the following diagnoses in part: End Stage Renal Disease, Essential Hypertension, Magnesium Deficiency, Depression, Type 2 Diabetes Mellitus, Urinary Tract Infection, Edema, Unspecified Atrial Fibrillation, Allergy, Wheezing, Rash And Other Nonspecific Skin eruption and Dry Mouth. Review of Resident #51's May 2023 physician's orders revealed the following orders and administration schedule (Time Code): Accuchecks BID with Humulin R (Regular) insulin sliding scale-Q12H7 (every 12 hours at 7 a.m. and 7 p.m.): Humulin 70-30 vial-give 15 units subq (subcutaneous) qAM (every morning) and qHS (every hour of sleep) Torsemide 20mg (milligram) QD8 (every day at 8a.m.) Metolazone 5mg tablet--QD8 Digoxin 0.25mg tablet--QD8 Acidophilus with Prectin--QD8 Claritin10mg tablet--QD8 Fluticasone Propionate 50 mcg (microgram) spray--QD8 Advair 250-50-diskus--Q12H6 (every 12 hours at 6a and 6P) Eliquis 2.5mg tablet- Q12h8--(every 12 hours at 8 a.m. and 8 p.m.) Hydroxyzine HCL (Hydrochloride) 50mg-Q12H8 Biotene Dry Mouth Oral Rinse Mouthwash: oral every 12 hours (8a and 8p) every day Toprol XL 25mg-Q12h8-(every 12 hours 8 a.m. and 8 p.m. Magnesium 200mg-QD7 (every day at 7 a.m.) Fluoxetine HCL 40mg-QD8 (every day at 8 a.m.) Wellbutrin SR (sustained-release) 100mg-Q12H8 Review of the Resident #51's medication administration history for 05/23/2023 revealed the following: 1. Medications scheduled for 6 a.m. were administered at the following times: Advair 250-50 Diskus: 10:40 a.m. 2. Medications and Accucheck scheduled for 7 a.m. were administered and conducted at the following times: Accucheck: 10:15 a.m. Humulin 70/30-15 units- 10:15 a.m. Magnesium 200mg-10:15 a.m. 3. Medications scheduled for at 8 a.m. were administered at 10:15 a.m. Metolazone 5mg (milligrams) Digoxin 0.25mg Acidophilus with Prectin Claritin10mg tablet- Fluticasone Propionate 50 mcg (microgram) spray Eliquis 2.5mg Hydroxyzine HCL (Hydrochloride) 50mg Biotene Dry Mouth Oral Rinse Mouthwash: Toprol XL 25mg Fluoxetine HCL 40mg Wellbutrin SR (sustained-release) 100mg tablet A review of the below resident's eMAR (electronic medication adminsitration record) revealed the following: Resident #6 had six 9 a.m. medications administered at 11:06 a.m. Resident #7 had five 8 a.m. medications administered at 10:32 a.m. Resident #10 had five 8 a.m. medications administered at 10:55 a.m., one 8 a.m. medication administered at 11:36 a.m. Resident #11 had eight 8 a.m. medications administered at 11:10 a.m., four 8 a.m. medications administered at 11:20 a.m. and his 8 a.m. CBG (capillary blood glucose) was done at 11:25 a.m. Resident #15 had one 8 a.m. and eight 9 a.m. medication administered at 11:14 a.m. Resident #22 had eight 8 a.m. medication administered at 10:37 a.m. and one 8 a.m. medication administered at 11:07 a.m. Resident #27 had seven 8 a.m. medications administered at 10:49 a.m. Resident #28 had six 8 a.m. medications administered at 10:45 a.m. Resident #37 had two 8 a.m. and six 9 a.m. medications administered at 10:52 a.m. Resident #42 had eleven 8 a.m. medications administered at 10:57 a.m. Resident #61 had one 7 a.m. and four 8 a.m. medications administered at 10:31 a.m. Resident #118 had four 7 a.m. and two 8 a.m. medications administered at 11:03 a.m., one 8 a.m. medication administered at 11:04 a.m. and one 8 a.m. medications administered at 11:26 a.m. Resident #370 had one 7 a.m. and five 8 a.m. medications administered at 11:01 a.m. On 05/23/23 at 8:06 a.m., a medication administration observation was conducted with S15LPN. S15LPN attempted to administer Resident #45's eye drops. The resident informed the nurse that they normally put a clear eye drop before the Simbrinza eye drops. The nurse informed the resident that she would have to go check for the other eye drops. S15LPN went to the nurse's station and did not return back to her medication cart until 8:40 a.m. She administered the resident the clear eye drops and informed the resident that she would have to wait 5 minutes before she could administer the Simbrinza eye drops. At 9:00 a.m., S15LPM proceeded to prepare the medications for Resident #51. As she opened her computer, a list of medications were highlighted late in red were observed. This included an Accucheck and insulin which should have been done at 7 a.m. S15LPN was asked if the medications were late and she stated yes. S15LPN was asked why she was late with her medication administration. She stated that she became busy at the beginning of her shift and this caused her to be late giving the resident's their medications. S15LPN was asked if she informed S2DON that she was late with administering the residents their medications. She stated, I like to do things independently and take care of it myself. As S15LPN prepared Resident #51's medication, she discovered that Resident#51's Acidophilus and Wellbutrin was not in the medication cart. S15LPN called from her headset and asked if someone could bring her Resident #51's Acidophilus. She stated that the stock bottle of Magnesium tablets were 400mg and the resident took 200mg. S15LPN locked her medication cart and walked to the nurse's station to get the correct Magnesium dose. On 05/23/2023 at 9:15 a.m., while waiting for S15LPN to return to the medication cart, Resident #18 was observed propelling himself down the hall in his wheelchair towards the medication cart. He was upset he had missed some of the activities this morning because the S12LPN told him after breakfast to wait in the room for her so she could administer his eye drops. He stated that the nurse had not come yet. He stated when that nurse works, which is once a week, she was always late with the medications. During the conversation with Resident #18, Resident #45 was observed in the doorway of her room asking this surveyor where S15LPN was because she had not come back to put her second eye drops. On 5/23/2023 at 9:20 a.m., S15LPN returned to her medication cart with a pill cutter and stated that she could not find the Magnesium in 200mg. She stated she would have to cut the Magnesium 400mg tablet in half. The Magnesium 400mg tab was not scored. S15LPN cut the tablet with the pill cutter and placed an unevenly divided half of the tablet in Resident #41's medication cup. S15LPN called again on her headset for someone to bring Resident #51's Wellbutrin. S2DON came to S15LPN's medication cart and informed her that Resident #51 was out of Wellbutrin and someone was going to the pharmacy to pick some up. At that time, an interview was conducted with S2DON who stated that S15LPN was behind on her medication administration because she had a resident on her hall that had fallen that took time for her to resolve. She stated that herself and/or the S2DON, if requested, would normally assist with medication administration when the nurses had an emergency they need to take care of that may cause them to be behind on administering their medications. S2DON stated that was unaware that S15LPN had fallen behind on her medication administration. S2DON was informed by this surveyor, S15LPN was late with her mediation administration. At that time, S2DON asked S2LPN if she was late with her medication pass. S2LPN confirmed the she had not administered medications to most of the residents on the hall. S2DON stated that she would assist with the medication administration. On 05/23/23 at 9:30 a.m., S2DON conducted Resident #18's blood sugar which was due since 7 a.m. The resident's CBG was 176. She also applied Artificial Tears and Azelastine HCL 0. 05% to both of eyes, which was due at 8 a.m. On 05/23/2023 at 10:00 a.m., S15LPN administered Resident #51's medications. She was asked if she should have cut the Magnesium 400 mg tablet since it was not scored and how could she ensure that she administered the correct dose since the Magnesium tablet was not scored. She stated, I used the pill cutter. On 05/23/2023 at 10:20 a.m., a review of the eMAR for Resident #6, Resident #7, Resident #10, Resident #11, Resident #15, Resident #22, Resident #27, Resident #28, Resident #37, Resident #42, Resident #61, Resident #118 and Resident #370 were reviewed with S15LPN. She confirmed that the medications for those residents that were highlighted in red meant marked late meant that she had not administered the residents their medications yet. 47965

Based on observation, interview and record review, the facility failed to ensure sufficient nursing staff with the appropriate competencies and skills set to provide nursing services to assure resident safety and attain the highest practicable physical well-being. This was evidenced when: 1. S8LPN (Licensed Practical Nurse) failed to write standing orders into Resident #12's electronic record, failed to document that a PRN (as needed) pain medication had been administered, failed to assess the resident's pain level prior to administration of the PRN medication, and failed to conduct a follow up evaluation of effectiveness of the PRN pain medication; 2. S14LPN (Licensed Practical Nurse) failed to follow the physician's parameters for administration of Metoprolol Tartrate medication for Resident #39; and 3. S15LPN failed to complete timely medication administration for 16 (#6, 7, 10, 11, 15, 18, 22, 27, 28, 37, 42, 45, 51, 61, 118, 370) residents during the morning medication pass on 05/23/2023, and she failed to ensure the correct dosage of Magnesium 200 mg was administered to Resident #51, when she cut an unscored 400 mg Magnesium tablet, for 18 residents investigated, of a total of 45 sampled residents. Findings: 1. Resident #12: A review of Resident #12's annual MDS (Minimum Data Set) assessment dated [DATE] revealed that she had occasional pain. A review of Resident #12's diagnoses included Pain, and Recurrent oral aphthae ulcer. On 05/22/2023 at 2:18 p.m., S8LPN entered into Resident #12's room and administered a medication. She reported to this surveyor that the medication she had administered was a PRN (as needed) pain medication. On 05/23/2023, a review of Resident #12's physician's orders failed to reveal an order for PRN pain medication. On 05/23/2023, a review of Resident #12's MAR (Medication Administration Record) for May 2023 failed to reveal that a PRN pain medication had been administered on 05/22/2023. Further review of Resident #12's record failed to reveal that the resident was assessed for pain before S8LPN administered the PRN pain medication on 05/22/2023 at 2:18 p.m. Further review of the record failed to reveal that an evaluation of effectiveness had been assessed after S8LPN administered the medication. On 05/23/2023 at 3:00 p.m., an interview was conducted with S8LPN. She reviewed Resident #12's echart (electronic) orders and confirmed that there was no order for PRN pain medication in the residents chart. She continued to review the echart and noted a PRN order for the medication Zofran, and stated that she thought it was a PRN order for Tylenol. She produced a PRN standing order for Acetaminophen (Tylenol). She reviewed the resident's MAR and confirmed that there was no evidence that she had administered the PRN standing order for Acetaminophen. S8LPN stated that she should have written the standing order into Resident #12's echart so it would have shown up on the MAR, and had failed to do so. She confirmed that she had failed to document that she had administered the PRN Acetaminophen, and had failed to assess the resident's pain before and after the administration of the medication, and that she should have. On 05/23/2023 at 4:00 p.m., an interview was conducted with S20ADON. She stated that S8LPN should have written the standing order for Acetaminophen into the resident's echart and failed to do so. She stated that since the order had not been written in, there was no ability to document that the PRN medication had been administered, nor the ability to assess a pain level before administration, or evaluate the effectiveness of the pain medication afterwards. 39319 Review of the facility's policy titled, Medication Administration: General Guidelines. The policy read in part, Procedure: . d. Eight rights--right resident, right drug, right dose, right route, right time, right reason, right documentation and right response are applied for each medication being administered . f. Tablet splitting: if breaking tablets is necessary to administer the proper dosage .the following guidelines are followed: . iv. since un-scored tablets may not be accurately broken, their use is discouraged if a suitable alternative is available. v. Where possible, the provider pharmacy is requested to package half tablets or the prescriber is contacted for an alternative dosage form (e.g. liquid) or therapeutic equivalent that does not require splitting . k. A scheduled of routine dose administration times is established by the facility and utilized on the administration record. l. Medications area administered between one (1) hour before and one (1) hour after scheduled time, except before, with or after meal orders . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. m. Medications designed to be administered over a 24-hour period (ex. sustained -release) are scheduled accordingly. On 05/23/2023 at 8:06 a.m., S15LPN administered Resident #45's Artificial Tears eye drops per the resident's request. She informed the resident that she would have to wait 5 minutes before she could administer her Simbrinza eye drops, which was due at 8AM. S15LPN did not return until 9:25 a.m. to administer the resident's Simbrinza eye drops. On 5/23/2023 at 9:00 a.m., S15LPN proceeded to prepare the medications for Resident #51. As she opened her computer a list of medications were highlighted late in red were observed. This included an accucheck (finger stick for blood sugar) and insulin which should have been administered at 7 a.m. S15LPN was asked if the meds were late and she stated yes. S15LPN was asked why she was late with her medication administration. She stated that she became busy at the beginning of her shift and this caused her to be late giving the resident's their medications. S15LPN was asked did she inform the S2DON that she was late with her medication administration. She stated, No, I like to do things independently and take care of it myself. As S15LPN prepared Resident #51's medication, she discovered that the stock bottle of Magnesium tablets were 400 mg (milligrams) and the resident was prescribed Magnesium 200 mg. S15LPN then locked her medication cart and walked to the nurse's station to get the correct Magnesium dose. On 05/23/2023 at 9:15 a.m., Resident #18 was observed propelling himself down the hall in his wheelchair towards the medication cart. He was upset he had missed some of the activities this morning because the S15LPN told him after breakfast to wait in the room for her so she could administer his eye drops. He stated that the nurse had not come yet. He stated when that nurse works, which is once a week, she is always late with the medications. Resident #45 was observed in the doorway of her room asking where S15LPN was because she had not come back to put her second eye drops. On 5/23/2023 at 9:20 a.m., S15LPN returned to her medication cart with a pill cutter and stated that she could not find the Magnesium in 200 mg. She stated she would have to cut the Magnesium 400 mg tablet in half. The Magnesium 400 mg tablet was not scored. S15LPN cut the tablet with the pill cutter and placed an unevenly divided half of the tablet in Resident #41's medication cup. At that time, an interview was conducted with S2DON who stated that S15LPN was behind with medication administration because she had a resident on her hall that had fell which took time for her to resolve. She stated that herself and/or S20ADON(Assistant Director of Nursing), if requested, would normally assist with medication administration when the nurses have an emergency they need to take care of that may cause them to be behind on their medication adminstration. She stated that was unaware that S15LPN had fallen behind with administering the resident's their medications. On 05/23/2023 at 10:00 a.m., S15LPN administered Resident #51's medications that included the unevenly cut 400 mg Magnesium tablet. She was asked if she should have cut the Magnesium 400 mg tablet since it was not scored and couldn't ensure that she administered the correct dose since the Magnesium tablet was not scored. She stated, I used the pill cutter. On 05/23/2023 at 10:20 a.m., a review of the eMAR (Electronic Medication Administration Record) for Resident #6, Resident #7, Resident #11, Resident #10, Resident #15, Resident #22, Resident #27, Resident #28, Resident #37, Resident #42, Resident #61, Resident #118 and Resident #370 were reviewed with S15LPN. She confirmed that the medications for those residents were highlighted in red meant late and that she had not administered those residents their medications, which were due at 7 a.m., 8 a.m. and 9 a.m. On 05/23/2023 at 3:30 p.m., a second interview was conducted with the S2DON. She stated that the pharmacy used to send Resident #51's Magnesium in 200 mg tablets pre-packaged. She stated she didn't know why they were no longer received that way. She stated they started using an OTC (over the counter) stock bottle of Magnesium 400 mg tablets. When asked if S15LPN should have used the pill cutter to divide the 400 mg Magnesium tablet since it was not scored, S2DON confirmed that S15LPN should have first attempted to get the correct dose of Resident #51's Magnesium medication (200mg) from the pharmacy before she used the pill cutter. S2DON was asked how S15LPN could ensure that she had divided the tablet evenly since the tablet was not scored. S2DON stated if she used the pill cutter correctly then it should have divided the tablet evenly. 41419 Resident #39 Review of the resident electronic record revealed an admitted [DATE] with diagnoses that included Acute on chronic systolic congestive heart failure, and Unspecified protein calorie malnutrition. Review of Resident #39's physician orders dated 05/2023 read in part Metoprolol Tartrate 50 mg (milligrams) give 1 tab by mouth twice daily. Hold if blood pressure is less than or equal to 100 and or pulse is less than or equal to 60. Review of the Electronic Medication Administration Record (EMAR) dated 05/2023 revealed that on 05/02/2023, 05/07/2023, 05/10/2023, 0512/2023, 05/15/2023, 05/16/2023, and 05/23/2023 Resident #38 was administered Metoprolol Tartrate 50 mg when her pulse was 60. On 05/24/2023 at 3:00 p.m., an interview was conducted with S14LPN (License Practical Nurse) who stated that the order for metoprolol is if the pulse is less than 60, then hold metoprolol. A review of the physician orders and vital signs sheet for 05/2023 was conducted with S14LPN, who confirmed that when the resident's pulse is less than or equal to 60, then the metoprolol should not have been given.

Based on interviews, observations and record reviews, the facility failed to ensure a resident was free from accidents hazards during a mechanical lift transfer for 1 (#1) out of 5 (#1, #2, #3, #4 and #5) sampled residents who required two-person transfer with a mechanical lift. The deficient practice resulted in an actual harm for Resident #1 on 7/26/22 at 6:00 a.m., when S3RA (Resident Assistant) used a mechanical lift to transfer the resident from the bed to the chair, from the chair to the shower bed, and from the shower bed to the chair without the assistance of another person. Resident #1 fell from the lift sling during the transfer from the shower bed to the chair and landed on the floor in the shower room hitting the back of his head. The resident sustained a hematoma to the back of his head and was transferred to the hospital. S3RA neglected to follow the resident's care plan of using two-person staff assistance to transfer the resident via mechanical lift. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's Transfer of Resident Using a Hoyer Lift Policy and Procedure revealed in part, Procedure: 1. Two people should assist in transfer involved in resident being lifted via hoyer lift. Review of Resident #1's medical record revealed that he was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], Type 2 Diabetes Mellitus, Unspecified Lack Of Coordination, Muscle Weakness, Cerebral Infraction and Unspecified Abnormalities Of Gait and Mobility. Review of Resident #1's MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 06/24/22 revealed the following in part, under Section C: Cognitive Patterns a BIMS (Brief Interview of Mental Status) score of 10, which indicated that the resident had moderately impaired cognition. Under Section G: Functional Status, the resident required extensive assistance with two+ person physical assist with bed mobility and transfers. Review of Resident #1's current Plan Of Care revealed the following in part that the resident required staff assistance with ADLs (Activities of Daily Living) due to Cerebral Infarction with left sided weakness and limited range of motion to bilateral upper and lower extremities. He required a mechanical liter with all transfers times two person assist. Start date 06/15/22. Review of the resident's nursing note dated 7/26/22 at 11:46 a.m. revealed that at approximately 6 a.m., the nurse was called into the shower room by S3RA. She observed the resident on the floor lying on his back on the side of the trolly shower bed and in front of the hoyer lifter. Resident was assessed .a small hematoma was noted to the center back of the resident's head .resident was asked if he was in pain and he stated that his head .change in mental status was noted .unable to hold attention of resident .had to repeat questions multiple times to get an answer .VS (Vital Signs) were obtained .resident transferred into bed and VS and mental status reassessed. Resident was more confused than usual and unable to focus .Resident sent out to the emergency room for evaluation .educated the RA on importance of two person assist when transferring, bathing or toileting residents who require two person assistance and hoyer lift and maintaining all safety at all times. Review of the resident's nursing note dated 7/26/22 at 3:53 p.m. revealed the resident returned to the facility from emergency room observed resident being brought in on stretcher and he was vomiting. Stated he was feeling nauseated Review of the resident's nursing note dated 7/27/22 at 4:18 p.m. read in part, 4:00 p.m., resident was on 72-hour neurological observation due to fall. He is awake, alert and oriented to person but complain of nausea. He did have a vomiting episode at 2 p.m . his color is pale, pupils equal in reaction to light and able to follow instruction but said that something doesn't feel right .pain to back of head .NP (Nurse Practitioner) was made aware and requested to send out to emergency room for evaluation due to trauma yesterday . Review of the hospital records revealed that a CT (Computed tomography) scan was conducted on 7/27/22 for complaint of headache, sudden, severe; head trauma 1 day ago. The findings included in part, a near CSF (Cerebral Spinal Fluid) density subdural collection on the right indicating enlarging subdural hygroma (a collection of CSF, without blood, located under the [NAME] membrane of the brain. Commonly seen in the elderly after a minor trauma) with development of 2-3 mm (millimeter) right-to-left midline shift. Review of the facility's Investigative Report date 7/26/22 revealed that nurse was called to the shower room at approximately 6AM and observed the resident lying on his back on the floor next to the trolly shower bed and in front of the hoyer lifter. Hematoma was noted to the back center of the resident's head. Resident was assessed and assisted from floor into geri chair. Assessed vital signs, level of consciousness and mental status. Sent to emergency room for evaluation. Review of the facility's Self Report dated 7/26/22 under Incident Investigation revealed based on a statement by S3RA, she failed to wait for assistance to transfer the resident when she went to get the resident for a shower and transferred him from the bed to the chair. She failed to wait for assistance when she transferred the resident from the chair to the shower bed and failed to wait for assistance when she transferred the resident from the shower bed to the chair. Her last competency for hoyer lift was 3/2/22. Further review revealed that the shower floor and equipment were examined with no issues. It was determined that S3RA did not follow proper procedure for hoyer lift transfers which is a two person assist. S3RA was terminated from the facility due to failure to follow and comply with facility policy and procedure for hoyer lift. A referral was made to the CNA/DSW (Certified Nurse Aid/Direct Service Worker) Registry for a substantiated allegation of neglect. Several attempts were made to contact S3RA which were unsuccessful. An interview with S2RAS was conducted on 9/6/22 at 2:45 p.m. S2RAS stated that she was present when the incident with the resident occurred. She stated that she heard when S3RA called for assistance with her headset. She stated that headset are used by the staff to communicate with each other instead of staff having to go and look for someone. S2RAS stated everyone can hear when someone used the headset. She stated that she responded to S3RA's call and informed her that everyone was busy at the moment, even herself and to wait for someone to come assist. She stated that she also instructed S3RA not to lift the resident alone. She stated that S3RA was trained and competent on using the hoyer lift and was aware there should be two persons at all times when using the lifter. An interview was conducted with S1DON on 9/6/22 at 3 p.m. S1DON stated the nurse called her and informed her that Resident #1 had fallen from the lifter in the shower. She stated that S3RA informed her that she had called for help but no one came to assist her. She confirmed that S3RA performed three separate lifts without assistance. She stated that she checked the schedule and determined there were enough available staff to assist S3RA with the transfers. S1DON stated S2RAS informed her that she had informed S3RA to wait until someone could come and assist. S1DON stated S3RA just didn't wait for assistance. She stated that S3RA was sent home on suspension pending the facility's investigation. After the investigation was completed, S3RA was terminated because she failed to follow facility policy and procedure for a hoyer lift. S1DON stated that all staff were in-serviced, including S3RA, on 7/26/22 that hoyer lifters are two person assist at all times and not to proceed with lift if there are not two people present. Staff have been informed to call a timeout and request for assistance if no one is available to help before using the hoyer lift alone. She stated that they conducted in-servicing through video with a post-test on proper hoyer lifting and competency checks with return demonstrations were conducted on all staff on the use of the hoyer lifter by herself or the RA Supervisor. Routine inspection were done of the hoyer lifts and pad for frays and tears prior to using them. Maintenance checked all lifters and pads weekly and then a general inspection was done monthly. The laundry department was also utilized as a back-up to inspection the hoyer pads for frays and tears. Ten audits per week on the hoyer lifter were performed by herself or the RA Supervisor. Multiple CNAs and nurses were interviewed between 9/6/22 - 9/7/22 about the use of the mechanical lift. All staff confirmed they have been trained on the facility's policy and procedure for use of the mechanical lifts, have watched a video on the use of mechanical lift and have had competency checks with return demonstrations conducted. They also confirmed that the DON, ADON (Assistant Director of Nursing) and the RA Supervisor conducted random visual checks of the staff performing a lift on a resident. Observations were made on 9/6/22 and 9/7/22, of the staff operating the mechanical lift effectively. Two and/or three person assisted with all lifts. The facility has implemented the following actions to correct the deficient practice: Quality Assurance Action Plan: 1. Employee removed from work until investigation is complete. Terminated 8/1/22 2. 7/26/22--Began education/re-education to all CNAs on hoyer lift transfers policy and procedure and began hoyer lift demonstration with return demonstration for competency in use of hoyer lifter will all CNAs. Re-educated on how to read kiosk for ADLs/transfer of residents 3. Ongoing inspection of lifter and lifter pads by CNA staff, laundry and maintenance. Timeout prior to using hoyer lifter for transfers until 2 staff members are present. 4. Monitoring performed by conducting ten hoyer lifter audits weekly per DON/CNA Supervisor. 9/1/22--All staff have received re-education on hoyer lift transfer with 2 person assist and monitoring conducted and documented with ongoing monitoring continued. QA process will end if no injuries occur with hoyer transfers.

Based on record reviews and interviews the facility failed to assure that each resident receives the necessary care and services to maintain the highest practicable physical and mental well-being during three consecutive nursing shifts for 1 out of 30 sampled residents (resident #66). This deficient practice had the potential to affect 37 residents that were diagnosed with [REDACTED]. The facility failed to: 1. immediately notify the physician of resident #66 ' s low blood pressures on three consecutive nursing shifts; 2. immediately notify the physician of a change in resident #66 ' s decline in mental status; 3. immediately notify the physician of resident #66 ' s oxygen saturation level of 79%; 4. ensure that oxygen was administered to resident #66 as ordered by the physician; Resident # 66 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 2:00 p.m. resident #66 ' s blood pressure was ,[DATE]. Resident #66 was placed in Immediate Jeopardy when S8 LPN failed to notify the physician of the decrease in blood pressure. At 7:00 p.m. on [DATE] the resident ' s blood pressure was ,[DATE]. Resident #66 remained in Immediate Jeopardy on [DATE] at 1:30 a.m. when his blood pressure was ,[DATE], his oxygen saturation level was 79 percent, skin color was pale, and he was having trouble breathing. S9 LPN failed to notify the physician of a significant change in resident #66 ' s condition. On [DATE] at 11:00 a.m. this resident ' s blood pressure was ,[DATE] and he was very confused and disoriented. Resident #66 ' s physician was not notified of these changes. On [DATE] at 12:00 p.m. the physician was notified of resident #66 ' s blood pressure of ,[DATE] and an order was given to send him to the emergency room . The immediate jeopardy situation ended when resident #66 was sent out to the emergency room to receive a higher level of care. On [DATE] at 3:00 p.m. the emergency room called and reported that resident #66 died within two hours of arrival to the emergency room . Findings: Record review of resident #66's clinical record revealed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Record review of resident #66 physician's order [REDACTED].@ 2 L (liter) /min (minute), [MEDICATION NAME] 6.25 mg i po BID 7:00 a.m., and 7:00 p.m. and [MEDICATION NAME] 10 mg i po qd 7:00 a.m. Record review of resident #66 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the Nurses Notes on the following dates revealed: 1. [DATE] a.m. revealed resident #66 was receiving O2 per NC @ 3L/min, there was no documentation that the doctor ordered the oxygen increased to 3 liters; 2. [DATE] at 2:00 p.m. BP ,[DATE], P47, R18, Temp 96.4, there was no documentation that the doctor was notified of the low blood pressure and no documentation that the blood pressure was retaken or monitored; 3. [DATE] at 7 p.m. BP ,[DATE], P64, R24, Temp 97, there was no documentation that the doctor was notified of the low blood pressure and no documentation that the blood pressure was retaken or monitored; 4. [DATE] at 11:00 p.m. revealed resident #66 was receiving O2 per NC @ 3L/min there was no documentation that the doctor ordered the oxygen increased to 3 liters; 5. [DATE] at 1:30 a.m. BP ,[DATE], R16, O2 Sat 79%, color pale, resident c/o having trouble breathing, O2 @ 4 liters, there was no documentation that the doctor was notified of the low blood pressure, no documentation that the blood pressure was retaken or monitored, no documentation that the low oxygen saturation or paleness was reported to the doctor, and oxygen increased and no documentation that the physician was notified to increase the oxygen. 6. [DATE] at 11; 00 a.m. Resident's mental status declining noted very confused & disoriented. CBG (capillary blood glucose) taken @87. CVS (complete vital signs) taken BP ,[DATE], P47, R18, T96.4. Fluids encouraged. ATB (antibiotics) therapy cont for UTI (Urinary tract infection), Pneumonia, and [MEDICAL CONDITION]. There was no documentation that the doctor was notified of the low blood pressure or slow pulse, no documentation that the declining mental status was reported to the doctor, and no documentation that the blood pressure was retaken or monitored; 7. [DATE] at 12:00 p.m. Resident more confused. CVS taken BP ,[DATE], P120, notified S13, Send to ER(emergency room ) for evaluation; 8. [DATE] at 12:15 p.m. .... phoned for transport to .... ER; 9. [DATE] at 12:20 p.m. Resident's mother and his uncle here visiting. Aware that resident to be sent to hospital for evaluation d/t (due to) low BP and decrease mental status/confusion. Family will accompany resident to hospital; 10. [DATE] at 12:30 p.m. ..... here to transport resident per stretcher, stable condition; 11. 3:00 p.m. .... ER called reported resident expired @ .... ER. A phone interview on [DATE] at 10:45 a.m. with S8LPN revealed that the physician would be notified when there was something abnormal with the resident so that evaluation could be made. She confirmed that resident #66's blood pressure of ,[DATE] that was taken on [DATE] was an abnormal blood pressure. She revealed that the resident ' s blood pressure was not retaken or monitored. S8LPN revealed that the doctor would have been notified. She revealed that she was not sure that she did and stated that she would have to come to the facility to review the chart. An interview on [DATE] at 11:55 a.m. with S9LPN revealed that she did not remember notifying the physician of the O2 Sat dropping on the resident she stated that if she did not chart it then she did not do it. She revealed that when the resident complained of not being able to breath, she assessed him and could not determine if he was getting oxygen. She revealed that she changed the tubing and started him on 4 liters. She revealed that she did not remember what percent of oxygen the resident was receiving. S9LPN revealed that she then took the vital signs. She revealed that she did not get an order to increase the oxygen to 3 or 4 liters. She revealed that she did not notify the doctor of the resident's blood pressure of ,[DATE], oxygen saturation of 79%, and she did not get an order to increase the oxygen to 3 or 4 liters. An interview on [DATE] at 12:45 p.m. with S13 revealed that he did not see the resident at the facility and he revealed that he was not notified of the change in the resident's condition. He revealed that he did not remember if the facility notified him on [DATE] of the resident's oxygen level of 79% and a blood pressure of ,[DATE]. He revealed that he did not give an order to increase the oxygen to 3 or 4 liters. S13 revealed that he did not remember being notified on [DATE] of the low blood pressures and the decline of the mental status of the resident. He stated that he would have been expected to be called so that orders could have been given to transport out to the hospital for evaluation. He revealed that he remembered being notified by the hospital that the resident had expired and that the family did not want any further measures to be done. Record review of the .. Hospital Emergency Physician Record revealed, Date [DATE]; Time: 1325; Chief Complaint: [MEDICAL CONDITION]; Onset/duration: PTA (prior to admission); Initial Findings: confused; sinus rhythm, normal respirations; Neuro/Psych: "Patient coded while I was collecting data and lab came to draw blood"; Clinical Impression: Altered mental status, Cardiopulmonary Arrest unsuccessful; Condition: deceased ; Time: 1420. Record review of the physician's order [REDACTED].#66 to the hospital ER for evaluation. The record review revealed that there was no orders to increase resident #66 ' s oxygen to 3 or 4 liter, no orders to withhold the hypertension medications. Further revealed that there were no parameters ordered for monitoring of low blood pressures. Record review of the facility's policy and procedure on notification of Change in Condition revealed, " All staff members shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or mental condition. The resident's responsible party or family will also be notified, except when the change is of a routine or technical nature. Some examples are: lab work, medication change or diet change. On occasion, the change may warrant contacting clergy or other significant persons. Notification of physician and/or responsible parties shall be documented in the clinical record. Status changes, which are not significant enough to be reported, must be documented in the medical record. The following is a list of some significant changes of condition: 1. Temperature elevation or fall of a significant value. 2. Onset of confusion. 3. Memory loss. 4. Drop or elevation in blood pressure of significant value. 5. Weakness in an extremity. 6. Nausea and vomiting that is not resolved timely. 7. Diarrhea that is not resolved timely. 8. Discovery of lump or growth. 9. Complaint of new significant pain. 10. Change in mobility or ambulation. 11. Change in speech pattern. 12. Weight loss. 13. Change in skin condition, color and/or integrity. 14. Change in lab values. "

Based on record reviews and interviews the facility failed to ensure that nurses from three consecutive shifts immediately notified the physician of a change in resident condition in 1 out of 30 sampled residents #66. This deficient practice had the potential to affect 37 residents that were diagnosed with [REDACTED]. The facility failed to notify the physician of the following: 1. low blood pressures and to obtain an order to withhold [MEDICATION NAME] and [MEDICATION NAME]; 2. change in mental status; 3. O2 (oxygen) Sat (saturation) of 79%; Resident # 66 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 2:00 p.m. resident #66 ' s blood pressure was ,[DATE]. Resident #66 was placed in Immediate Jeopardy when S8 LPN failed to notify the physician of the decrease in blood pressure. At 7:00 p.m. on [DATE] the resident ' s blood pressure was ,[DATE]. Resident #66 remained in Immediate Jeopardy on [DATE] at 1:30 a.m. when his blood pressure was ,[DATE], his oxygen saturation level was 79 percent, skin color was pale, and he was having trouble breathing. S9 LPN failed to notify the physician of a significant change in resident #66 ' s condition. On [DATE] at 11:00 a.m. this resident ' s blood pressure was ,[DATE] and he was very confused and disoriented. Resident #66 ' s physician was not notified of these changes. On [DATE] at 12:00 p.m. the physician was notified of resident #66 ' s blood pressure of ,[DATE] and an order was given to send him to the emergency room . The immediate jeopardy situation ended when resident #66 was sent out to the emergency room to receive a higher level of care. On [DATE] at 3:00 p.m. the emergency room called and reported that resident #66 died within two hours of arrival to the emergency room . According to the Resident Census and Conditions of Residents there were 51 residents that lived in the facility. Findings: Record review of resident #66's clinical record revealed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Record review of resident #66 physician's order [REDACTED]. Record review of the Nurses Notes revealed the following: 1. [DATE] at 2:00 p.m. BP ,[DATE], P47, R18, Temp 96.4, there was no documentation that the doctor was notified of the low blood pressure and no documentation that the blood pressure was retaken or monitored; 2. [DATE] at 7 p.m. BP ,[DATE], P64, R24, Temp 97, there was no documentation that the doctor was notified of the low blood pressure and no documentation that the blood pressure was retaken or monitored; 3. [DATE] at 1:30 a.m. BP ,[DATE], R16, O2 Sat 79%, color pale, resident c/o (complaint of) having trouble breathing, O2 @ 4 liters, there was no documentation that the doctor was notified of the low blood pressure, no documentation that the blood pressure was retaken or monitored, and no documentation that the low oxygen saturation or paleness was reported to the doctor. 4. [DATE] at 11; 00 a.m. Resident's mental status declining noted very confused & disoriented. CBG (capillary blood glucose) taken @87. CVS (complete vital signs) taken BP ,[DATE], P47, R18, T96.4. Fluids encouraged. ATB (antibiotics) therapy cont for UTI (Urinary tract infection), Pneumonia, and [MEDICAL CONDITION]. There was no documentation that the doctor was notified of the low blood pressure, no documentation that the declining mental status was reported to the doctor, and no documentation that the blood pressure was retaken or monitored; 5. [DATE] at 12:00 p.m. Resident more confused. CVS taken BP ,[DATE], P120, notified S13, Send to ER(emergency room ) for evaluation; 6. [DATE] at 12:15 p.m. .... phoned for transport to .... ER; 7. [DATE] at 12:20 p.m. Resident's mother and his uncle here visiting. Aware that resident to be sent to hospital for evaluation d/t (due to) low BP and decrease mental status/confusion. Family will accompany resident to hospital; 8. [DATE] at 12:30 p.m. ..... here to transport resident per stretcher, stable condition; 9. 3:00 p.m. .... ER called reported resident expired @ .... ER. A phone interview on [DATE] at 10:45 a.m. with S8LPN revealed that the physician would be notified when there was something abnormal with the resident so that evaluation could be made. She confirmed that resident #66's blood pressure of ,[DATE] that was taken on [DATE] was an abnormal blood pressure. She revealed that the resident ' s blood pressure was not retaken or monitored. S8LPN revealed that the doctor would have been notified. She revealed that she was not sure that she did and stated that she would have to come to the facility to review the chart. An interview on [DATE] at 11:55 a.m. with S9LPN revealed that she did not remember notifying the physician of the O2 Sat dropping on the resident she stated that if she did not chart it then she did not do it. She revealed that when the resident complained of not being able to breath, she assessed him and could not determine if he was getting oxygen. She revealed that she changed the tubing and started him on 4 liters. She revealed that she did not remember what percent of oxygen the resident was receiving. S9LPN revealed that she then took the vital signs. She revealed that she did not get an order to increase the oxygen to 3 or 4 liters. She revealed that she did not notify the doctor of the resident's blood pressure of ,[DATE], oxygen saturation of 79%, and she did not get an order to increase the oxygen to 3 or 4 liters. An interview on [DATE] at 12:45 p.m. with S13 revealed that he did not see the resident at the facility and he revealed that he was not notified of the change in the resident's condition. He revealed that he did not remember if the facility notified him on [DATE] of the resident's oxygen level of 79% and a blood pressure of ,[DATE]. He revealed that he did not give an order to increase the oxygen to 3 or 4 liters. S13 revealed that he did not remember being notified on [DATE] of the low blood pressures and the decline of the mental status of the resident. He stated that he would have been expected to be called so that orders could have been given to transport out to the hospital for evaluation. He revealed that he remembered being notified by the hospital that the resident had expired and that the family did not want any further measures to be done. Record review of the .. Hospital Emergency Physician Record revealed, Date [DATE]; Time: 1325; Chief Complaint: [MEDICAL CONDITION]; Onset/duration: PTA (prior to admission); Initial Findings: confused; sinus rhythm, normal respirations; Neuro/Psych: "Patient coded while I was collecting data and lab came to draw blood"; Clinical Impression: Altered mental status, Cardiopulmonary Arrest unsuccessful; Condition: deceased ; Time: 1420. Record review of the physician's order [REDACTED].#66 to the hospital ER for evaluation. There were no orders for parameters to address low blood pressure. Further review revealed that there was no order to increase resident #66 ' s oxygen to 3 or 4 liters. Record review of the facility's policy and procedure on notification of Change in Condition revealed, " All staff members shall communicate any information about resident status change to appropriate licensed personnel immediately upon observation. The resident's primary physician or designated alternate will be notified immediately of any change in resident's physical or mental condition. The resident's responsible party or family will also be notified, except when the change is of a routine or technical nature. Some examples are: lab work, medication change or diet change. On occasion, the change may warrant contacting clergy or other significant persons. Notification of physician and/or responsible parties shall be documented in the clinical record. Status changes, which are not significant enough to be reported, must be documented in the medical record. The following is a list of some significant changes of condition: 1. Temperature elevation or fall of a significant value. 2. Onset of confusion. 3. Memory loss. 4. Drop or elevation in blood pressure of significant value. 5. Weakness in an extremity. 6. Nausea and vomiting that is not resolved timely. 7. Diarrhea that is not resolved timely. 8. Discovery of lump or growth. 9. Complaint of new significant pain. 10. Change in mobility or ambulation. 11. Change in speech pattern. 12. Weight loss. 13. Change in skin condition, color and/or integrity. 14. Change in lab values. "