Every finding on record at The Greens at Hickory

Based on record reviews, and resident, family member, staff, and Medical Director interviews, the facility failed to ensure medications were administered as prescribed by the physician when Nurse #8 administered medications to Resident #83 prescribed for Resident #33 which included Metformin (an antidiabetic agent), Coreg (beta-blocker that affects the heart and circulation), Trazadone (an antidepressant), Melatonin (hormone that regulates sleep), Senna (plant-based product used as laxative) and Tizanidine (muscle relaxant). In addition, Nurse #6 administered medications to Resident #139 prescribed for Resident #23 which included Tylenol (an analgesic) and Buspar (an anti-anxiety medication). This deficient practice affected 2 of 6 residents reviewed for medication errors. The findings included: 1. Resident #83 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, hypertension, constipation, restless leg syndrome, hallucinations and major depressive disorder. Review of Resident #83's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and received antidepressant and hypoglycemic medications during the look back period. Review of a Change in Condition form dated 11/06/25 and completed by the Director of Nursing (DON) indicated that the form was being completed because of a medication variation on the night of 11/06/25. Resident #83's vital signs were taken after the medication variation at 10:14 PM and recorded as blood pressure 130/62 (normal range is between 120/80 and 90/60), pulse 66 (normal pulse is between 60 and 100 beats per minute), respiratory rate 18 (normal range is between 12 to 20 breaths per minute), temperature 98.2 (normal body temperature is between 97.0 and 99.0), oxygen saturation 94% (normal oxygen saturation level is between 95% and 100%) and blood glucose 115 (normal blood sugar range is between 70-99 when fasting). The form noted Resident #83's allergies were penicillin and tuberculin solution. There were no changes in Resident #83's mental, physical and behavioral symptoms. The Resident, who was his own responsible party was made aware of the medication errors and the on-call physician service was made aware of the errors and gave orders to monitor Resident #83 for changes. The form did not indicate what medications were given to Resident #83. Review of Resident #33's Medication Administration Record (MAR) for November 2025 revealed the following medications that were administered to Resident #83 in error on 11/06/25: - melatonin (a hormone the body produces to regulate sleep-wake cycle) 5 milligrams (mg) tablet by mouth at bedtime for insomnia. - sennosides (laxative) 8.6 mg 2 tablets by mouth at bedtime for constipation. - tizanidine (muscle relaxant) 2 mg one tablet by mouth for muscle relaxant. - trazadone (antidepressant) 50 mg one tablet by mouth at bedtime for insomnia. - carvedilol (antihypertensive) 25 mg tablet by mouth twice a day for hypertension. - metformin (hypoglycemic) 1000 mg tablet by mouth twice a day for diabetes mellitus. Review of a typed statement made by the Director of Nursing on 11/07/25 revealed the DON spoke with the second shift (3:00 PM to 11:00 PM) Supervisor #9 by phone who was present at the time of medication variation. Per Supervisor #9, Nurse #8 was assigned to Resident #83's and Resident #33's section and was in the process of completing her bedtime medication pass (on 11/06/25). When Nurse #8 arrived at Resident #83's and Resident #33's room, the Nurse pulled Resident #33's medications and mistakenly gave them to Resident #83. As soon as Nurse #8 realized that she had administered the wrong medications to Resident #83, Nurse #8 immediately informed Supervisor #9 of her mistake. Supervisor #9 then notified the on-call provider to let them know what had happened and received response from the on-call provider to monitor Resident #83 for any changes and notify the on-call provider of any changes. Per Supervisor #9, Nurse #8 checked Resident #83's vital signs twice within the first hour after the event occurred. Resident #83 was his own responsible party and was made aware of the situation. Nurse #8 informed the oncoming shift of what happened. It was documented that Nurse #8 was at her other place of employment and was unable to write/send a statement at this time. Review of Resident #83's vital signs taken after 10:14 PM on 11/06/25: - 11/07/25 at 4:48 AM, blood pressure 122/63, pulse 67, respiratory rate 16, oxygen saturation 93% - 11/07/25 at 8:17 AM, blood pressure 130/64, pulse 83, respiratory rate 20, oxygen saturation 96% - 11/07/25 at 5:13 AM, blood sugar 110 Review of a progress note written by the Director of Nursing on 11/07/25 at 11:05 AM revealed she spoke with the Medical Director regarding Resident #83 receiving Resident #33's medication last night at bedtime. Per the Medical Director the Resident's roommate was not on anything that could harm Resident #83. Received orders to check blood glucose and vital signs every six hours for forty-eight hours and neuro checks every six hours for twenty-four hours. Review of Resident #83's physician orders for 11/07/25 were: check blood glucose, vital signs every six hours for forty-eight hours and check neuro checks for every six hours for twenty-four hours and report any abnormal results to the provider immediately. Review of Resident #83's medical record revealed the Resident's vital signs, blood sugars and neurological checks were obtained as ordered with no abnormal findings. Review of the Nurse Practitioner's (NP) progress note dated 11/07/25 included the Resident and nurse stated he was given the wrong medication yesterday, he was given metformin, coreg and trazadone by the nurse accidently that belonged to his roommate. There was no further mention in the note by the NP regarding the medication errors. An interview was conducted with Resident #83 on 01/23/26 at 1:04 PM who explained that he remembered when he was given Resident #33's medications. He stated that the nurses kept checking on him and he did not suffer any ill effects from the medications. Attempts were made to interview Nurse #8 by telephone on 01/23/26 at 3:43 PM and 01/26/26 at 10:00 AM but were unsuccessful. An interview was conducted with Supervisor #9 on 01/23/26 at 3:45 PM who explained that on 11/06/25 she was acting second shift Supervisor when Nurse #8 informed her of a medication error that she made by giving Resident #83 Resident #33's medications. Supervisor #9 continued to explain that she immediately called the on-call provider and reported the medication errors, and the doctor told her to monitor Resident #83's vital signs and to call them back if there were any changes. The Supervisor stated Resident #83 had no negative effects from receiving the wrong medications. She reported that Resident #83 was his own responsible party, and she explained to him that Nurse #8 gave him Resident #33's medications and encouraged him to report any changes that he may experience which the Resident did not report any changes. Supervisor #9 stated she reported the incident to the oncoming Supervisor #10. An interview was conducted with the third shift (11:00 PM-7:00 M) Supervisor #10 on 01/26/26 at 10:05 AM. The Supervisor explained that she remembered the night of the medication error 11/06/25 and was notified of the medication error by Supervisor #9. Supervisor #10 continued to explain that Resident #83 was monitored throughout the night and there were no changes in his vital signs that would warrant notifying the physician. Interviews were conducted with the Director of Nursing (DON) on 01/23/26 at 1:28 PM and 01/28/26 at 10:00 AM. The DON explained that on the night of 11/06/25 Nurse #8 administered Resident #33's medications to Resident #83 by mistake and immediately reported her mistake to Supervisor #9. Supervisor #9 called the on-call doctor and reported the medication errors to the doctor, and the doctor gave orders to monitor Resident #83 for any changes and to hold Resident #83's other bedtime medications. She continued to explain that Resident #83 had no negative side effects from the medication and in fact, Resident #83 was on some of the medications that were given to him by mistake. The DON reported the next day, on 11/07/24, the Nurse Practitioner saw Resident #83 and gave orders to monitor his vital signs and blood sugar every six hours for forty-eight hours and to monitor neurological checks every six hours for twenty-four hours and Resident #83 had no negative effects from the medication errors. The DON explained that the only explanation for the medication errors was that Nurse #8 who was an agency Nurse, did not check the five rights before she administered the medications to Resident #83. She stated Nurse #8 was immediately terminated from working at the facility for not following facility protocol for medication administration. The DON stated she expected all the nurses to practice safe medication pass such as checking the five rights of medication administration. During an interview with the Administrator on 01/23/26 at 1:45 PM the Administrator stated he expected the nurses to practice medication administration by checking the five rights of safe medication administration before they administer the residents' medications. An interview was conducted with the Medical Director on 01/23/26 at 1:50 PM. The Medical Director indicated that the medication errors were unfortunate and that Resident #83 did not have any negative side effects from the medications. He stated Resident #83 was prescribed some of the medications that he received and he did not consider the medication errors to be significant. 2. Resident #139 was admitted to the facility on [DATE] and discharged on 12/16/25. His admitting diagnoses included end stage renal disease dependent on dialysis, coronary artery disease, hypertension, diabetes mellitus type II, and chronic obstructive pulmonary disease. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #139 was cognitively intact. The MDS revealed Resident #139 received antidepressant and hypoglycemic medications during the assessment period but had not received anti-anxiety medication. A review of the physician orders dated October 2025 revealed Resident #139 was prescribed the following medications but none were scheduled for 2:00 PM: Duloxetine HCl oral capsule delayed release sprinkle 20 milligrams (mg) 1 capsule by mouth one time a day for depression. Insulin Glargine Solostar Subcutaneous Solution Pen-Injector 100 units/milliliter (ml) Inject 18 units subcutaneously one time a day for diabetes mellitus type II. Levothyroxine Sodium oral tablet 100 micrograms (mcg) 1 tablet by mouth one time a day for hypothyroidism. Pravastatin Sodium oral tablet 1 tablet by mouth one time a day for hyperlipidemia. Insulin Aspart Subcutaneous Solution Pen-Injector 100 units/ml Inject 5 units subcutaneously with meals for diabetes mellitus. Hold if blood sugar is less than 150. Resident #23 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia following stroke, diabetes mellitus type II and chronic pain syndrome. A review of the physician orders dated October 2025 revealed Resident #23 was prescribed the following medications: Acetaminophen oral tablet 325 mg 3 tablets by mouth three times a day for pain at 8:00 AM- 2:00 PM- 8:00 PM Buspirone HCl oral tablet 7.5 mg 1 tablet by mouth three times a day for anxiety at 8:00 AM- 2:00 PM- 8:00 PM Review of Resident #139's Situation, Background, Appearance, Review and Notify (SBAR) Communication Form dated 10/26/25 revealed Resident #139 had received Resident #23's medication during a 2:00 PM medication pass. The medications Resident #139 received were Acetaminophen (an analgesic) 325 mg three tablets and Buspirone HCl (Hydrochloride) (an antianxiety medication) 7.5 mg 1 tablet. The incident was discovered when Resident #139's family member asked Nurse # 2 (family member could not find Nurse #6 who had administered the medication) what medications Resident #139 had received at 2:25 PM because he usually did not take medicines at that time. Nurse #2 looked at the Medication Administration Record (MAR) for Resident #139 and discovered he was not ordered medications at 2:00 PM and asked the family member what the pills looked like. The family member was able to describe he had taken 3 white oblong pills that appeared to be all the same and one white small round pill. Nurse #2 reviewed the records of the residents that were administered medications by Nurse #6 and discovered that Resident #139 had received Resident #23's 2:00 PM medications. Nurse #6 immediately notified the on-call provider who reviewed the medications Resident #139 was on and determined there was no drug interaction with the medications he had received belonging to Resident #23. The on-call provider gave orders to monitor Resident #139's vital signs every 6 hours for 24 hours and report any change in his condition. Nurse #2 notified the family member and the resident of the medication error and the orders for his vital signs to be monitored every 6 hours for 24 hours. The family member and resident were notified of the error on 10/26/25 at 2:27 PM. The Assistant Director of Nursing (ADON) was notified of the medication error on 10/26/25 at 2:32 PM and the DON was notified of the medication error on 10/26/25 at 2:58 PM. Review of a typed statement dated 10/26/25 made by Nurse #2 revealed at approximately 2:20 PM Resident #139's family member approached Nurse #2 and asked her if Resident #139's medications had changed. Nurse #2 explained to the family member that she had not been assigned to Resident #139 earlier but she could check his electronic medical record (EMR) and review his current medications with her. Nurse #2 verified the family member was listed in the EMR as his emergency contact before providing the information. Nurse #2 informed the family member of the medications Resident #139 should have received and the family member then asked what he received after lunch and Nurse #2 stated he did not have medications ordered after lunch. The family member then stated to Nurse #2 that Nurse #6 had brought medications in for the resident after lunch and the cup was still in the room but said the resident had taken the medications. Nurse #2 told the family member that she would discuss this with the weekend supervisor and get back to her about the medications Resident #139 had taken. Nurse #2 made Unit Manager #1 aware of the situation, and they began reviewing the MARs of all the residents Nurse #6 had medicated during the 7:00 AM to 3:00 PM shift. Nurse #6 had been sent home when she had completed her medication pass and documentation and was not at the facility at the time the error was discovered. Nurse #2 and Unit Manager #1 discovered that Resident #139 had been administered medications that were ordered to be given to Resident #23 at 2:00 PM. Nurse #2 and Unit Manager #1 explained what had happened to the family member and Resident #23. Nurse #2 explained to them that the on-call provider was being contacted as well as the ADON and Director (DON) to inform them of the medication error. A telephone interview on 01/20/26 at 3:29 PM with Resident #139's family member revealed Resident #139 had received medications on 10/26/25 that were not prescribed to him. The family member stated Nurse #6 brought 4 pills (3 white oblong pills and 1 white small round pill) in a cup into his room around 2:30 PM and gave them to him. The family member stated she was not aware of him taking medications at that time of day, so she had gone out a few minutes later and asked Nurse #2 (could not find Nurse #6) what the medications were that Resident #139 had received. She stated Nurse #2 came back to her later and told her that Resident #139 had received medications that were prescribed for another resident (Resident #23). A telephone interview on 01/22/26 at 2:01 PM with Nurse #2 revealed she was working on 10/26/25 on the 7:00 AM to 3:00 PM shift with Nurse #6 and after Nurse #6 had left for the day discovered that she had administered medications to Resident #139 that were prescribed for Resident #23. She stated the family member had made her aware that Nurse #6 had brought medications into Resident #139's room around 2:00 PM and asked if his medications had changed. Nurse #2 said she reviewed Resident #139's medications with the family member and discovered he had no medications ordered to be given at 2:00 PM. Nurse #2 explained that she then notified Unit Manager #1 that Resident #139 had been administered medications that were not prescribed for him and said they began reviewing the MARs for all the residents Nurse #6 had administered medications to during her shift. Nurse #2 said they discovered that Resident #139 had received medications prescribed for Resident #23 during the 2:00 PM medication pass. She stated she explained what had happened to the family member and Resident #139 and immediately called the on-call provider, ADON, and DON to notify them of the error. Nurse #2 stated the on-call provider reviewed Resident #139's medications and the medications he had received that were not prescribed for him and determined there was no drug interaction and no listed allergies for Resident #139 to the medications. Nurse #2 further stated the on-call provider had given order to monitor Resident #139's vital signs every 6 hours for 24 hours and notify him if there were any changes in the resident. Nurse #2 stated Unit Manager #1 called the agency that employed Nurse #6 and made her do not return to the facility with her agency to prevent any future medication errors. An interview on 01/22/26 at 1:43 PM with Unit Manager #1 revealed she was the Weekend Supervisor on 10/26/25 and remembered getting a call from Nurse #2 that Resident #139 had received medications that were not prescribed for him. Unit Manager #1 stated she and Nurse #2 began looking at the residents the agency nurse (Nurse #6) had medicated to try to determine the medications Resident #139 had taken. She stated they discovered based on the description of the pills from the family member that Resident #139 had taken the 2:00 PM medications prescribed for Resident #23. Unit Manager #1 stated they immediately contacted the on-call provider and reviewed Resident #139's medications with him and the medications he had taken. Unit Manager #1 said Resident #139 had taken Acetaminophen 325 mg 3 tablets and Buspirone HCl 7.5 mg 1 tablet and the provider determined there was no drug interactions, so he gave orders to monitor Resident #139 and take his vital signs every 6 hours for 24 hours and call with any change in his condition. Unit Manager #1 said she and Nurse #2 then went into Resident #139's room and explained to him and the family member what had happened and what the provider had instructed them to do for the resident. She said they both understood and then she stated she notified the ADON and DON about the medication error and called the agency the nurse worked for and made her do not return to avoid any future medication errors. Several attempts were made to contact Nurse #6 but they were unsuccessful. Review of a verbal order given by the on-call provider on 10/26/25 revealed the following: Monitor vital signs every 6 hours for 24 hours and notify provider of any changes. Resident #139's documented vital signs dated 10/26/25 at 5:30 PM revealed the following: blood pressure (BP) 145/79 (normal range systolic (top number) less than 120 and diastolic (bottom number) less than 80), temperature (T) 98.0 (normal range 97 to 99), pulse (P) 79 beats per minute (normal range 60-100), respirations (R) 16 breaths per minute (normal range 12-20), oxygen saturation 96% (normal range 92% or higher) on room air. His documented vital signs on 10/27/25 at 6:39 AM were BP 140/80, T 97.8, P 80, R18, and oxygen saturation 97% on room air. Resident #139's documented vital signs on 10/27/25 at 11:03 AM were BP 132/75, T97.5, P 61, R16, and oxygen saturation 97 % on room air. His documented vital signs on 10/27/25 at 4:46 PM were BP 122/74, T98, P 62, R16, and oxygen saturation 98%. Resident #139's documented vital signs on 10/27/25 at 7:31 PM were BP 137/74, T 97.9, P 72, R 18, and oxygen saturation 97% on room air. Review of an interdisciplinary team (IDT) risk meeting progress note dated 10/27/25 revealed the following: It was noted that resident did receive medication that was not prescribed for him. On-call provider was notified immediately and no concerns regarding medication interaction. A verbal order was given by on-call provider to monitor vital signs every 6 hours for 24 hours and notify provider of any changes. The DON and Assistant DON (ADON) were notified as well as the resident and his family member. The agency nurse was the nurse who administered the medications and she was DNR (do not return) from the facility to assist in preventing future incidents. An interview on 01/23/26 at 3:35 PM with the Director of Nursing (DON) revealed she had been made aware of the medication error by Unit Manager #1 and ADON on 10/26/25. She stated she had instructed them to call the on-call provider to notify him of the medication error and to let her know the orders obtained from him. The DON stated she didn't understand why the family member allowed the resident to take the medications if she knew he didn't take medications at that time of day but said the medications should not have been given to Resident #139 and it was the nurse's error for giving him medications prescribed to another resident. The DON stated Nurse #6 who gave the wrong medications was made do not return to facility with her agency to prevent another medication error from happening. An interview on 01/23/26 at 3:50 PM with the Administrator revealed he was aware of the medication error and was disappointed that the medication error had occurred. He stated they were working diligently to hire their own staff so they would not have to use agency but said they still needed agency to fill shifts where they have vacancies. The Administrator stated he did think his staff had acted promptly and appropriately once the error was discovered but stated it was unfortunate for Resident #139 that he had been given another resident's medication. An interview on 01/23/26 at 1:50 PM with the Medical Director revealed that he had heard about the medication error with Resident #139 receiving medications that belonged to Resident #23. The Medical Director indicated that while it was unfortunate the medication error had occurred Resident #139 did not have any negative side effects from the medications. He further stated he did not consider the medications given to Resident #139 in error to be significant medication errors.

Based on observations, record reviews and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 28 opportunities, resulting in a medication error rate of 7.14% for 2 of 4 residents observed during medication administration (Resident #62 and Resident #112).The findings included:1. The manufacturer's instructions for prefilled Tresiba insulin pen indicated the pen contained long-acting insulin that was injected once daily subcutaneously in the thigh, abdomen or upper arm. Prime the pen with 2 units before each dose. Priming the pen (essential): turn the dose selector to 2 units, hold the pen with the needle up, tap gently, and press the button until the counter shows 0 and a drop of insulin appears. Resident #112's medical record revealed a physician order dated 12/06/25 for Tresiba insulin via pen injector, inject 20 units subcutaneously one time a day for diabetes mellitus. On 01/22/26 at 9:10 AM an observation was made of Nurse #5 preparing to administer insulin to Resident #112 via an insulin pen. The Nurse removed the Tresiba insulin pen from the medication cart and set the counter to 20 units. Nurse #5 administered the 20 units of insulin without priming the insulin pen as advised by the manufacturer's instructions.An interview was conducted with Nurse #5 at 11:35 AM on 01/22/26. The Nurse was asked to explain the procedure when giving insulin using an insulin pen and Nurse #5 stated she gave the insulin by the five rights of giving any medication. When the Nurse was asked if she was aware of priming the insulin pen before giving the insulin the Nurse stated she knew she should have primmed the pen and thought she had primed the pen before giving Resident #112 the insulin.An interview was conducted with the Director of Nursing (DON) on 01/22/26 at 12:55 PM. The DON explained that she had already heard that Nurse #5 did not prime the pen before giving the insulin. She stated she watched a video about the correct way to inject the insulin using a pen and the video showed to prime the insulin to ensure insulin was in the needle before it was injected into the resident.During an interview with the Pharmacy Consultant on 01/22/26 at 1:55 PM the Pharmacy Consultant explained priming the insulin pen was recommended especially with small doses because there could be air bubbles in the chamber of the pen and the air bubbles needed to be removed to ensure the resident was getting the full amount of insulin ordered.2. Review of Resident #62's physician orders dated 01/13/26 revealed fluticasone furoate one spray in both nostrils one time a day for 30 days for sinus/allergies.On 01/22/26 at 9:30 AM Nurse #5 was observed as she prepared and administered Resident #62's medications. The Nurse administered fluticasone furoate 2 sprays in each nostril.An interview was conducted with Nurse #7 on 01/22/26 at 12:35 PM. The Nurse recounted her actions when giving Resident #62 her nasal spray earlier and stated she gave the Resident 2 sprays in each nostril. Nurse #7 read the order for the nasal spray which stated to give one spray in each nostril and stated she should have read the order closer.During an interview with the Director of Nursing (DON) on 01/22/26 at 12:55 PM the DON stated that she had already heard about the medication error made by Nurse #7 and explained that Nurse #7 should give the medication according to the five rights which would have ensured she gave the correct dose.

Based on observations, record review and staff interviews, the facility failed to provide a dignified dining experience when the Speech Therapist (ST) stood in the hallway beside a dependent resident while assisting him during a meal 1 of 8 residents reviewed for dignity (Resident #70). The reasonable person concept was applied to this deficiency as individuals might feel a lack of dignity when staff assisted them in the hallway and when standing over them. Findings included:Resident #70 was admitted to the facility 11/23/22 with diagnoses including malnutrition and feeding difficulty. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #70 had severe cognitive impairment and required partial/moderate staff assistance with eating. A continuous observation of the lunch meal was conducted on 01/20/26 from 1:13 PM through 1:18 PM. Resident #70 was sitting in his wheelchair in the hall directly across from the nurse's station with his meal tray on an overbed table in front of him. Three empty chairs were observed behind the nurse's station. The Speech Therapist (ST) was observed standing on Resident #70's right side giving him bites of food. In an interview with the ST on 01/22/26 at 1:20 PM she confirmed she fed Resident #70 the lunch meal on 01/20/26 in the hallway and stood during the entire time she was assisting Resident #70. She stated she did not see any chairs available and that was why she did not sit while assisting Resident #70. The ST stated Resident #70 normally ate in the dining room but ate in the hallway on 01/20/26 due to the flu/COVID-19 outbreak. An interview with the Director of Nursing (DON) on 01/23/26 at 11:12 AM revealed she expected staff to be seated when feeding residents. She stated she felt feeding residents in the hallway was a safer option than in their rooms because more staff were available if an emergency occurred. An interview with the Administrator on 01/23/26 at 12:11 PM revealed he expected residents to be fed in a respectful manner and for staff to be seated when they fed residents.

Based on record reviews and staff interviews, the facility failed to obtain consent and inform the resident or responsible party in advance of the risks and benefits of psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) prior to the initiation of the anticonvulsant and mood-stabilizing medication divalproex sodium for 3 of 6 residents reviewed for unnecessary medications (Resident #8, Resident #11, and Resident #16).The findings included:1. Resident #8 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, psychotic mood disturbance and anxiety, depression, and anxiety disorder.An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was severely cognitively impaired. The MDS indicated Resident #8 received antianxiety, antidepressant, and antipsychotic medications on a routine basis during the 7-day look back period. A Psychiatric Nurse Practitioner progress note dated 12/16/25 indicated Resident #8 had increased aggressive behavior with residents, displayed hoarding behaviors, and visual hallucinations. The plan recommended to start divalproex sodium (an anticonvulsant medication used primarily to treat seizures, mood disorders and bipolar disorder) 125 milligrams by mouth twice daily.Resident #8's physician orders revealed an order dated 12/17/25 through 12/30/25 for divalproex sodium 125 milligrams by mouth twice a day for unspecified dementia, psychotic mood disorder, and anxiety. An order dated 12/30/25 through 1/20/26 for divalproex sodium 250 milligrams by mouth twice daily for unspecified dementia, psychotic mood disorder, and anxiety. An order dated 1/20/26 and ongoing for divalproex sodium 500 milligrams by mouth twice daily for unspecified dementia, psychotic mood disorder, and anxiety.A review of Resident #8's medical record revealed no documentation that Resident #8's representative consented to or was informed in advance of the risks versus benefits of initiating divalproex sodium. The Medication Administration Record (MAR) from 12/17/25 to 01/21/26 indicated Resident #8 was administered divalproex sodium as ordered by the physician.An interview with Unit Manager #4 was conducted on 01/21/26 at 3:02 PM. Unit Manager #4 stated she was responsible for providing education about the risk versus benefits of medication and obtaining consent for psychotropic medications. Physician orders were reviewed daily for new psychotropic medications, and any new medications should have consent before initiating the medication. The Unit Manager #4 stated she did not obtain consent for divalproex sodium for Resident #8 from her responsible party because it was overlooked.An interview with the Director of Nursing (DON) was conducted on 01/23/26 at 9:20 AM. The DON stated she was responsible for providing education about the risk versus benefits of medication and obtaining all psychoactive medication consents. Medication changes and new orders were discussed daily in the morning team meeting. All new physician orders were printed and reviewed daily. The DON stated she was busy with other things, and the medication consents for divalproex were overlooked. The DON verbalized she had not obtained a consent from Resident #8's responsible party for divalproex sodium. The DON stated that all psychotropic medication consents should be in place prior to initiating psychotropic medication. An interview with Administrator was conducted on 01/23/26 at11:58 AM. The Administrator stated that he expected informed consents including a discussion of the risks and benefits to be obtained prior to starting or changing psychotropic medication.2. Resident #11 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, Alzheimer's disease, bipolar disorder, and delusional disorder.A significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #11 was severely cognitively impaired. The MDS indicated Resident #11 received antidepressant, anticonvulsant, and antipsychotic medications on a routine basis during the 7-day look back period. A Psychiatric Nurse Practitioner progress note dated 09/23/25 indicated Resident #11 had increased irritability with interview and assessment. Nursing staff reported ongoing episodes of anger and agitation. The recommendation was to start divalproex sodium (an anticonvulsant medication used primarily to treat seizures, mood disorders and bipolar disorder) 125 milligrams by mouth daily.Resident #11's physician orders revealed an order dated 09/23/25 through 11/06/25 for divalproex sodium 125 milligrams by mouth daily for unspecified dementia and bipolar disorder. An order dated 11/06/25 through 11/25/25 for divalproex sodium 125 milligrams by mouth twice daily for unspecified dementia and bipolar disorder. An order dated 11/25/25 through 12/30/25 for divalproex sodium 250 milligrams by mouth twice daily for unspecified dementia and bipolar disorder. An order dated 12/30/25 and ongoing for divalproex sodium 500 milligrams by mouth twice daily for unspecified dementia and bipolar disorder.A review of Resident #11's medical record revealed no documentation that Resident #11's representative consented to or was informed in advance of the risks versus benefits of initiating divalproex sodium.The Medication Administration Record (MAR) from 09/23/25 to 01/21/26 indicated Resident #11 was administered divalproex sodium as ordered by the physician. An interview with Unit Manager #4 was conducted on 01/21/26 at 3:02 PM. Unit Manager #4 stated she was responsible for providing education about the risk versus benefits of medication and obtaining consent for psychotropic medications. Physician orders were reviewed daily for new psychotropic medications, and any new medications should have consent before initiating the medication. The Unit Manager #4 stated she did not obtain consent for divalproex sodium for Resident #11 from her responsible party because it was overlooked.An interview with the Director of Nursing (DON) was conducted on 01/23/26 at 9:20 AM. The DON stated she was responsible for providing education about the risk versus benefits of medication and obtaining all psychoactive medication consents. Medication changes and new orders were discussed daily in the morning team meeting. All new physician orders were printed and reviewed daily. The DON stated she was busy with other things, and the medication consents for divalproex were overlooked. The DON verbalized she had not obtained a consent from Resident #11's responsible party for divalproex sodium. The DON stated that all psychotropic medication consents should be in place prior to initiating psychotropic medication. An interview with Administrator was conducted on 01/23/26 at11:58 AM. The Administrator stated that he expected informed consents including a discussion of the risks and benefits to be obtained prior to starting or changing psychotropic medication.3. Resident #16 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, major depressive disorder, hallucinations, and anxiety disorder.A Psychiatric Nurse Practitioner progress note dated 03/07/25 indicated Resident #16 had increased agitation during the evening hours including cursing and yelling at staff and peers. The plan recommended to start divalproex sodium (an anticonvulsant medication used primarily to treat seizures, mood disorders and bipolar disorder) 250 milligrams by mouth twice daily for disturbed mood and anxiety.Resident #16's physician orders revealed an order dated 03/07/25 through 04/28/25 for divalproex sodium 250 milligrams by mouth twice a day for unspecified dementia and anxiety.An order dated 04/28/25 through 11/13/25 for divalproex sodium 375 milligrams by mouth twice daily for unspecified dementia and anxiety. An order dated 11/13/25 and ongoing for divalproex sodium 500 milligrams by mouth twice daily for unspecified dementia and anxiety.The Medication Administration Record (MAR) from 10/01/25 to 01/21/26 indicated Resident #16 was administered divalproex sodium as ordered by the physician. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was severely cognitively impaired. The MDS indicated Resident #16 received antidepressant, anticonvulsant, and antipsychotic medications on a routine basis during the 7-day look back period. A review of Resident #16's medical record revealed no documentation that Resident #16's representative consented to or was informed in advance of the risks versus benefits of initiating divalproex sodium.An interview with Unit Manager #4 was conducted on 01/21/26 at 3:02 PM. Unit Manager #4 stated she was responsible for providing education about the risk versus benefits of medication and obtaining consent for psychotropic medications. Physician orders were reviewed daily for new psychotropic medications, and any new medications should have consent before initiating the medication. The Unit Manager #4 stated she did not obtain a consent for divalproex sodium for Resident #16 from her responsible party because it was overlooked.An interview with the Director of Nursing (DON) was conducted on 01/23/26 at 9:20 AM. The DON stated she was responsible for providing education about the risk versus benefits of medication and obtaining all psychoactive medication consents. Medication changes and new orders were discussed daily in the morning team meeting. All new physician orders were printed and reviewed daily. The DON stated she was busy with other things, and the medication consents for divalproex were overlooked. The DON verbalized she had not obtained a consent from Resident #16's responsible party for divalproex sodium. The DON stated that all psychotropic medication consents should be in place prior to initiating the medication.An interview with Administrator was conducted on 01/23/26 at11:58 AM. The Administrator stated that he expected informed consents including a discussion of the risks and benefits to be obtained prior to starting or changing psychotropic medication.

Based on record review and staff interviews, the facility failed to have advanced directives accurate throughout the medical record for 2 of 2 residents reviewed for advanced directives (Resident #8 and Resident #32). The findings included: 1. Resident #32 was admitted to the facility on [DATE]. Resident #32's care plan initiated on 04/18/25 indicated Resident #32's health directive was a full code. Interventions included to call 911 immediately and to intercede rapidly and begin immediate resuscitative efforts utilizing all life-sustaining measures available if the resident's heart stops beating, or the resident stops breathing such as cardiopulmonary resuscitation, oxygen administration and defibrillation. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #32's cognition was intact. A review of Resident #32's medical record indicated a physician's order dated 01/12/26 for Do Not Resuscitate (DNR). On 01/20/26 at 3:20 PM a review of the advance directive binder at the nurses' station revealed a DNR form for Resident #32 which was dated 01/12/26. An interview was conducted on 01/22/26 at 4:25 with Minimum Data Set (MDS) Coordinator who explained that it was the MDS Nurse's responsibility to update the care plans when necessary and Resident #32's care plan should have been updated on 01/13/26 during the morning team meeting when they reviewed all the new orders that were written the previous day. The MDS Coordinator stated she had been sick and out of work and came back on 01/13/26 and was not feeling well and missed revising Resident #32's care plan during the meeting. On 01/23/26 at 1:19 PM an interview was conducted with the Administrator who explained that he expected advanced directives to match throughout all the residents' medical records. 2. Resident #8 was admitted to the facility on [DATE]. A review of Resident #8's physician orders revealed an order for code status of do not resuscitate (DNR) dated 11/13/25. A care plan dated 11/14/25 included an area of focus for advanced directives. Resident #8 was noted to have a code status of DNR with a stated goal that no aggressive life-saving measures would be implemented. Interventions included effectively communicating DNR wishes by placing form in the front of the chart and when resident must be transferred outside the facility. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was severely cognitively impaired. A review of Resident #8's electronic medical record (EMR) revealed the advanced directive banner at the top of Resident #8's EMR page documented that her advance directive was DNR. An observation of the advanced directives notebook kept at the nurse's station revealed Resident #8 did not have a DNR form present in the notebook. On 01/21/26 at 2:49 PM an interview was conducted with Nurse #5 who explained that if she had to immediately determine a resident's code status, she would look in the resident's medical record on the computer and she would look in the advanced directives notebook kept at the nurse's station. Nurse #5 reported that if there was no DNR form in the code status notebook then the resident was determined to be a full code. Nurse #5 looked in the code status notebook for Resident #8's DNR form and acknowledged the form was not in the book. The Nurse stated she would determine Resident #8 to be a full code in the event of any emergency. An interview with Unit Manager #4 was conducted on 01/21/26 at 3:17 PM. Unit Manager #4 indicated that residents with DNR orders would have a DNR form completed by the Admissions Director when admitted to the facility. This form would be kept in the advanced directive notebook at the nurse's station for reference in the event of an emergency. The original form would go to the hospital with the resident if they were transferred. Unit Manager #4 indicated that Resident #8 was recently sent out to the hospital and her form must not have been returned with her. Unit Manager #4 explained that the nurse who received Resident #8 back from the hospital should have verified the form was in place. Unit Manager #4 verbalized she was responsible for checking the book weekly and had not recently checked it. Unit Manager #4 stated she did not check the notebook for the form after Resident #8 returned from the hospital. In the event of an emergency, the staff would follow the physician's order in absence of the DNR form. An interview was conducted with the Director of Nursing (DON) on 01/23/26 at 9:20 AM. The DON explained that if a resident was a DNR then there should be a DNR form in the advanced directive notebook at the nurse's station in case of an emergency. The DON verbalized that Resident #8 was recently transferred to the hospital and her DNR form did not return with her. The DON stated that Unit Managers should check the advanced directive books to ensure the correct forms were in place. The DON reported staff had not noticed the form was missing when Resident #8 returned from the hospital and the form was not replaced. An interview with the Administrator was conducted on 01/23/26 at 11:58 AM. The Administrator stated that the DNR forms should be available for facility and emergency staff in case a resident had an emergency.

Based on record review and staff interviews, the facility failed to have evidence that a request for an evaluation for a Level II Preadmission Screening and Resident Review (PASRR) was submitted for a resident with a newly identified diagnosis of a serious mental health disorder for 1 of 2 residents reviewed for PASRR (Resident #3).Findings included:Resident #3 was admitted to the facility on [DATE].Review of Resident #3's Level I PASRR dated 04/13/22.Review of Resident #3's list of cumulative diagnoses revealed active diagnoses of Post Traumatic Stress Disorder (PTSD) dated 03/14/24 and Major Depressive Disorder, Recurrent Severe without Psychotic Features dated 03/19/24.The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was not currently considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. Resident #3's active psychiatric/mood disorder diagnoses included depression and PTSD. He received antidepressant medications during the MDS assessment period.A Psychiatric progress note dated 12/23/25 revealed Resident #3 was seen for follow-up of 1) major depressive disorder, recurrent severe without psychotic features with severity level low and stable and 2) PTSD with severity level low and stable. The progress note indicated Resident #3 was prescribed citalopram (antidepressant) 10 milligram one tablet by mouth every day for the depression and to continue to monitor for symptoms of depression and PTSD.A care plan last revised on 01/13/26 revealed Resident #3 has possible history of unknown traumatic event/experience as manifested by signs and symptoms of PTSD and recent suicidal ideations. Interventions included assisting Resident #3 in meaningful activities that match the Resident's abilities and interests, reducing any known stimuli that is known to trigger Resident #3's trauma and utilizing techniques such as art (coloring) to reminisce on past positive memories.Review of Resident #3's medical record revealed there was no Level II PASRR evaluation.The facility was unable to provide documentation that a request for an evaluation for a Level II PASRR determination had been submitted for Resident #3.An interview was conducted with Social Worker (SW) #1 on 01/23/26 at 9:45 AM. The Social Worker reviewed Resident #3's medical record and reported that the Resident was admitted on [DATE] and did not have a diagnosis of PTSD. SW #1 stated the diagnosis for PTSD was added to the cumulative diagnosis listing on 03/14/24 and when the diagnosis was added she reviewed the medical record to see if Resident #3 was displaying any new behaviors which he was not, so she did not request a Level II PASRR screen. The SW stated she reviewed Resident #3's medical record to see if and when a request for a Level II PASRR evaluation had been submitted and could not find one. The SW stated she was employed at the facility before Resident #3 was admitted and she did not know of him to have any behaviors to warrant a Level II PASRR. The SW indicated if the Resident did require a Level II PASRR that he was already getting the psychiatric services that he would require.During an interview with the Administrator on 01/23/26 at 1:26 PM the Administrator stated his expectation was that a Level II PASRR's be requested when indicated of a new psychiatric diagnosis.

Based on observations, record review, and staff interviews, the facility failed to complete thorough skin assessments to identify and obtain orders for the care of a reddened area on the right palm caused by the resident's middle fingernail extending 1/4 inch beyond the end of his finger and pressing into the palm of his hand for 1 of 3 residents reviewed for contracture care (Resident #24). The findings included:Resident #24 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease, diabetes mellitus, contracture of left hand, contracture of right hand and dementia.A physician order dated 01/30/24 specified a head-to-toe skin assessment every Tuesday on 3:00 PM to 11:00 PM shift. Review of Resident #24's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required total assistance with all activities of daily living except eating for which he required partial to moderate assistance. The assessment also revealed he was at risk of developing pressure ulcers/injuries but at present had no unhealed pressure ulcers or injuries or open lesions.Review of a physician order dated 10/23/25 indicated to apply bilateral palm guards as tolerated - check skin integrity prior to applying. One time a day per therapy services and removed per schedule. Review of Resident #24's care plan dated 10/30/25 revealed a focus area for the resident having an activity of daily living (ADL) self-care performance deficit related to disease process, risk for decline in physical function, chronic obstructive pulmonary disease, respiratory failure, diabetes mellitus, dementia and bilateral hand contractures. The goal was for Resident #24 to have all needs anticipated and met by staff through the review date of 01/30/26. The interventions included:Adaptive equipment to help resident to feed self - universal cuff (an assistive device that helps residents with weak grip or limited dexterity hold objects like utensils, pens or toothbrushes, promoting independence in daily activities by securing the item in a pocket on the hand), dycem (a unique, grippy, antimicrobial polymer material available in mats or rolls used for non-slip stabilization) placemat and divided plate.The resident requires partial to moderate assist of one and divided plates with meals.Physical therapy (PT) and occupational therapy (OT) evaluation and treatment as per MD orders.The care plan also revealed a focus area for the resident having an alteration in musculoskeletal status related to contractures of bilateral hands. The goal was for Resident #24 to remain free of injuries or complications related to bilateral hand contractures through the review date of 01/30/26. The interventions included:Monitor/document/report as needed any signs or symptoms or complications related to arthritis, joint pain, joint stiffness, usually worse on wakening, swelling, decline in mobility, decline in self-care activity, contracture formation/joint shape changes, crepitus (creaking or clicking with joint movement), pain after exercise or weight-bearing.Adaptive equipment for eating, bilateral hand splints per orders. Provide good hygiene and monitor skin. Notify provider of any complications.Review of Resident #24's weekly skin assessment dated [DATE] and completed by Nurse #3 revealed his skin was dry, he had a pressure-reducing device on his bed, he had no edema and his fingernails were cleaned and trimmed.Review of Resident #24's daily skilled nursing notes dated 01/01/26 through 01/23/26 revealed a progress note on 01/15/26 written by MDS Coordinator #1 regarding the resident. MDS Coordinator #1 indicated the resident had contractures to bilateral hands and had special devices he used to feed himself and bilateral hand splints per orders as well. She indicated in her note that although Resident #24 was at risk for skin breakdown that he currently had none.A telephone interview on 01/26/26 at 2:16 PM with MDS Coordinator #1 revealed she had completed the assessment on Resident #24 on 01/15/26. She stated that she typically assessed the resident herself and reviewed the notes in his electronic medical record. MDS Coordinator #1 stated she had not taken the resident's splints off his hands and observed his hands for skin issues and stated that she typically did not take his splints off to observe his hands when he had them on. She further stated she was not aware of any skin issues on his hands.An observation of Resident #24 on 01/20/26 at 9:15 AM revealed him sitting up in his high-back wheelchair in his room dressed for the day. The resident's hands were noted bilaterally to be contracted with the right hand greater than the left hand. His fingernails on the left hand were noted to be long and extended 1/4 inch beyond the end of his fingers. On his right hand the thumb, middle, and pinkie fingernails were long and extended 1/4 inch beyond the end of his finger. The middle finger on the right hand was bent at the proximal digit to the palm of the hand causing the finger and nail to press into the palm and the fingernail had made an indention in the palm of the hand. Upon closer observation the middle finger had made a reddened area approximately 0.2 centimeters (cm) by 0.2 cm by 0.1 cm that appeared to have been open at one time but no longer open but red in color. The indention was a match to his nail on the middle finger. The fourth finger on his right hand was bent at the distal digit with the bottom of the finger pressed into the palm of the hand and the nail on the fourth finger was thick and uneven on the top of the nail. Resident #24 stated he would like for his fingernails to be trimmed and said he didn't like for them to be long because they dug into the skin of his hand.An observation on 01/21/26 at 9:13 AM revealed Resident #24 sitting in his high-back wheelchair in the hallway with other residents participating in activity with snacks and drinks. The resident's fingernails remained long and appeared the same as on 01/20/26. An observation on 01/21/26 at 3:35 PM revealed Resident #24 resting in bed with clothes on with his universal cuff still on his left hand from lunch. The right hand had no palm guard on and the resident's right palm had a malodor coming from his hand. The resident stated the left hand splint (universal cuff) allowed him to be able to feed himself using built up utensils and stated the staff put the utensil in the pocket for him in his left palm. He stated no one had been in and talked with him about cutting his fingernails.Review of Resident #24's weekly skin assessment dated [DATE] and completed by Nurse #1 revealed his skin was dry and cool, he had a pressure-reducing mattress with no edema present and no new skin abnormalities noted. The document also revealed his fingernails were cleaned and trimmed.A telephone interview on 01/22/26 at 12:09 PM with Nurse #1 revealed she had completed Resident #24's skin assessment on 01/21/26. She stated she had not noticed any area on the palm of his right hand or that his nails were long and said maybe she should have used a flashlight so she could see his skin better when completing her assessment. Nurse #1 further stated she had noticed a malodor in his right hand before and had removed and cleaned moist exudate from the palm and put powder on his palm after cleaning it.An observation of Resident #24 and interview on 01/22/26 at 10:03 AM with Nurse #3 revealed the resident was not wearing his palm guards and when Nurse #3 saw the resident's fingernails he agreed his fingernails needed to be trimmed, and he stated he was not aware of the red area on the resident's palm caused by his fingernail. Upon closer observation the middle finger had made a reddened area approximately 0.2 cm by 0.2 cm by 0.1 cm that appeared to have been open at one time but no longer open but red in color. The indention in his palm was a match to his nail on the middle finger. An interview on 01/22/26 at 9:52 AM with Nurse Aide (NA) #1 revealed that she cared for Resident #24 frequently on 1st shift (7:00 AM to 3:00 PM). NA #1 stated she was caring for Resident #24 on 01/22/26 and that he had adaptive equipment that he used and a special splint that he used on his left hand that allowed him to feed himself. She stated they sometimes assisted him with his meals but said he liked to use his splint to feed himself. NA #1 further stated that Resident #24 usually got his showers on 2nd shift (3:00 PM to 11:00 PM) and said that was usually when staff trimmed his fingernails after his shower but said she didn't know the last time they were trimmed and filed. She further stated he was dependent for his care and said she had occasionally noted a foul odor coming from his right hand and had cleaned it good and dried it so there was no moist exudate in the hand. NA #1 walked into Resident #24's room and observed his fingernails and the reddened area on his right palm caused by his middle fingernail pressing into his palm and said his fingernails needed to be trimmed. NA #1 stated she had not noticed the area on his palm before 01/22/26. She further stated she would let the nurse know Resident #24's fingernails needed to be trimmed since he was diabetic, and she could not trim them.An observation of Resident #24 and interview on 01/22/26 at 10:23 AM with the Director of Nursing (DON) revealed the resident's middle finger on the right hand was bent at the proximal digit to the palm of the hand causing the finger and nail to press into the palm and the fingernail had made an indention in the palm of the hand. Upon closer observation the middle finger had made a reddened area approximately 0.2 centimeters (cm) by 0.2 cm by 0.1 cm that appeared to have been open at one time but no longer open but was red in color. The indention was a match to his nail on the middle finger. The DON stated the reddened area on his right palm from his middle fingernail pressing into his palm should not have happened and said that his fingernails needed to be trimmed and filed. The DON further stated the nurses should be checking his hands and palms daily and especially during their weekly skin assessments and should be removing the palm guards to thoroughly observe his skin. She stated it should have been recognized and reported to the Wound Nurse for treatment. The DON indicated she would get OT to see him to see what type of palm guards they could get him to prevent his nails from breaking the skin in his palm.An observation of Resident #24's palm and interview on 01/22/26 at 10:32 AM with the Certified Occupational Therapy Assistant (COTA) revealed the resident was not currently on caseload for OT but had been in the past. She stated when she had worked with him previously she had soaked his bilateral hands in warm water and cleaned them due to having moist exudate with an odor in his palm. The COTA observed his hands on 01/22/26 and noticed the reddened area caused by his middle finger nail and said he had an odor today in his right hand. An interview on 01/22/26 at 4:35 PM with Unit Manager #2 revealed she was not aware until today (01/22/26) that Resident #24 had a reddened place on his right palm caused by his middle fingernail.An interview on 01/23/26 at 12:14 PM with the Wound Nurse revealed no one had notified her of any skin issue on Resident #24's right hand. She stated if there had been an area on his palm the staff should have notified her so that she could put treatment in place for the area. A follow up interview on 01/23/26 at 3:35 PM with the DON revealed it was her expectation that the nurses assess resident's skin on the weekly skin assessments and identify any new skin issues and notify the appropriate discipline. The DON stated the Nurse Aides (NAs) and nurses caring for Resident #24 should have noticed the area on his palm caused by his fingernail and it should have been documented and treatment put into place to treat it and therapy consulted to evaluate him for a different type of palm guard. An interview with the Administrator on 01/23/26 at 3:50 PM revealed he was disappointed that his staff had not assessed and addressed Resident #24's reddened area to his palm. He stated it was his expectation that staff assess and address any skin issues on residents as soon as possible.

Based on observations, record review, and interviews with the Resident Council, staff and residents, the facility failed to provide a meal that was palatable in taste and temperature for 3 of 4 residents reviewed for palatable food (Resident #9, Resident #10, and Resident #23). The findings included:1.Resident #9 was admitted to the facility on [DATE].Resident #9's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact.Review of facility provided grievance logs revealed Resident #9 filed a grievance on 07/02/25 regarding the presentation and appealing nature of the meal trays being served. Per the grievance, Resident #9 complained that there was excess liquid saturating the meal plates. The facility investigated the grievance and determined that there was excess liquid from the vegetables and indicated that vegetables would be served separately moving forward.An interview with Resident #9 on 01/20/26 at 12:15 PM revealed he had multiple concerns about the quality and the presentation of food served in the facility. Resident #9 reported food was often undercooked, there was a lot of grease or other liquids that run into the different foods on the meal trays, toast was burnt, and mashed potatoes are extremely runny. Resident #9 stated he had voiced his concerns but indicated that the quality and presentation of the meal trays had not improved. 2. Resident #10 was admitted to the facility on [DATE].Resident #10's quarterly MDS assessment dated [DATE] revealed Resident #10 was cognitively intact.An interview with Resident #10 on 01/20/26 at 2:12 PM revealed that the meal trays were often cold and did not have good flavor or texture.3. Resident #23 was admitted to the facility on [DATE].Review of Resident #23's quarterly MDS assessment dated [DATE] revealed Resident #23 was cognitively intact with no delusions, behaviors, or rejection of care.An interview with Resident #23 on 01/20/25 at 12:52 PM revealed he was not pleased with the quality or temperature of the food served on the meal trays. He described the meal trays as looking like vomit and stated most days the meals were cold when they arrived at his room.An observation of food temperatures on the meal service line completed on 01/21/26 at 12:02 PM revealed all foods were above the minimum holding temperature of 135 degrees Fahrenheit (F) and ranged from 161 - 185 degrees.After obtaining temperatures of the food items on the tray service line on 1/21/25, the Dietary Manager was informed of a request for two test trays, one of the main meal and one of the alternate offering meal. The test trays were plated at 12:23 PM and left the kitchen at 12:26 PM. The test trays arrived on the hall at 12:29 PM and the first tray delivered to a resident occurred at 12:32 PM with the final tray being delivered to a resident occurred at 12:41 PM. The following were the observations of the two requested test trays that occurred at 12:45 PM:Test Tray #1 consisted of sliced ham, broccoli, yams, and a dinner roll. When the dome lid was removed, there was no observable steam rising from the plate. The ham was observed to be warm, but not hot with good flavor and good texture. The broccoli was cool but had good flavor and still had some crunch, indicating that it had not been overcooked. The yams were mushy and no real flavor outside of what was already prepared when they were canned. The yams were also warm but not hot. The dinner roll was almost room temperature but had a good crust on the outside but remained soft on the inside.Test Tray #2 consisted of chicken tenders, diced cabbage, rice, and a dinner roll. When the dome lid was removed there also was no observable steam rising from the plate. The chicken tenders were warm but not hot, they appeared pale and the breading was soft and mushy. The diced cabbage was warm but not hot with an overwhelming flavor of butter when tasted, almost drowning out any flavor of cabbage. The rice was warm, tender and tasted like plain white rice. There was observable liquid bleeding from the cabbage and into the chicken tenders and rice. The dinner roll was almost room temperature but had a good crust on the outside but remained soft on the inside.An interview with the Dietary Manager on 01/21/26 at 12:53 PM revealed the test tray meals were not warm but that test tray #2 held the temperature better than test tray #1. She stated the exterior of the chicken tenders did look pale, soft, and not crispy as you would expect fried chicken tenders to be but stated it also could be from the type of breading used on the chicken tenders as they are precooked and shipped to the facility frozen. She also indicated that the mushy breading of the chicken tenders could be caused by steam from the meal getting trapped in the dome lid and causing the breading to become soft. During a follow up interview with Resident #9 on 01/21/26 at 12:32 PM, Resident #9 reported that his meal tray had broccoli and 2 chicken tenders. Resident #9 reported the chicken tenders were pale in color and reported overall, the meal was just okay. Resident #9 declined wanting anything else or different from the facility's kitchen.During a follow up interview with Resident #10 on 01/21/26 at 1:12 PM, Resident #10 reported on a scale of 1 to 3, 1 being terrible and 3 being great, that he would rate his meal as a 1. Resident #10 reported he received a meal that consisted of chicken tenders, mashed potatoes, cabbage, a dinner roll and dessert. Resident #10 indicated that the meal was cool and did not have a good appearance.During a follow up interview with Resident #23 on 01/21/26 at 3:16 PM, Resident #23 reported his while his lunch meal was better than it normally was, he did not eat all of it, but it still was not very appetizing and was not very warm.During the Resident Council group interview completed on 01/22/26 at 11:02 AM, the attending residents reported that there were issues with the food served from the kitchen. The interviewed residents (Resident #53, Resident #54, Resident #108, and Resident #111) reported their main food complaints had to do with lack of seasoning of food and the over or undercooking of various food items. During a follow up interview with the Dietary Manager on 01/21/26 at 1:26 PM, she reported the facility does have a Food Committee that consists of residents within the facility and that they meet monthly to review any food concerns and to talk about what menu items are working or if there need to be changes made to the menus. She indicated that most of the complaints that she heard from the food committee dealt with individual preferences and stated that she believed that the majority of temperature complaints regarding the meal trays had more to do with how long the meal trays sat on the halls before the floor staff pass them out. The Dietary Manager continued, stating that for a resident like Resident #23, whose room was at the end of a hall, if the meal trays were not passed timely, it could result in his meal tray not being warm.During an interview with the Administrator on 01/23/26 at 3:54 PM he revealed he had received some complaints about the food served from the kitchen. He reported most of the complaints were preference-related and he felt they had been handled. The Administrator reported it was very difficult to please over 100 residents but stated there should not be as many complaints about the quality and temperature of the food as there had been reported. The Administrator stated he had not had a test tray from the kitchen in some time and stated with the amount of food complaints being brought to his attention, he should be requesting a test tray more often.

Based on observations, record review, and interviews with the resident, Registered Dietitian (RD) and staff, the facility failed to follow the physician's diet order to provide double portions for 2 of 5 residents reviewed for nutrition (Resident #10 and Resident #2).Findings included: 1. Resident #10 was admitted to the facility 07/08/25 with a diagnosis including hypothyroidism (underactive thyroid). Resident #10 had a physician order dated 07/09/25 for a regular diet with double portions for weight management. A summary of the Registered Dietitian (RD) note dated 11/04/25 was as follows: Resident #10 was seen for a significant weight change and skin review. Resident #10 had a good appetite with his current diet order (regular, cardiac/no salt, double portions) and usually ate 75-100% of meals. The RD note further stated she added double portions to all meals for weight management and increased kilocalorie (unit of energy) intake and this helped stabilize Resident #10's weight. The care plan for nutrition last revised 11/09/25 revealed Resident #10 had the potential for a nutritional problem related in part to a history of unintentional weight loss. Interventions included providing Resident #10's diet as ordered and monitoring his dietary intake. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact, weighed 151 pounds, and had not had any weight gain or weight loss. An observation of Resident #10's lunch meal ticket on 01/21/26 at 1:12 PM revealed he was to receive a regular diet with double portions. An observation of Resident #10's meal tray at the same date and time revealed he received 2 chicken tenders, one serving of mashed potatoes, one serving of cabbage, and one dinner roll. Resident #10 had just received his meal tray at the time of the observation. An interview with Resident #10 on 01/21/26 at 1:12 PM revealed he was supposed to get double portions for meals, and he had only received double portions approximately twice since he was admitted . Resident #10 stated he could eat 4 chicken tenders if he had them. An observation of Resident #10's meal tray with the Dietary District Manager on 01/21/26 at 1:19 PM revealed Resident #10 had not received a double portion of chicken tenders on his plate. The Dietary District Manager stated double portions were considered to be two servings of protein and Resident #10 should have received four chicken tenders. An interview with the Dietary Manager on 01/21/16 at 1:26 PM revealed that since Resident #10 had a physician order for double portions he should have received four chicken tenders on his lunch meal plate. The Dietary Manager stated the last person on the meal tray line was responsible for checking meal trays to ensure meal plates matched tray cards. An interview with Dietary Aide #1 on 01/21/26 at 1:30 PM revealed she was responsible for checking meal trays for accuracy for the lunch meal and she overlooked that Resident #10 did not get a double portion of meat. A telephone interview with the Registered Dietitian (RD) on 01/22/26 at 10:48 AM revealed she suggested Resident #10 receive double portions because he experienced some weight loss after he was admitted and in November 2025, and the double portions seemed to help stabilize his weight. She stated a diet order of double portions meant the resident received double protein servings. The RD stated she expected residents to receive double portions as ordered. An interview with the Administrator on 01/23/26 at 10:01 AM revealed he expected residents to receive double portions as ordered. A telephone interview with the Medical Director on 01/23/26 at 2:02 PM revealed he expected residents to receive double portions as ordered. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses that included diabetes and adult failure to thrive. The nutrition care plan last reviewed/revised on 10/01/25 revealed Resident #2 had a nutritional risk related in part to multiple comorbidities, abnormal nutrition-related lab values and need for a texture modified diet. Interventions included having the Registered Dietician (RD) evaluate and make diet changes as needed and serving Resident #2's diet as ordered. The quarterly Minimum Data Set (MDS) assessment dated [DATE] noted Resident #2 had moderate impairment in cognition and was dependent on staff assistance with eating. He received a mechanically altered diet and nutrition or hydration intervention to manage skin problems. A RD progress note dated 01/09/26 revealed Resident #2 had a current order for a mechanical soft diet with double protein portions and had end of life skin failure on the sacrum, left heel, right lateral midfoot, and right fifth toe. The RD noted Resident #2's current plan of care was ongoing, and the RD would follow-up as needed. Review of Resident #2's physician's orders revealed a diet order dated 01/17/25 for a mechanical soft diet with double protein portions. An observation of Resident #2's meal ticket on 01/22/26 at 12:48 PM revealed he was to receive a mechanical soft diet with double protein portions. An observation of Resident #2's meal tray at the same date and time revealed he received a chicken salad sandwich, a scoop of potato salad, a scoop of chopped broccoli salad, and mandarin oranges for dessert. The sandwich consisted of chicken salad placed between two slices of bread and was cut diagonally. The edges of all four sides of the slices of bread were touching, and the sandwich appeared uniformly thin without central bulging, indicating that Resident #2 did not receive a double protein portion. During an interview on 01/22/26 at 12:49 PM, Nurse Aide (NA) #1 confirmed she assisted Resident #2 with his lunch meal. NA #1 stated he received one chicken salad sandwich, but she could not state for certain if the sandwich had a double protein portion. During a phone interview on 01/23/26 at 11:35 AM, the RD stated Resident #2 was to receive double protein with his meals and when he was served a sandwich, it should contain double the meat. The RD stated the primary reason Resident #2 had a diet order to receive double protein portions was due to end-of-life skin failure and she would expect for him to receive double protein portions with meals as ordered. During an interview on 01/23/26 at 1:21 PM, the Dietary Manager explained for residents with a diet order for double proteins, dietary staff were to use a #8 scoop, equivalent to 4 ounces. She explained that when properly portioned, the meat should prevent the bread slices from fully meeting at the edges and should be visible between the slices of bread when the sandwich was cut. The Dietary Manager reported that she was usually present on the tray line to ensure meals were being plated according to the meal ticket; however, she was not present on the tray line when Resident #2's lunch meal was prepared on 01/22/26. The Dietary Manager stated she would have expected for dietary staff to ensure Resident #2 received a double protein portion as ordered. During an interview on 01/23/26 at 2:02 PM, the Medical Director explained for wound healing, adequate protein intake was beneficial for wound healing, as it promoted granulation of tissue (new, connective tissue that develops from the base of a wound during the healing process). The Medical Director stated he would expect for residents to receive double protein portions if ordered. During an interview on 01/23/26 at 3:50 PM, the Administrator stated he would expect for diet orders to be followed, and residents received double protein portions as ordered.

Based on record review and staff interviews, the facility failed to maintain a complete and accurate medical record that included the medications given in error for 1 of 1 resident reviewed for accuracy of medical records (Resident #83).The findings included:Resident #83 was admitted to the facility on [DATE].Review of Resident #83's medical record revealed a Change in Condition form dated 11/06/25 and completed by the Director of Nursing (DON) which indicated that the form was being completed because of a medication variation on the night of 11/06/25. Resident #83's vital signs were taken after the medication variation at 10:14 PM and recorded as blood pressure 130/62 (normal range is between 120/80 and 90/60), pulse 66 (normal pulse is between 60 and 100 beats per minute), respiratory rate 18 (normal range is between 12 to 20 breaths per minute), temperature 98.2 (normal body temperature is between 97.0 and 99.0), oxygen saturation 94% (normal oxygen saturation level is between 95% and 100%) and blood glucose 115 (normal blood sugar range is between 70-99 when fasting). The form noted Resident #83's allergies were penicillin and tuberculin solution. There were no changes in Resident #83's mental, physical and behavioral symptoms. The Resident, who was his own responsible party was made aware of the medication errors and the on-call physician service was made aware of the errors and gave orders to monitor Resident #83 for changes. The form did not indicate what medications were given to Resident #83.Review of Resident #83's medical record revealed there was no documentation in the Resident's medical record that indicated what medications were given to Resident #83 in error on 11/06/25.Multiple attempts were made to interview Nurse #8 on 01/23/26 at 3:43 PM and 01/26/26 at 10:00 AM but the attempts were unsuccessful. Nurse #8 was the Nurse who made the medication errors on 11/06/25.An interview was conducted with Supervisor #9 on 01/23/26 at 3:45 PM who explained that on 11/06/25 she was the acting second shift Supervisor when Nurse #8 informed her of medication errors that she made by giving Resident #83 Resident #33's medications. Supervisor #9 continued to explain that she did not document the medications that were given to Resident #83 in error on 11/06/25 because Nurse #8 should have documented the medication errors since she was the Nurse who made the errors. The Supervisor stated she was not aware that Nurse #8 did not document the medications she gave Resident #83 in error on 11/06/25.An interview was conducted with the Director of Nursing (DON) on 01/28/26 at 10:00 AM. The DON explained that on the night of 11/06/25 Nurse #8 administered Resident #33's medications to Resident #83 by mistake and immediately reported her mistake to Supervisor #9. The DON acknowledged that neither Nurse #8 or Supervisor #9 documented the specific medications that were given to Resident #83 by mistake on 11/06/25 in the Resident's medical record and stated the documentation should have been entered into the medical record at the time of the incident. The DON indicated she should have included all the medications that were given to Resident #83 when she completed the Change in Condition form on 11/06/25. The DON added that she expected the nurses to document accurately in the residents' medical record as situations develop and that included the specific medications that were given to Resident #83 on 11/06/25 in error.

Based on observations and staff interviews, the facility failed to maintain a sanitary wheelchair and sanitary geriatric chairs for 3 of 4 residents reviewed for safe, clean, comfortable and homelike environment (Resident #70, Resident #13, and Resident #68). Findings included:A. An observation of Resident #70's wheelchair on 01/20/26 at 1:13 PM revealed dried yellow-brown substance to both arm rests, the frame, and all four wheels. Additional observations of Resident #70's wheelchair on 01/21/26 at 10:17 AM, 01/21/26 at 12:47 PM, and 01/23/26 at 9:50 AM revealed the wheelchair remained in the same condition with a dried yellow-brown substance to both arm rests, the frame, and all four wheels. B. An observation of Resident #13's geriatric chair on 01/20/26 at 12:23 PM revealed dried white and yellow substances to both arm rests, a dried yellow-brown substance on the padding to the left of the resident's head, and visible strands of hair or string-like debris wrapped around parts of all four wheels.Additional observations of Resident #13's geriatric chair on 01/21/26 at 10:25 AM and 01/23/26 at 8:32 AM revealed the geriatric chair remained in the same condition with dried white and yellow substances to both arm rests, a dried yellow-brown substance on the padding to the left of the resident's head, and visible strands of hair or string-like debris wrapped around parts of all four wheels.C. An observation of Resident #68's geriatric chair on 01/20/26 at 12:24 PM revealed a dried white substance to both arm rests and visible strands of hair or string-like debris wrapped around parts of all four wheels. Additional observations of Resident #68's geriatric chair on 01/21/26 at 10:27 AM, 01/22/26 at 12:44 PM, and 01/23/26 at 9:50 AM revealed the geriatric chair remained in the same condition with a dried white substance to both arm rests and visible strands of hair or string-like debris wrapped around parts of all four wheels. A joint interview was conducted with the Environmental Services Director and Administrator on 01/23/26 at 9:50 AM. The Environmental Services Director stated wheelchairs, and geriatric chairs were cleaned once a month and as needed by housekeeping staff, and they were last cleaned on 12/11/25. The Environmental Services Director further stated housekeeping staff were not notified by nursing staff that the wheelchair or geriatric chairs needed to be cleaned. The Administrator stated he expected wheelchairs and geriatric chairs to be clean, and he expected nursing staff to notify the housekeeping staff if chairs needed to be cleaned more frequently than once a month.

Based on observations and staff interviews the facility failed to remove expired medications and intravenous fluids stored for use in 3 of 4 medication storage rooms (East, North, and Memory Care) reviewed for medication storage. The findings included: a. An observation was conducted on 11/12/2024 at 11:34 am of the East Medication Storage Room. The East Medication Storage Room contained 3 syringes of Heparin (blood thinning medication) that expired 2/2022, 2 syringes of Heparin that expired 3/31/2022, 2 syringes of Heparin that expired 4/30/2022, 8 syringes of Heparin that expired 6/30/2022, 2 syringes of Heparin that expired on 7/31/2022, 1 syringe of Heparin that expired on 8/31/2022, 10 syringes of Heparin that expired on 11/30/2022, 21 syringes of Heparin that expired 3/2023, 9 syringes of Heparin that expired 7/31/2023, 14 syringes of Heparin that expired 8/2023, 4 syringes of Heparin that expired 3/31/2024, 2 syringes of Heparin that expired 5/2024, 3 syringes of Heparin that expired 6/2024, and 1 syringe of Heparin that expired on 7/2024. b. An observation was conducted on 11/12/2024 at 12:42 pm of the North Medication Storage Room. The North Medication Storage room contained 3 bags of 0.45% Normal Saline that expired 8/2024. c. An observation was conducted on 11/12/2024 at 2:28 pm of the Memory Care Unit Medication Storage Room. The Memory Care Unit Storage Room contained 2 syringes of Heparin that expired on 4/20/2024, 7 syringes of Heparin that expired on 5/2024, 1 bag of Normal Saline 250 ml that expired 5/2024, 2 syringes of Heparin that expired on 6/2024, 3 syringes of Heparin that expired on 7/2024, 19 syringes of Heparin that expired on 8/2024, and 4 syringes of Heparin that expired 9/2024. An interview was conducted on 11/12/2024 at 2:30 pm with the Assistant Director of Nursing (ADON). The ADON stated she audited all the medication carts and medication storage rooms recently and there were not any expired medications at that time. An interview was conducted on 11/14/2024 at 12:14 pm with the Unit Manager. The Unit Manager stated she and the ADON were responsible for checking to ensure there were no expired medications on the medication carts or in the medication storage rooms. The Unit Manager stated medication carts are checked daily and medication storage rooms are checked weekly. The Unit Manager stated she was not sure why there were expired medications in the medication storage rooms. A follow-up interview was conducted on 11/14/2024 at 2:45 pm with the ADON. The ADON stated she had audited the medication carts, uncertain about medication storage rooms, 11/8/2024. The ADON stated when she checked medication carts, she checked opened insulin pens to ensure they were not expired, checked expiration dates on other medications, and check to ensure medications on the cart were prescribed. The ADON stated when the medication storage rooms were checked, she checked for the same things. The ADON stated she had never looked in the drawers where the Heparin was stored. An interview was conducted on 11/14/2024 at 3:03 pm with the Director of Nursing (DON). The DON stated the ADON should have checked for expired medications and supplies at least weekly. The DON stated the facility had not followed the medication storage process.

Based on record review and resident and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of opioid medications and bowel continence for 2 of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR) (Resident #65 and Resident #67). The findings included: 1. Resident #65 was admitted to the facility on [DATE] with diagnoses that included chronic pain A review of Resident #65's most recent quarterly Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. Resident #65 was not coded as taking any opioid medications during the assessment lookback period (7 days ending on the assessment date). A review of Resident #65's physician orders dated 3/15/24 included the following: [hydrocodone-acetaminophen] (an opioid analgesic medication) 7.5 - 325 milligrams (mg) - Give one tablet by mouth, two times a day for pain. A review of Resident #65's August and September 2024 medication administration records revealed Resident #65 received opioid pain medication two times per day during the assessment lookback period. A review of Resident #65's care plan, last reviewed on 09/13/24, revealed a care plan for the following area: [Resident #65] is at risk for developing complications secondary to .opioid medication [use]. Interventions included to monitor for effectiveness of medication among others. An interview with Resident #65 on 11/13/24 at 12:14 PM revealed she occasionally had some pain and that she did take pain medication that helped control the pain. She indicated she was unsure what the pain medication she took was called. During an interview with MDS Nurse #2 on 11/15/24 at 10:23 AM, she reported she had noted that Resident #65 was on receiving opioid medications and that it should have been accurately coded in her quarterly MDS assessment dated [DATE]. MDS Nurse #2 reported she must have just mis-clicked the box. During an interview with the Director of Nursing on 11/15/24 at 10:53 AM, she reported MDS assessments should be completed accurately and indicated if Resident #65 was taking opioid medications, it should have been correctly coded on her quarterly MDS assessment dated [DATE]. During an interview with the Administrator on 11/15/24 at 11:47 AM she stated MDS assessments should accurately reflect the individual resident and the medications they take. She stated she expected MDS assessments to be accurate and complete. 2. Resident #67 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur. A review of Resident #67's significant change in status MDS assessment dated [DATE] revealed he had moderate cognitive impairment. Resident #67's bowel continence was coded as not rated. Review of Resident #67's bowel movement records from 08/06/24 through 08/12/24 which would be the MDS assessment lookback period revealed he had 10 bowel movements over those 7 days and was noted as being incontinent. During an interview with MDS Nurse #1 on 11/15/24 at 10:20 AM she revealed if a resident was coded as not rated for bowel continence on the Minimum Data Set assessment, it would indicate that they either had an ostomy or had not had a bowel movement during the assessment lookback period. She indicated she was aware that Resident #67 did not have an ostomy. After she reviewed Resident #67's record, she noted he had multiple bowel movements documented during the lookback period. She stated she should have coded Resident #67's bowel continence as always incontinent based on the information in the medical record. MDS Nurse #1 surmised that she must have mis-clicked not rated. During an interview with the Director of Nursing on 11/15/24 at 10:53 AM, she reported Minimum Data Set assessments should be completed accurately and indicated if Resident #67 was incontinent of bowel, it should have been correctly coded on the Minimum Data Set assessment dated [DATE]. During an interview with the Administrator on 11/15/24 at 11:47 AM she stated Minimum Data Set assessments should accurately reflect the individual resident and their continence status. She stated she expected Minimum Data Set assessments to be accurate and complete.

Based on observations, record review and staff and Resident interviews, the facility failed to ensure supplemental oxygen was delivered at the physician prescribed rate for 1 of 1 resident reviewed for respiratory care (Resident #61). The finding included: Resident #61 was admitted to the facility on [DATE] with diagnoses that included coronary artery disease, heart failure and chronic obstructive pulmonary disease (COPD). A review of Resident #61's physician orders indicated an order dated 01/03/24 for supplemental oxygen to be delivered continuously at 2 liters per minute. A review of Resident #61's care plan revised 07/12/24 revealed a diagnosis of COPD which required oxygen therapy with a goal that the Resident would show no signs and symptoms of poor oxygenation. The interventions included delivering supplemental oxygen at the prescribed rate of 2 liters per minute via nasal cannula. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61's cognition was moderately impaired, and she received oxygen therapy. The MDS also indicated the Resident required substantial to maximal assist for turning side to side while in the bed. On 11/12/24 at 12:21 PM an observation and interview made with Resident #61 revealed she was lying in bed on her back wearing supplemental oxygen delivered through a nasal cannula. The oxygen concentrator was positioned at the foot of the bed with the gage facing the bed. The concentrator was rolled outward to reveal the oxygen was set to deliver 4 liters per minute. Resident #61 remarked she stayed in the bed most of the time unless she went to a doctor's appointment. She stated she did not know how much oxygen she was supposed the be receiving and that she did not mess with the concentrator setting nor could she reach it. An observation was made on 11/13/24 at 08:59 AM of Resident #61's oxygen concentrator which was set to deliver 4 liters per minute. The concentrator was positioned at the foot of the Resident's bed with the gauge facing the bed. At 11:46 AM on 11/13/24 during an observation of Resident #61's oxygen concentrator the setting remained at 4 liters per minute. The Resident again remarked she could not reach the dial on the oxygen concentrator and did not know what the machine should be set on. An interview was conducted with Nurse #1 on 11/13/24 at 2:12 PM. The Nurse explained that she was responsible for Resident #61 on 11/12/24 and 11/13/24 day shift (7 AM - 3 PM) but had not checked the oxygen concentrator setting yet that day. Nurse #1 reviewed the order for the oxygen which was for 2 liters per minute then went to Resident #61's room to find the oxygen concentrator was set on 4 liters and adjusted the flow back to 2 liters per minute. Nurse #1 explained she could not remember if she had checked the oxygen concentrator setting the day prior (11/12/24) during her shift then checked the Resident's Treatment Administrator Record (TAR) to find that Unit Manager (UM) #1 had checked the TAR on 11/12/24 day shift for the correct setting. An interview was conducted on 11/13/24 at 2:24 PM with Unit Manager #1 who explained that she did initial Resident #61's TAR on 11/12/24 for the correct setting but admitted that when she looked at the oxygen concentrator she only looked to see if the tubing and bag had been changed and dated within the correct timeframe. Attempts were made to interview Nurse #2 who initialed Resident #61's TAR for the correct setting of 2 liters on 11/12/24 evening and night shifts but the attempts were unsuccessful. During interviews with the Director of Nursing (DON) on 11/13/24 at 3:13 PM and 11/15/24 at 9:54 AM she explained that the nurses were responsible for checking the oxygen concentrator for the correct setting every shift and initialing the TAR when the procedure was completed. The DON stated she learned on 11/14/24 from a staff member that Resident #61 would use her bed remote to lower her bed then use her Reacher to adjust the knob on the oxygen concentrator to the setting she desired. When the DON was asked why the facility had not identified that as a problem and care planned the situation to monitor her more frequently, the DON replied, we should have. An interview was conducted with the Administrator on 11/15/24 at 10:40 AM who explained that her expectation was for the nurses to monitor the oxygen setting as ordered and not initial off the TAR until the procedure was completed.

Based on record reviews and staff and Consultant Pharmacist interviews, the facility failed to follow the pharmacy recommendation to add side effect monitoring to an antipsychotic medication (used to treat mental disorders) for 1 of 5 residents (Resident #96) reviewed for unnecessary medications. The finding included: Resident #96 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had intact cognition and received an antipsychotic medication. A review of Resident #96's physician orders revealed orders for - risperidone 2 milligrams (mg) by mouth twice a day for schizophrenia dated 07/02/24. - risperidone 2 mg by mouth once a day in the morning and 3 mg once a day at bedtime for schizophrenia dated 08/08/24. - risperidone 3 mg by mouth twice a day for schizophrenia dated 08/30/24. A review of a Pharmacy report dated 08/16/24 revealed a suggestion to add side effects and behavior monitoring to the antipsychotic medication (risperidone). Reviews of the Medication Administration Records (MAR) for 07/2024, 08/2024, 09/2024, 10/2024 and 11/2024 revealed there were no directions to monitor for side effects and behaviors for the antipsychotic medication on the MARs. An interview was conducted on 11/14/24 at 9:36 AM with the Pharmacy Consultant who explained that she routinely pulled a report about every other month to ensure that all psychoactive medications have monitoring instructions for the medications. She acknowledged that she notified the facility to add the monitoring of behaviors and side effects to Resident #96's antipsychotic order on her 08/16/24 report and stated she would follow up on her request this month during her next review because her schedule had to be adjusted because of the recent hurricane. The Pharmacist indicated that it was her expectation for the facility to have added the monitoring before her next medication regimen review. During an interview with the Director of Nursing (DON) on 11/14/24 at 9:49 AM the DON stated she was aware of the Consultant Pharmacist's request to add the monitoring instructions to Resident #96's antipsychotic medication, but it just slipped by her and it should have been done because she has had ample time to do it. An interview was conducted with the Administrator on 11/15/24 at 10:36 AM who explained that she expected the staff to address the Pharmacy recommendations when they were provided to the facility.

Based on record reviews and staff and Consultant Pharmacist interviews, the facility failed to identify the lack of monitoring for side effects and behaviors for an antipsychotic medication (used to treat mental disorders) for 1 of 5 residents reviewed for unnecessary medications (Resident #96). The finding included: Resident #96 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #96 had intact cognition and received an antipsychotic medication. A review of Resident #96's physician orders revealed orders for - risperidone 2 milligrams (mg) by mouth twice a day for schizophrenia dated 07/02/24. - risperidone 2 mg by mouth once a day in the morning and 3 mg once a day at bedtime for schizophrenia dated 08/08/24. - risperidone 3 mg by mouth twice a day for schizophrenia dated 08/30/24. A review of a Pharmacy report dated 08/16/24 revealed a suggestion to add side effects and behavior monitoring to the antipsychotic medication (risperidone). Reviews of the Medication Administration Records (MAR) for 07/2024, 08/2024, 09/2024, 10/2024 and 11/2024 revealed there were no directions to monitor for side effects and behaviors for the antipsychotic medication on the MARs. On 11/13/24 at 3:38 PM during an interview with Nurse #1, she confirmed she was Resident #96's full time Nurse on first shift. The Nurse explained that the admitting nurse was responsible for putting the monitoring directions for the psychoactive medications on the MARs. Nurse #1 reviewed Resident #96's last three monthly MARs and acknowledged there were no behavioral or side effects monitoring on the MARs and stated, oh well, I guess that was my fault. An interview was conducted on 11/14/24 at 9:36 AM with the Pharmacy Consultant who explained that she routinely pulled a report about every other month to ensure that all psychoactive medications have monitoring instructions for the medications. She acknowledged that she notified the facility to add the monitoring of behaviors and side effects to Resident #96's antipsychotic order on her 08/16/24 report and stated she would follow up on her request this month during her next review. She indicated she would have pulled another report during her October visit, but her schedule had to be readjusted for her reviews at the facilities because of the hurricane and had not been able to review the facility's medication regimen for this month yet but indicated that her expectation was for the facility to have added the monitoring before her next review. During an interview with the Director of Nursing (DON) on 11/14/24 at 9:49 AM the DON explained that the unit managers and the nurses were responsible for adding the monitoring instructions to the psychoactive medications. The DON stated she was aware of the Consultant Pharmacist's request to add the monitoring instructions to Resident #96's antipsychotic medication, but it just slipped by her and it should have been done because she has had ample time to do it. An interview was conducted with the Administrator on 11/15/24 at 10:36 AM who explained that she expected the staff to address the Pharmacy recommendations when they were provided to the facility.

Based on observations, record reviews and staff interviews, the facility failed to implement their policy for handwashing/hygiene when Nurse Aide (NA) #1 failed to sanitize her hands after removing soiled gloves during incontinent care. The facility also failed to handle soiled linen in a manner to prevent the spread of infection when Nurse Aide #2 threw soiled linen on the floor after providing incontinent care. This occurred for 2 of 2 staff members observed for infection control practices (NA #1 and NA #2). The findings included: A review of the facility's policy for Handwashing/Hand Hygiene revised October 2023 revealed the facility considered hand hygiene to be the primary means to prevent the spread of healthcare-associated infections. 1. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. Indications for Hand Hygiene: c. after contact with blood, body fluids, or contaminated surfaces; f. before moving from work on a soiled body site to a clean body site on the same resident, and g. immediately after glove removal. A review of the facility's policy for Making an Occupied Bed revised October 2010 revealed 4. Do not put soiled linen on the floor. As you remove it, place it into the container you are using for soiled laundry/linen. On 11/14/24 at 3:02 PM to 3:45 PM a continuous observation was made of Nurse Aide (NA) #1 and NA #2 providing incontinence care for Resident #85. Unit Manager (UM) #1 was present during the Resident's care. The NAs brought clean bed linens into the room and trash bags. NA #1 and NA #2 donned gloves and gowns because the Resident was on Enhanced Barrier Precautions because of a stage IV sacral wound. The NAs proceeded to turn the Resident over on her side to discover the Resident was incontinent of stool which had soiled her sacral dressing. NA #1 proceeded to remove the soft stool using multiple wipes then removed her gloves and applied clean gloves multiple times without washing or sanitizing her hands. The UM asked NA #1 to remove the soiled dressing so that another dressing could be applied. After the NA removed the dressing, she removed her gloves and applied clean gloves without using hand sanitizer or washing her hands. While waiting for the Wound Nurse to apply a new sacral dressing, NA #1 applied lotion on the Resident's back. After the new dressing was applied by the Wound Nurse the two NAs proceeded to turn the Resident over to her other side then NA #2 removed the Resident's bed linen and threw the dirty/soiled linen on the floor. The two NAs finished putting clean sheets on the bed and NA #2 picked up the soiled linen from the floor and put the linen in a trash bag. The 2 NAs removed their gowns and gloves and sanitized their hands after they left the Resident's room. An interview was conducted with NA #1 on 11/14/24 at 3:46 PM. The NA was asked about the incontinence care provided to Resident #85 and the NA explained that she knew she did not wash her hands after she removed her gloves even though there was a hand sanitizer dispenser on the Resident's wall in her room. She indicated she was nervous being watched during the procedure. During an interview with NA #2 on 11/14/24 at 5:17 PM, the NA explained that she did not take care of Resident #85 often but thought she needed to get the dirty soiled linen off the bed before the Resident had another stool and NA #1 turned the Resident over on the linen. She indicated it was instinct that she threw it on the floor and knew that she should not have done that. During an interview with Unit Manager (UM) #1 on 11/14/24 at 4:53 PM, the UM explained that she noticed NA #2 threw the dirty/soiled linen on the floor and she should not have done that because of infection control. The UM remarked the NAs had several plastic bags that they brought in with them for the dirty linen. The UM indicated she did not have time to correct NA #2 because it happened so fast. The UM also stated she did not notice that NA #1 never used hand sanitizer when she changed her gloves multiple times during the incontinence care. She reported that the facility had a skills fair about a month ago and everyone was educated on infection control. An interview was conducted with the Director of Nursing (DON) on 11/15/24 at 9:58 AM who reported she was informed of the mistakes the two NAs made during Resident #85's incontinence care yesterday and explained that they both attended a skills fair about a month ago and infection control and handwashing was covered in the skills fair. The DON indicated the NAs needed to be reeducated on infection control. On 11/15/24 10:46 AM during an interview with the Administrator, she explained that the two NAs knew better and had recently been educated on infection control and would be reeducated.

Based on observations, record review, staff, resident, and Physician Assistant interviews the facility failed to ensure a Bilevel Positive airway Pressure (BiPAP) machine (machine used to push air into your lungs), was in working order (Resident #38), failed to ensure oxygen concentrators and filters were clean (Resident #6, Resident #9, Resident #18, and Resident #65), failed to ensure an oxygen concentrator had external filters (Resident #21), and failed to ensure an oxygen flow rate was at the prescribed rate (Resident #6). This affected 6 of 6 residents reviewed for respiratory care. The findings included: 1. Resident #38 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident #38's diagnoses included chronic obstructive pulmonary disease, acute/chronic respiratory failure with hypoxia, and others. Review of a physician order dated 07/31/23 read, BiPaP machine at night. Inspiratory pressure 12, Expiratory Pressure 6, and timed rate 14 with 3 liters of oxygen for chronic obstructive pulmonary disease. Review of the Treatment Administration Record (TAR) dated 08/01/23 through 08/31/23 revealed that Resident #38 wore her BiPaP nightly as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #38 was cognitively intact and required oxygen during the assessment reference period. An interview and observation were conducted with Resident #38 on 08/14/23 at 9:45 AM. Resident #38 was resting in bed with an oxygen cannula in her nose at 3 liters per minute. Resident #38 stated she recently returned to the facility from the hospital and had a new BiPaP machine that she wore each night. She stated that last night the BiPaP machine did not work, and she did not sleep most of the night because her machine was not working. She stated that Nurse #1 had tried to get it working but could not. Resident #38 was in no respiratory distress. An interview and observation were conducted with Resident #38 on 08/15/23 at 8:46 AM. Resident #38 was resting in bed and had an oxygen cannula in her nose at 3 liters per minute. She stated that she could not use her BiPaP machine last night because it was still not working. She stated she had slept a bit but not for long and it certainly was not good sleep. Resident #38 was in no respiratory distress. An interview and observation were conducted with Resident #38 on 08/16/23 at 8:46 AM. Resident #38 was resting in bed and had oxygen in use at 3 liters per minute. She stated that her BiPaP machine did not work again last night, and she was not sure who the nurse was, but she tried to get it to come on but couldn't. Attempts to speak to Medication Aide (MA) #1 were made on 08/16/23 at 9:58 AM and were unsuccessful. An interview was conducted with MA #2 on 08/16/23 at 11:07 AM. MA #2 confirmed that she was caring for Resident #38 and that she had relieved MA #1 this morning. During report MA #2 stated that MA #1 did not report anything to her about Resident #38's BiPaP machine not working. If he had reported that, MA #2 stated she would report that to her nurse immediately so they could get it repaired. MA #2 confirmed that when she arrived for her shift, Resident #38 did not have her BiPaP machine on but did have her oxygen on. Nurse #2 was interviewed on 08/16/23 at 12:01 PM who confirmed that she had worked second shift with Resident #38 the previous day. Nurse #2 stated she was not aware that Resident #38's BiPaP machine was not working until earlier on 08/16/23 when MA #2 had reported it to her. She stated she was busy and asked MA #2 to alert the Unit Manager (UM) about the BiPaP machine that was not working. The Physician Assistant (PA) was interviewed via phone on 08/16/23 at 2:35 PM. The PA stated that BiPaP machines should be worn each night and if the resident did not wear it every night, they may wake up with a headache and feel exhausted. She explained that if the resident's oxygen level dropped through the night and they did not have their BiPaP machine on the resident would not be getting enough oxygen to the brain which would lead to the headache and fatigue the next day. The UM was interviewed on 08/16/23 at 3:53 PM who confirmed that MA #2 had reported to her earlier that day that Resident #38's BiPaP machine was not working, and she had called the rental company and they were going to send her another machine immediately. The UM stated she had gone down to speak to Resident #38, and she reported that it had not been working for a couple of days. The UM again confirmed that she was unaware of the BiPaP machine not working until early during her shift on 08/16/23. Nurse #1 was interviewed on 08/17/23 at 6:56 AM and confirmed that he had worked with Resident #38 on 08/14/23. Nurse #1 stated that around 2:00 AM on 08/14/23 Resident #38 called Nurse #1 to her room and reported her BiPaP machine was not working. Nurse #1 stated he could not get the machine to work properly even after resetting it several times, so he gave Resident #38 a breathing treatment, checked her oxygen saturation level, and made sure her oxygen was in place at 3 liters. Nurse #1 also stated that he looked for a manual for the machine but could not locate one. Nurse #1 thought that he had reported the BiPaP machine to Nurse #4 on Tuesday morning during report. He added that Nurse #2 was on duty on second shift Monday night, and she may have been aware of the BiPaP machine that was not working as well. Nurse #4 was interviewed on 08/17/23 at 9:11 AM who stated that she was the nurse responsible for Resident #38 earlier in the week. She stated she was not aware that Resident #38's BiPaP machine was not working. She confirmed that Nurse #1 nor MA #1 reported any issues to her regarding the BiPaP machine. If she had been aware she would have let the UM know so that someone could have come and repaired the machine. An interview and observation were conducted with Resident #38 on 08/17/23 at 9:14 AM who reported that she did not wear her BiPaP machine last night because it was still not working properly. She stated the staff had told her they were sending her a new one, but she was not sure when it would arrive. Resident #38 was in no respiratory distress. The Director of Nursing (DON) was interviewed no 08/17/23 at 10:32 AM. The DON stated she was on vacation 08/14/23 and 08/15/23 and returned to the facility on [DATE] and was informed that Resident #38's BiPaP machine was not working. She stated she went and looked at the machine and it appeared the start/stop button had stopped working, she stated that she got the machine to come on using the auto on feature that the machine had but then it could not be turned off unless you unplugged the machine. The DON stated that they had contacted the rental company and they were going to send a replacement to the facility for Resident #38. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, acute/chronic respiratory failure, and others. Review of a physician order dated 04/22/21 read; oxygen at 3 liters continuous via nasal cannula to maintain oxygen saturation levels above 90%. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #6 was cognitively intact and required oxygen use during the assessment reference period. No shortness of breath was noted during the look back period. Review of Resident #6's medical record revealed her oxygen saturation range for August 2023 was 90-95% except on 08/15/23 Resident #6's oxygen saturation level was 88%. An observation and interview were conducted with Resident #6 on 08/14/23 at 11:51 AM. Resident #6 was resting in bed with oxygen in use at 1 liter per minute via nasal cannula. Her oxygen concentrator was sitting in a corner or her room out of Resident #6's reach. Resident #6 was in no respiratory distress but stated she thought she was supposed to be on 2 liters of oxygen. Resident #6 stated she felt like she needed to be on 2 liters of oxygen, and she would have the staff fix the concentrator when they came back into the room. Resident #6's oxygen concentrator had 2 external filters one on each side of the concentrator. Both external filters were supposed to be black in color but were white due to the dust that covered each of them. An observation and interview were conducted with Resident #6 on 08/15/23 at 9:08 AM. Resident #6 was resting in bed with oxygen in use at 1 liter via nasal cannula. She stated that she had forgotten to say anything to the nursing staff about her oxygen but felt better today. Both external filters of the oxygen concentrator were supposed to be black in color but were white due to the dust that covered each of them. Resident #6 was in no respiratory distress. An interview was conducted with Nurse #4 on 08/15/23 at 2:53 PM who confirmed that she was caring for Resident #6. Nurse #4 stated that Resident #6 was supposed to be on 2 liters of oxygen and that she generally checked the flow rate at least once every day during her shift. Nurse #4 stated that the oxygen concentrators did not have filters that would requiring cleaning or changing. Nurse #4 was asked to accompany the State Surveyor to Resident #6's room. She confirmed that Resident #6's oxygen level was at 1 liter per minute and bumped it to 2 liters per minute. Nurse #4 was also shown both external filters of the oxygen concentrator and agreed that the filters were dirty with dust and needed to be cleaned. Nurse #4 stated she would take care of them immediately. An observation of Resident #6 was made on 08/17/23 at 10:15 AM. Resident #6 was resting in bed with her eyes closed and had oxygen in use at 2 liters per minute via nasal cannula. Both external filters of the oxygen concentrator had been cleaned and where black in color with no dust noted on either of them. The Director of Nursing (DON) was interviewed on 08/17/23 at 10:32 AM. The DON stated that the oxygen flow rate should be checked at least every shift and when switching a resident between a concentrator and a e-tank (portable tank of oxygen), to ensure the correct flow rate. She was made aware of Resident #6's oxygen flow rate and her oxygen saturation level of 88% on 08/15/23 and stated she would speak to the medical provider for guidance regarding Resident #6's oxygen level. The DON stated that the oxygen filters were scheduled to be cleaned or changed once a month and when visibly soiled. The DON stated that the facility may need to adjust the frequency of the cleaning of oxygen filters so that the dust did not build up. She stated that the facility had recently been undergoing some renovations and believed that the increase in dust particles came from that construction. 3. Resident #9 was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE]. Resident #9's diagnoses included chronic obstructive pulmonary disease, obstructive sleep apnea, acute respiratory failure, and others. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #9 was cognitively intact and required oxygen use during the assessment reference period. An observation of Resident #9 was made on 08/14/23 at 10:32 AM. Resident #9 was resting in bed and had oxygen in use. Resident #9's oxygen concentrator was sitting next to her bed and there was no external filter noted on the machine. The oxygen concentrator was observed to have large clumps of dust and debris seeping out of the seam of the machine where the two side of the concentrator came together. The side handles of the concentrator were covered with white dust particles and the machine itself was covered with dirt and grim. Resident #9 stated she could not remember the last time she had seen the staff clean her oxygen concentrator. An observation of Resident #9 was made on 08/15/23 at 8:53 AM. Resident #9 was resting in bed and had oxygen in use. Resident #9's oxygen concentrator was sitting next to her bed and there was no external filter noted on the machine. The oxygen concentrator was observed to have large clumps of dust and debris seeping out of the seam of the machine where the two side of the concentrator came together. The side handles of the concentrator were covered with white dust particles and the machine itself was covered with dirt and grim. An interview with Nurse #4 was conducted on 08/15/23 at 2:53 PM who confirmed that she was responsible for Resident #9. Nurse #4 was asked to accompany the State Surveyor to Resident #9's room to observe the oxygen concentrator. Nurse #4 stated that she had observed Resident #9's flow rate but had not paid attention to the concentrator itself. Nurse #4 agreed the concentrator was dirty and contained dust buildup. She stated that she was going to see if maintenance could get Resident #9 a new oxygen concentrator. An observation was made on 08/16/23 at 9:54 AM. The maintenance staff was observed delivering a new oxygen concentrator to Resident #9. The Director of Nursing (DON) was interviewed on 08/17/23 at 10:32 AM. The DON stated that she had just returned from vacation and about a week prior to her vacation she had spoken to the Respiratory Therapist (RT) about having the internal oxygen concentrator filters cleaned. She explained that the facility had recently undergone renovations and she believed that the increase in dust particles came from the renovations. The DON added that normally the internal oxygen concentrator filters were cleaned annually but she had requested for them to be done sooner due to the renovations and increase in dust particles. 37280 4. Resident #18 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). A review of Resident #18's care plan revised 01/20/17 indicated the use of oxygen related to the diagnosis of COPD with the goal that the Resident would have no signs or symptoms of poor oxygenation. The interventions utilized included administering supplemental oxygen at the prescribed rate and monitor for symptoms of poor oxygenation. A review of Resident #18's physician order dated 01/28/21 indicated check and clean concentrator filter every month and PRN (as needed) every night shift starting on the 28th and ending on the 28th every month. A review of Resident #18's physician order revised 06/03/23 indicated continuous oxygen at 2-6 liters per minute via nasal cannula to maintain oxygen saturation greater than 88%. Resident #18's quarterly Minimum Data Set assessment dated [DATE] indicated the Resident was cognitively intact and received supplemental oxygen therapy. A review of Resident #18's July 2023, Treatment Administration Record (TAR) revealed on 07/28/23 the TAR was initialed by Nurse #3. An interview and observation were conducted with Resident #18 on 08/14/23 at 9:21 AM. The Resident wore oxygen via nasal cannula and explained that she wore the oxygen continuously. The oxygen concentrator had a black filter attached to the back of the concentrator which had a thick accumulation of dust that the filter appeared gray. An observation of Resident #18's oxygen concentrator filter on 08/15/23 at 8:43 AM remained unchanged with the black imprint still in the filter. On 08/15/23 at 2:24 PM an interview was conducted with Nurse #4 who confirmed that she was the full time Nurse on Resident #18's hall. The Nurse explained that the oxygen filters were cleaned every week or two by the housekeeping department because they had the stuff used to clean the filters. The Nurse stated if the filters were dusty then they needed to be changed because they would stop up. During the interview, the Nurse observed the dusty gray filter on the back of Resident #18's concentrator and remarked that she needed to go get some supplies and clean the filter. During an interview with the Unit Manager (UM) on 08/15/23 at 3:03 PM explained the oxygen concentrator filters were checked and cleaned monthly on the 15th by the third shift nurse. The UM stated her expectation was that the filters be cleaned more often because since the facility recently had remodeling, there had been more dust and the filters should be cleaned as needed. An interview was conducted with Nurse #3 on 08/15/23 at 10:12 PM who initialed that she checked and cleaned Resident #18's oxygen filter on 07/28/23. The Nurse explained that the oxygen concentrators were cleaned once a month and the schedule would be on the TAR. The Nurse stated she did not remember when she cleaned the Resident's filter last but if her initials were on the TAR then she cleaned the filter. During an interview with the Director of Nursing (DON) on 08/17/23 at 11:06 AM the DON explained that it was the nurses' responsibility to clean the oxygen concentrators once a month and as needed so if the concentrator filters were dusty then they needed to be cleaned more often than monthly. An interview was conducted with the Administrator on 08/17/23 11:46 AM who explained that she expected the oxygen concentrator filters to be cleaned according to the facility policy of monthly and as needed and in Resident #18's case if should have been done as needed. 5. A review of the Invacare Platinum Oxygen Concentrator manual dated 2016 provided by the facility revealed on page 24 section 7.3 Cleaning the Cabinet Filter, CAUTION! Risk of Damage, To avoid damage to the internal components of the unit: - DO NOT operate the concentrator without the filter installed or with dirty filter. Resident #21 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD). A review of Resident #21's physician orders revealed an order dated 07/19/23 of oxygen at 2 liters per nasal cannula. The annual Minimum Data Set assessment dated [DATE] revealed Resident #21 was cognitively intact and received supplemental oxygen therapy. A review of Resident 21's care plan revised on 07/24/23 indicated the Resident was at risk for respiratory difficulty related to oxygen therapy. The goal to not have respiratory complications would be attained by utilizing interventions such as monitoring for respiratory distress and administering oxygen as ordered. A review of Resident #21's Treatment Administration Record (TAR) dated 08/2023 revealed the oxygen had been administered every day. The TAR also indicated on 08/01/23 the oxygen concentrator filters were to be checked and cleaned monthly and PRN (as needed) every night shift on the first of the month. On 08/01/23 the TAR was initialed by Nurse #3 which indicated the treatment had been done. An interview and observation were made of Resident #21 on 08/14/23 at 11:25 AM. The Resident was sitting in his wheelchair at his bedside and wore oxygen via nasal cannula. The Resident stated he received oxygen at 2 liters per minute which was what the oxygen concentrator was set at. It was also noted that the two bilateral external filters were missing off the oxygen concentrator. An observation made on 08/15/23 at 8:50 AM of Resident #21's oxygen concentrator. The external filters were still missing. On 08/15/23 at 2:40 PM an interview was conducted with Nurse #4 who explained that she was responsible for Resident #21 when she had to cover for the medication aide. The Nurse explained that the oxygen filters were checked and cleaned every week or two by the housekeeping department because they had the stuff used to clean the filters. During the interview the Nurse observed that there were no external filters on Resident #21's oxygen concentrator and stated, it does not surprise me and walked out of the room. An interview was conducted with the Unit Manager (UM) on 08/15/23 at 3:09 PM. The UM explained that the third shift nurses were responsible for checking and cleaning the oxygen concentrator filters once a month on the 15th and as needed. She stated the facility had undergone remodeling recently and the external filters were more likely to be dusty and needed to be cleaned more than once a month. When the UM was informed that multiple observations were made of Resident #21 not having external filters on his oxygen concentrator, she remarked that the nurse should have gotten a new concentrator for Resident #21, or the nurse should have made sure that someone on first shift got the Resident a new concentrator. On 08/15/23 at 10:15 PM an interview was made with Nurse #3. The Nurse explained that the oxygen concentrator filters were cleaned once a month and the schedule would be on the TAR. The Nurse stated she did not remember when she cleaned the Resident's filter last or even if the Resident had filters on his concentrator but if her initials were on the TAR then she cleaned the filters. On 08/16/23 at 2:00 PM an observation of Resident #21's oxygen concentrator remained without the two external filters. Attempts were made to interview the Respiratory Therapist, but the attempts were unsuccessful. During an interview with the Director of Nursing (DON) on 08/17/23 at 11:06 AM the DON explained that it was the nurses' responsibility to check and clean the oxygen concentrators once a month and as needed and if the external filters were missing then the nurse should have changed out the concentrator. The DON was informed that the missing filters was brought to Nurse #4's attention on 08/15/23 and as of last round on 08/16/23 the oxygen concentrator remained in the Resident's room and the DON stated Nurse #4 should have made sure that something was done about the missing filters even if it was to change out the oxygen concentrator herself. An interview was made with the Administrator on 08/17/23 at 11:48 AM who stated Resident #21's oxygen concentrator should have been changed out when it was brought to the nurse's attention that there were no external filters on his concentrator. 47478 6. Resident #65 was admitted to the facility on [DATE]. Resident #65 had diagnosis that included Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #65's medical record stated that a physician order dated 09/15/2022 read: Oxygen at 2 liters per minute as needed. Resident #65's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #65 was cognitively intact. She was receiving oxygen during the assessment reference period. An observation was completed of Resident #65 on 08/14/23 at 10:06 AM where her oxygen was noted to be running at 2 liters per minute (LPM). The oxygen concentrator had two external filters that were white in color from the dust particles. (The color of the filters were supposed to be black with no white from dust particles.) Resident #65 did not appear to be in any respiratory distress. An additional observation and interview were completed with Resident #65 on 08/15/23 2:54 PM where resident was resting in bed without her oxygen on. She did not have any signs or symptoms of shortness of breath. The two-filters on the concentrator continued to be white in color from the dust particles. Resident #65 stated that she only wore oxygen at night. She stated that she had COPD and had some coughing however it was not all the time. An interview was completed with Nurse #4 on 08/15/23 at 2:43 PM. Nurse #4 stated that she was assigned to Resident #65. She stated that she cleaned the concentrator daily and monitored the oxygen daily by ensuring that the concentrator settings were correct as ordered. She stated that oxygen filters and tubing were to be changed and cleaned on third shift weekly. She also stated that concentrators should be dusted off. Accompanied Nurse #4 to Resident #65's room to demonstrate the white colored filters. Nurse #4 stated that she would change the filter immediately. An interview with the Unit Manager was conducted on 08/15/23 at 3:03 PM. She stated that filters on the oxygen concentrators should be cleaned monthly and as needed by the nurse assigned to the unit. Unit Manager stated that she would expect the oxygen filters to be clean, she added that the facility has had more dust due to the recent remodel, but she would expect the staff to clean them. An observation of Resident #65 was conducted on 08/16/23 at 3:49 PM. Resident #65 was resting in bed with her oxygen concentrator next to her, the external filers were noted to have been cleaned and were free from dust and debris. An interview with Nurse #1 was conducted on 8/17/23 at 6:56 AM. Nurse #1 stated that oxygen filters were washed and laid out to dry by the third shift nursing staff on a monthly basis and as needed. The Director of Nursing (DON) was interviewed on 08/17/23 at 10:32 AM. The DON stated that the oxygen filters were scheduled to be cleaned or changed once a month and when visibly soiled. The DON stated that the facility may need to adjust the frequency of the cleaning of oxygen filters so that the dust did not build up. She stated that the facility had recently been undergoing some renovations and believed that the increase in dust particles came from that construction.

Based on observations, record reviews, staff, resident, and Physician Assistant interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint survey of 03/18/22. This failure was for 1 deficiency that was originally cited in the area of Quality of Care (F695) and was subsequently recited on the current recertification and complaint survey of 08/17/23. The repeat deficiency during two federal surveys of record showed a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F695: Based on observations, record review, staff, resident, and Physician Assistant interviews the facility failed to ensure a Bilevel Positive airway Pressure (BiPAP) machine (machine used to push air into your lungs), was in working order (Resident #38), failed to ensure oxygen concentrators and filters were clean (Resident #6, Resident #9, Resident #18, Resident #21, and Resident #65), and failed to ensure an oxygen flow rate was at the prescribed rate (Resident #6). This affected 6 of 6 residents reviewed for respiratory care. During the recertification and complaint survey of 03/18/22 the facility failed to secure an oxygen tank that was stored upright on the floor in the resident room. The Administrator was interviewed on 08/17/23 at 11:16 AM who stated the quality assurance committee met monthly and included the Medical Director and all department heads. The Administrator added the consultant pharmacist attended the quality assurance committee meetings quarterly. She explained that during the meetings they went over every department in the facility included previous minutes, clinical systems, rehospitalization s, care delivery, operations, educations, financials, safety issues, any policy issues, and grievances. The Administrator stated that after all departments had been reviewed the Medical Director gave his input on ways to improve things. She further explained that the implemented interventions from the previous recertification survey continued but the audits had stopped, and she felt like the facility had achieved ongoing compliance. The Administrator stated that the facility would have to implement procedures to ensure all respiratory devices were functioning properly and cleaned and monitor them more closely to ensure nothing fell to the wayside.

Based on observations and staff interviews the facility failed to maintain a safe homelike environment when an electrical outlet was not secured to the wall (room [ROOM NUMBER]) and failed clean side rails on resident beds (room [ROOM NUMBER] B, room [ROOM NUMBER] A, room [ROOM NUMBER] A, and room [ROOM NUMBER] B) this affected 1 of 4 units in the facility (North). The findings included: 1. An observation of room [ROOM NUMBER] A on the North unit was made on 08/14/23 at 10:37 AM. The electrical outlet behind the resident bed was noted to be unsecured to the wall in which it was placed. The outlet had been placed inside the dry wall and a bit of caulk (flexible material used to seal cracks and gaps) had halfway been applied. The open wall space behind the outlet was visible. There was medical equipment plugged into the outlet. An observation of room [ROOM NUMBER] A on the North unit was made on 08/15/23 at 9:07 AM. The electrical outlet behind the resident bed was noted to be unsecured to the wall in which it was placed. The outlet had been placed inside the dry wall and a bit of caulk had halfway been applied. The open wall space behind the outlet was visible. There was medical equipment plugged into the outlet. An observation of room [ROOM NUMBER] A on the North Unit was made on 08/16/23 at 8:38 AM. The electrical outlet behind the resident bed was noted to be unsecured to the wall in which it was placed. The outlet had been placed inside the dry wall and a bit of caulk had halfway been applied. The open wall space behind the outlet was visible. There was medical equipment plugged into the outlet. The Maintenance Assistant was interviewed on 08/16/23 at 9:45 AM who confirmed that he was covering for the Maintenance Director who was out of work. He stated that anytime that there was a needed repair within the facility the staff (any staff) would fill out a repair slip and place it in the book at the nurse's station. Each morning the Maintenance Assistant stated he would check the book and make any needed repairs. The Maintenance Assistance accompanied the State Surveyor to room [ROOM NUMBER] A on the North unit to observe the electrical outlet behind the resident bed. The Maintenance Assistant confirmed that no one had reported the outlet to him, and he was unaware of the condition of the outlet. He stated that it did not look very safe, and he would repair it immediately. The Administrator was interviewed on 08/17/23 at 11:08 AM and was made aware of the condition of the electrical outlet. Her only response was that the Maintenance Assistant had changed it right away. 2a. Observations of Room # 103 B on the North unit were made on 08/14/23 at 9:49 AM, 08/15/23 at 8:45 AM, and 08/16/23 at 8:34 AM. The inside corner of the side rails on the occupied resident bed were noted to be full of food crumbs, dirt, and debris. The left side rail contained more crumbs, dirt, and debris than the right-side rail contained. b. Observations of room [ROOM NUMBER] A on the North unit were made on 08/14/23 at 10:15 AM, 08/15/23 at 8:47 AM, and 08/16/23 at 8:22 AM. The side rails on the occupied resident bed were full of food crumbs, dirt, and debris. The right-side rail contained more crumbs, dirt, and debris than did the left side rail. c. Observations of room [ROOM NUMBER] A on the North unit were made on 08/14/23 at 11:33 AM, 08/15/23 at 9:08 AM, and 08/16/23 at 8:34 AM. The side rails on the occupied resident bed were full of food crumbs, dirt, and debris. The right-side rail contained more crumbs, dirt, and debris than did the left side rail. d. Observations of room [ROOM NUMBER] B on the North unit were made on 08/14/23 at 2:18 PM and 08/16/23 at 8:40 AM. The side rails on the occupied resident bed were full of food crumbs, dirt, and debris. An interview was conducted with Housekeeper #1 on 08/16/23 at 9:00 AM who confirmed that she worked on North unit. She stated each morning she reported to work she would go to her assigned resident rooms and empty the trash, dust the rooms, and make sure all high touch surfaces were cleaned and sanitized before cleaning the bathroom. Once the resident room and bathroom were cleaned Housekeeper #1 stated she would sweep and mop the room before moving to the next resident room. Housekeeper #1 stated that side rails were a high touch surface area, and they were cleaned with a disinfectant cleaner on a daily basis and of course as needed. Housekeeper #2 was interviewed on 08/16/23 at 9:04 AM who confirmed that she worked North unit anytime she was assigned to do so. She stated that each resident room was cleaned daily including weekends. She stated that first she would empty the trash can in the resident room before wiping down the bed side tables and other high touch surfaces and before she left, she would sweep and mop the floor. Housekeeper #2 confirmed that resident side rails were high touch surface areas and those were cleaned on a daily basis. The Director of Housekeeping was interviewed on 08/16/23 at 9:10 AM who confirmed that Housekeepers #1 and #2 were responsible for cleaning resident rooms on a daily basis. He stated that he checked behind the housekeepers and graded the cleanliness of their assigned rooms as way of ensuring they were doing what was expected of them. The Director of Housekeeping accompanied the State Surveyor to Room # 103 B, room [ROOM NUMBER] A, room [ROOM NUMBER] A, and room [ROOM NUMBER] B and agreed that the residents side rails were full of food crumbs, dirt, and debris and stated that he would take care of it immediately. The Administrator was interviewed on 08/17/23 at 11:08 AM and indicated she was aware of the resident side rails but declined to further comment on the subject.

Based on observations staff and resident interviews, record review and review of manufacturer's instructions, the facility failed to properly secure 1 of 2 residents who were transported on the facility's transport van. Resident #61 was seated in an unsecured wheelchair while being transported in the facility van and flipped backwards during transport. Resident #61 struck her head on the floor of the transportation van and diagnosed with [REDACTED]. The findings included: Review of the manufacturer's instructions for the L Track Applications and Retractors with S-hooks which is the system used on the facility's transport van to secure residents who are seated in wheel chairs during transport specified, Release the lever and place the S-hook securely around a structural member of the chair. Pull on the S-hook to ensure full engagement around the structural member. Repeat procedure with the other front retractor. Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] specified the resident's cognition was intact, she had no behaviors but required limited assistance with activities of daily living. The MDS also specified the resident used a wheelchair for locomotion. Review of the medical record revealed a care plan for falls updated 05/15/18 to reflect an incident in which the wheelchair tipped back in transport van, hematoma to back of head. Further review of the medical record revealed a progress note dated 05/15/18 at 3:00 PM that read in part, Resident out to DR (doctor) apt(appointment), arrived back around 3pm. Incident Report completed and neuro (neurological) checks initiated and are WNL (within normal limits). PA (Physician's Assistant) in to see resident and new orders received to send to ER (emergency room ) for evaluation. Resident aware and is own RP (Responsible Party). EMS (Emergency Medical Services) notified and are in route to facility at this time. A progress note dated 5/15/18 completed by the Physician's Assistant (PA) specified Resident #61 was complaining of a terrible headache and neck pain after her wheelchair fell backwards in van. The resident tells me this happened about 45 minutes ago and that when the van took off her wheelchair went down backwards and landed on the ground and the back of her head hit the door. She complains of a terrible headache and points to the front of her head. The PA wrote an order to send the resident to the Emergency Department for evaluation. The Emergency Department (ED) report dated 05/15/18 was reviewed and revealed the resident presented to ED after she fell out of her wheelchair today. The report read in part, patient states that her wheelchair was placed in a wheelchair van for transport. She states the wheelchair was not affixed to the floor of the van and then when the van drove off her wheelchair rolled backwards and tipped to the left. Patient struck the left side of her head on the door of the wheelchair van. She states she now has left-sided back pain. Resident #61 received a computerized tomography (CT) scan and x-rays that were negative for injury. Resident #61 was diagnosed with [REDACTED]. On 06/19/18 at 10:02 AM Resident #61 was interviewed in her room and reported she had never had any issues with the facility ' s transportation van but 4 or 5 weeks ago she was not properly strapped in. The Resident reported that the van driver secured her wheelchair as usual, closed the rear door to the van but when she looked down, the S hooks (metal hooks used to secure a tightened strap to the frame of the wheelchair) were not hooked. She added, before I could say anything, he (van driver) jumped in the front seat, flew out of the parking lot and I went whirling backwards and hit my head on the door. If the door had been open I would have fallen out of the van. The resident described that she hollered awful and van driver stopped the van and went to the back of the van, opened the rear door to check on the resident. Resident #1 stated she hit her head from the fall and was assisted back up by the van driver. She also stated, the van driver re-secured the resident's wheelchair and drove her back to the facility. Resident #61 stated she told the Administrator after the incident the hooks had not been attached properly. On 06/19/18 at 2:58 PM the Administrator was interviewed and stated the facility had a van incident. The Administrator reported she was not certain about what caused the incident but through an investigation concluded a problem occurred with the way Resident #61's wheelchair had been secured. The Administrator explained the van driver had been driving for the facility for [AGE] years and no previous incidents had been reported. She added the driver was trained yearly on a skills check list that was completed by herself or another corporate representative. The skills check list included online modules and demonstrations. The Administrator described that on 05/15/18 she was called by the Director of Nursing (DON) to come to the front entrance because there had been a van incident. She described seeing Resident #61 seated in a wheelchair and secured properly in the van using a 4-point security system and 2-point shoulder harness. The Administrator stated she was told by the van driver that Resident #61's wheelchair flipped backwards. She added there was a third person in the van when the incident occurred, nurse aide (NA) #1. The Administrator directed the DON to tend to Resident #61 to assess for injury while she separated the van driver and NA #1 and obtained statements. She stated the van driver and NA #1 stated the van driver had attached the front S hooks to the resident's wheelchair but when the wheelchair flipped backwards, the S hooks were no longer attached to the frame of the wheelchair. The Administrator reported that she also interviewed Resident #61 who reported to her the S-hooks were off the wheelchair causing her to flip backwards. During the interview, the Administrator provided the van driver's last annual skills check dated 07/25/17. Review of the skills check revealed the driver demonstrated he was aware of the manufacturer's instructions for securing a resident. On 06/19/18 at 3:09 PM the van driver was interviewed and reported he was the only van driver for the facility. He stated he had been in his position for [AGE] years and only had one incident. The van driver added that on 05/15/18 he was picking Resident #61 up from a medical appointment when an unfortunate incident occurred. The van driver described it was a typical day and he performed his usual routine of rolling the resident in her wheelchair into the back of the van, proceeded to secure the resident using the van's 4-point S-hook system. The van driver reported Resident #61 had a tendency of using her feet to press away from the front straps. The van driver added he secured the front S-hooks to the frame of the wheelchair in the front and back and tightened the straps. The van driver added he was not certain if the resident had her feet pressed in opposing force from the front straps or not and did not ask her to raise her feet to verify she was securely tightened. He then closed the back door, got in the front seat, drove out of the parking lot and when he accelerated out of the parking lot he heard a thump. The van driver stated he stopped the van, ran to check on the resident and observed the resident had flipped backwards in the wheelchair and the front S-hooks were unhooked from the front of the wheelchair. He added he assessed the resident and saw no visible injury and the resident stated she was fine and wanted up. Nurse aide (NA) #1 was also witness. During the same interview the van driver reported he called the DON to notify her of the situation and asked her to meet him outside of the facility because the incident happened less than a mile away from the facility. The van driver explained that once he was able to determine the resident was not seriously injured, he sat her up in the wheelchair and re-secured everything. Once he arrived at the facility, he was asked to reenact the incident and submit to a drug test. The van driver stated the only possible cause he could think of for why the front straps came off the wheelchair was that when the resident relaxed her legs, it allowed for slack in the straps and the S-hooks fell off. On 06/19/18 at 3:35 PM nurse aide (NA) #1 was interviewed on the telephone and reported that part of her duties included assisting residents to medical appointments by riding along in the van. She stated she had not been trained on the van's securement system. The NA explained on 05/15/18 she was assisting Resident #61 to a medical appointment. When the van driver arrived at the medical office, she waited behind the van and watched as the van driver loaded Resident #61 into the back of the van and used a 4-point S-hook system to secure the resident into the van. The NA added that the resident was loaded first, then she got in the van, seated in front of the resident. NA #1 stated she observed the front S-hooks attached to the wheelchair prior to take off. The she described the van was leaving the parking lot and she heard Resident #61 holler and looked back and the resident had flipped backwards in the wheelchair. On 06/21/18 at 8:40 AM the van driver was observed loading a resident into the van. The observations revealed he followed manufacturer's instructions, asked the resident to raise his legs to ensure the straps were secure. The facility provided the following plan of correction with the correction date of 05/17/18: F689-Free of Accidents Hazards/Supervision/Devices Criteria 1- The plan of correcting cited deficiency of F689 and the processes that lead to the citation; · On 5/15/18, Resident #61, who is alert and oriented with a BIMS of 13, was returning to the facility via facility transport van with the van driver and a transportation attendant. Approximately one mile away from the facility, Resident #61's wheelchair came loose from the 4-point security straps, causing her to tip backwards landing on the backs of the armrests, and hitting her head. The transportation attendant immediately notified the facility van driver, who immediately stopped the van. The resident denied pain or injury to the attendant and driver. The driver and attendant assisted Resident #61 into an upright position, secured her wheelchair into the security straps and proceeded to the facility. The Director of Nursing (DON) was notified immediately and met the driver and the attendant in the parking lot when they arrived. Resident #61 was assessed by the DON while in the van, no complaints of or obvious signs of pain or injury were noted. Resident #61 was taken to her room, placed in her bed, and further assessed by the DON, with still no complaints of pain or injury noted. The Nurse Practionier (NP) was available, and assessed the resident at the bedside, neuro checks completed and within normal limits. Per policy, the neuro checks continued through 5/18/18. As the day continued, Resident #61 began to complain of shoulder pain and a headache, she was sent to the Emergency Department for evaluation and all diagnostic testing came back negative. ·On 5/15/18, The van driver and transport attendant were interviewed separately by the Administrator (NHA) and DON regarding the incident; both interviews yielded the same details. Both indicated that the 4 S hooks were attached to the frame of the wheelchair at the start of the transport and could not explain how the incident occurred. ·On 5/15/18, Resident #61 was interviewed by the administrator and stated she was not sure how the straps came loose. ·On 05/15/18 van driver was not allowed to transport residents, transportation was stopped and outside transport was obtained for 5/15/18, and 5/16/18. ·On 5/15/18, after removing resident #61 from the van, the NHA removed the van from service until deemed safe and all upcoming transports were rescheduled with a contracted transportation service. ·On 5/15/18 at 4:30 pm the Staffing Coordinator conducted a drug screen for the van driver, per facility policy. The results were negative. ·On 5/15/18 The van driver performed a return demonstration to the NHA regarding proper procedures for securing a wheelchair prior to transport. ·On 5/15/18 The van driver completed a test drive with the NHA serving as the passenger, in the same wheelchair that involved in the incident. No issues were noted with the technique of the driver or mechanics of the van. ·On 5/15/18 the Sava Senior Care Manager of OSHA and Compliance (Compliance Manager) was notified by the NHA of the incident. The NHA, DON, Van Driver and Compliance Manager conducted a root cause analysis regarding this van incident. It was determined by the team that the strap securing the wheelchair to the van was likely not sufficiently tightened and the S hook became dislodged during travel allowing the wheelchair to tip backwards. The following plan of correction was implemented to ensure both human error or equipment failures were addressed. Criteria 2- The procedure for implementing the plan of correction for F689; ·Per the Compliance Manager's phone recommendations on 5/15/18, the facility cleaned the van well and the securement straps were removed to another area on the security track by van driver and validated by the NHA. ·On 5/15/18 AD H[NAME] QAPI meeting was held with the following members; Administrator, Van Driver, Director of Nursing, OSHA Compliance Manager. ·On 5/16/18 the Compliance Manager performed van inspection and van driver re-education provided following the manufacturer guidelines, along with participation in demonstration by the van driver in wheelchair security and driving technique, with no irregular findings. ·Any Van Drivers of this facility will be trained in safe operation of the transportation van before being allowed to transport residents. Training will be done by Administrator or the Compliance Manager. ·The facility Van Driver will complete a Safety Securement checklist with every resident transport and any negative finding will be immediately communicated to the facility administrator and addressed immediately. ·On 5/16/18 a new securement system was installed by the OSHA Compliance Manager who is certified by the manufacturer. A new securement system was installed to update the older system that was in place providing more safety and security. ·On 5/16/18 van driver was trained on the new manufacturer securement system by OSHA Compliance Manager by video, thru the manufacturer's Safe and Secure video Doing It Right Training Program and demonstration, and skill check company was completed. ·The van driver, who had been a paramedic, felt he was able to complete a minimal assessment to determine there were no visual injury or deformity. Resident #61 who is alert and orientated denied any pain or injury at the time of the observation. However, per the facility policy of safety responsibility for authorized drivers, for incidents or accidents not involving vehicle accidents the driver is to report all incidents to the administrator and wait for instruction. The driver was re-educated n this policy on 5/16/18. ·On 5/17/18 A new system for loading residents, all residents will be loaded in the facility ' s main entrance for easy visibility ·On 5/17/18 the formal S hook securement hook was replaced with a Snap Hook and D-Ring with a Quick Strap by van driver who was trained by OSHA Compliance Manager who is Sure-Lok certified. ·On 5/17/18 Replaced 2-point seat belt harness with a three-point seat belt harness. This provides extra security and safety. ·On 5/15/18 Administrator reviewed daily transport log to determine and validate that driver had enough time scheduled between appointments to apply the securement system appropriately without the need to rush through the process. ·Starting 5/17/18 the van driver is required to give the administrator the daily securement checklist at the end of each day. This securement checklist is completed by the van driver before/ after each transportation with residents. This checklist was developed by the Manager of OSHA Compliance. The van driver was educated by the Manager of OSHA Compliance on completing this check list. ·Criteria 3- The monitoring procedure to ensure that the plan of correction is effective and that the deficiency remains corrected and/or in compliance with the regulatory requirements include the following; The Administrator has completed visual audits of the securement of the resident and the safety securement checklist while residents are in the van and prior to being transported, 2x daily for 1 week then; 1x daily for 1 week then; 3x weekly for 6 weeks. At this time there has been no negative finding and audits will continue for up to 12 weeks. Administrator has interviewed alert and oriented residents after their transportation for any adverse events. At this time, no further, adverse events have occurred and no residents have had any concerns regarding safety techniques or issues with wheelchair securement. In addition administrator has reviewed weekly facility vehicle inspection checklist with van driver for the last 4 weeks. Administrator has verified the proper working condition of the securement and the operations of the van. Any negative finding will be corrected immediately, if unable to correct immediately van will be place in out of service status until correction is made. Results will be reported to the QAPI committee monthly. The QAPI committee will determine the need for further auditing after the initial 12 weeks. Criteria 4- The person responsible for implementing the plan of correction. The Administrator is responsible for implementing the corrective action. The date of compliance is 5/17/18. The plan of correction was validated on 06/21/18 and concluded the facility implemented an acceptable plan of correction on 05/17/18. The validation including observing the van driver loading and securing a resident in the transportation van. During the observation, the van driver asked the resident to lift his legs to ensure there was no slack in the straps. Observations were made of the new secure system installed in the transportation van. The facility provided documentation of the van driver s drug test, in-service records and monitoring. Documentation included facility audits and daily monitoring of the van driver. Resident #61 and other residents were interviewed and reported they had been secured properly in the van after the correction date of 05/17/18.

Based on observations, staff and resident interviews and review of medical records the facility failed to raise the side rail and/or use safe technique when providing care to 1 of 3 sampled residents (Resident #46) and failed to keep the call light within reach for 1 of 3 sampled residents (Resident #46) reviewed for falls resulting in a fall in which Resident #46 sustained a fracture to her left humerus. Findings included: Resident #46 was admitted on [DATE] with [DIAGNOSES REDACTED]. A 3/26/15 Fall Risk Evaluation revealed the resident was a HIGH RISK for falls scoring 23 (10 or above is high risk). The 3/26/15 Side Rail Safety Review indicated the recommendations were to have the right and left side rail up. The review indicated side rails were needed while the resident was in bed and served as an enabler to promote independence. The review indicated that while the resident had not requested the use of the side rails, she had fluctuations in her level of consciousness, visual deficits, a history of falls, problems with balance or poor trunk control, and that while the resident may climb over the side rails, there was no risk to the resident if side rails were used. A 5/29/15 Quarterly Minimum Data Set (MDS) revealed Resident #46 was cognitively intact. No behaviors or rejection of care were identified. The MDS coded the resident as requiring extensive assistance for bed mobility, transfer, dressing, toilet use, personal hygiene and total assistance for bathing. She was identified as occasionally incontinent of bladder and continent of bowel. The resident was not coded as having falls since the previous assessment. Review of Resident #46 ' s medical record failed to reveal a quarterly fall risk assessment or side rail safety review for June 2015 had been completed. A 6/16/15 psychiatric consultation indicated Resident #46 had blindness in the left eye. The physician noted per the neurological evaluation of November 2014, the resident's strength was decreased due to advanced age and deconditioning. The physician noted Resident #46 was alert and oriented to person. The physician documented the resident ' s thought process was logical. Her attention and concentration was noted to be intact while her memory, insight and judgement were moderately impaired. A Situation, Background, Assessment, Recommendation (SBAR) communication form and a nurse ' s progress note, dated 7/4/15 and signed by Nurse #1 at 7:10 AM, indicated the resident had been found on the floor on right side of the bed with the bedrails down. Resident #46 complained of pain in her left arm and shoulder. Nurse #1 documented Resident #46 had elbow swelling and bruises were noted to her upper forearm. Nurse #1 completed an Interdisciplinary Post Fall Review on 7/4/15 with no time specified. The review indicated Resident #46 ' s fall had occurred at 7:00 AM. The nurse documented the resident had been found on the right side of the bed and the bed rails were down. The nurse practitioner (NP) on call was notified and X-rays were ordered. At 2:50 PM, the nurse noted the X-ray report was positive for a left shoulder/humerus fracture. The NP was again notified and an orthopedic consultation, ice to the left arm/shoulder three times daily and ibuprofen (a medication that helps relieve pain) 400 milligrams (mgs) three times daily for 1 week was ordered. Review of nurse ' s notes, dated 7/4/15 at 2:50 PM, indicated Nurse #2 documented she had medication Resident #46 for pain three times during her shift. She added the resident ' s arm remained swollen and bruised. At 7:30 PM on 7/4/15, Nurse #3, documented in the nurse ' s notes that Resident #46 was crying and complaining of left arm pain. He documented he called (name of NP) and received an order to send the resident to the emergency room (ER). The nurse documented the resident was transported by Emergency Medical Services (EMS) at 7:45 PM. Nurse ' s notes dated 7/5/15 at 4:00 AM, indicated Resident #46 had returned to the facility with a sling in place to her left arm. He noted the resident ' s pain seemed to be controlled with the Ibuprofen. The nurse noted the resident was alert to person and place. The Investigation Follow Up, completed by the Director of Nursing (DON) #1 with no date for the investigation, indicated the incident occurred on 7/4/15. Summary of the investigation revealed staff reported resident sometimes tried to get up alone. This time, the DON documented, Nursing Assistant (NA) #1 was providing incontinent care. His left hand was on the resident ' s hip to stabilize her and the side rails were down. When he reached for a brief, the resident fell from the bed. Under Recommendations and New Interventions, the DON documented a scoop mattress and a reminder to raise the rail or work in front of the front side of the resident versus pushing the resident from behind. The care plan for Resident #46, reviewed on 7/20/15, Resident #46 was at risk of falls and required extensive assistance with her activities of daily living (ADL) due in part to recent falls, utilization of assistive devices, decreased muscle coordination, arthritis, osteoporosis, and use of psychotropic medications. The goals were Resident #46 would not sustain injury from a fall and ADL needs would be identified and met with staff assistance while maintaining her highest level of independent function. Approaches to attain the goals included encouraging the resident to ask for assistance, therapy as needed, call light in reach, toilet frequently and to keep frequently used items in reach. On 7/4/15, a hand written notation indicated the scoop mattress had been added. At 8:22 AM on 7/21/15, Resident #46 was observed in bed eating breakfast. The call light was on the left side of the bed out of the resident's reach. When asked if she could reach the call bell to request assistance, the resident stated no . She added the call bell was on her left side and she had broken her arm and could not move her arm to reach the bell. A sling was observed to her left arm. The resident stated she had been dropped by 2 men transferring her. She was unable to recall the time, date or the names of the people involved. Nurse #1 was interviewed on 7/22/15 at 8:17 AM. She stated she was the nurse assigned to care for Resident #46 and was on duty during the 11 to 7 shift when the resident had fallen. Nurse #1 stated NA #1 had been providing incontinent care. She stated he told her he had rolled the resident on her side. When he reached for a brief, the resident continued to roll and fell to the floor. Nurse #1 added the fall occurred right at 7:00 AM and she and Nurse #4 checked the resident over. She stated at the time of the fall, Resident #46 complained of pain and stated her arm was broken. The nurse added the on-call physician was notified and X-rays were ordered. Nurse #1 described Resident #46 as alert and oriented but at times could be confused. An observation was made on 7/22/15 at 8:55 AM. The resident was lying in bed. Her sling was on her left arm shoulder. The call bell was observed lodged between the wall and the bed rail with the end of the call bell that needed to be pushed lower than the edge of the bed. The dinner bell (also used to call for assistance) was on the over bed table approximately 3 feet on the right side of the resident and out of reach. Resident #46 stated if she needed to call for help, she did not know how she would call. She added she was right handed and she could not reach over her body and try to get the call bell. She added the dinner bell was also out of reach. NA #2 was interviewed at this time. She stated she had been assigned to care for Resident #46. The NA stated the resident could use both her right and left hand. On observation, the NA stated the call bell was not within reach and with the sling, the resident's mobility was limited. The NA had to move the entire bed to dislodge the call bell and place it within reach of the resident. She added the dinner bell was also out of the resident's reach. A telephone interview with NA #1 was held on 7/22/15 at 9:55 AM. He stated he had been assigned to care for Resident #46 on 7/4/15 when she fell . NA #1 stated he was providing incontinent care for Resident #46. The NA added both side rails were down at the time he was providing the care. NA #1 described the incident by saying he had placed his right hand on the resident ' s hip and with his left hand had reached toward the end of the bed for a brief. As he reached for the brief, Resident #46 continued to roll out of bed, landing on her left side. The NA stated he knew that previously, when the resident had lived in a different room, one side rail had been raised. When he reported for his shift the night of the resident ' s fall, the side rails were both down, so he left them down, even when providing care and the resident required turning from side to side. The NA stated the position of Resident #46 ' s side rails, up or down, varied depending on what staff member worked. The NA added prior to the 7/4/15 fall, he would not have considered her a fall risk. The NA stated if a resident were a fall risk, the information was found in the resident's chart, the nurse would tell the staff or the information could be found on the NA assignment sheet at the nurse's station. NA #2 was interviewed on 7/22/15 at 10:17 AM. The NA stated if a resident had been identified as a fall risk, the information is passed from shift to shift or could be found on the assignment sheet next to the resident ' s name. Review of the assignment sheet revealed Resident #46 had not been identified as a fall risk. The NA stated she was unaware Resident #46 was a fall risk. The NA stated she had to move the bed this morning to get the call bell from behind the bed. She stated she had moved the dinner bell out of Resident #46 ' s reach when she removed the breakfast tray and had forgotten to place the bell within the resident ' s reach. The NA stated the resident required assistance for getting out of bed, could take a few steps but required hands on assistance for stabilization. NA #2 stated Resident #46 had not attempted to get out of bed independently while she had worked with her. During a telephone interview with Nurse #4 on 7/22/15 at 10:30 AM, she stated she had just arrived for her 7 to 3 shift on 7/4/15 when another staff member said Resident #46 had fallen. The nurse added she and Nurse #1 went to the resident ' s room. At the time of the fall Resident #46 complained of pain in her left shoulder. Nurse #4 stated she saw no obvious shoulder deformities. Nurse #4 added while Nurse #1 completed the assessment, she called the on call physician. She stated she was not assigned to the resident for 7/4/15 Nurse #2 was interviewed on 7/22/15 at 10:51 AM. Nurse #2 stated she had been assigned to care for Resident #46 during the 7 to 3 shift on 7/4/15. The nurse added when she arrived to work around 7:00 AM, she received report the resident had fallen. Nurse #2 stated she first saw Resident #46 between 8:30-9:00 AM. She added she found the resident alert and oriented and complaining of pain. The nurse stated she told the resident she had received pain medication. Nurse #2 stated the resident next received Tylenol 650 mg at 10:45 AM. At 1:30 PM, she received Ultram (a type of pain medication. By the end of the shift, the resident's pain seemed under control. An interview was held with DON #1 and DON #2 on 7/22/15 at 11:36 AM. The DONs stated information, including fall risk was pulled from the board in the conference room and reviewed during morning meetings. They added information about fall risk would be added to the new assignment sheets that would be placed this week. The DONs added the Unit Managers also attend morning meetings and take the information, such as fall risk, back to the staff on the floors. The DONs reviewed the NA assignment sheets currently used and stated the sheets did not have enough information about residents. They acknowledged Resident #46 had not been identified as a fall risk. DON #1 was interviewed on 7/22/15 at 12:13 PM. The DON stated her expectation was for the call bell or the dinner bell to be within reach of the resident. She added quarterly fall assessments were completed by the MDS nurse. DON #1 added if a resident was assessed as a high risk for falls, the falls risk should be care planned and information for fall prevention and risk relayed to the direct care team. The DON stated side rail assessments were also completed by the MDS nurse. The DON reviewed the side rail assessment for Resident #46 and added the assessment indicated her side rails should be raised to increase independence. In order to determine side rails should not be used, the use of side rails should also be reviewed by the interdisciplinary team. Nurse #3 was interviewed on 7/22/15 at 3:02 PM. The nurse stated he worked with Resident #46 during the 3 to 11 shift on 7/4/15. He stated he received the information about Resident #46 ' s fractured arm when he arrived to work. After report, at approximately 3:30-4:00 PM, Nurse #3 stated he assessed Resident #46 and she was resting. The nurse stated later in the shift, he reassessed the resident and she stated she was in pain. He offered pain medicine, but added she only had Ultram and Tylenol was not a very strong pain medication. Nurse #3 added the resident stated she wanted to go to the hospital, so he called the on call provider (the NP). The nurse stated he explained the resident's pain and the fact she wanted to go to the hospital and received the orders to go to the hospital. The nurse stated the resident was alert and oriented, but forgetful. The nurse added Resident #46 was able to use a call bell and had used her call bell before. The resident was observed on 7/23 at 7:40 AM. She was lying in bed with diathermy (a therapy treatment to lessen pain) being administered. The resident stated she was unable to reach her dinner bell and demonstrated by extending her arm fully. The call bell was approximately 12 inches out of reach. She stated she had tried to call for help, but could not reach the call bell. NA #3 was interviewed on 7/23/15 at 7:45 AM. She stated she had checked on Resident #46 at approximately 6:30 AM. The diathermy she stated, had been placed by the therapy department around 7:00 AM. NA #3 observed Resident #46 ' s call bell and her unsuccessful attempt to reach the call bell. The NA stated therapy staff should have either placed the over bed table within the resident ' s reach or placed the bell in the resident's bed so she could call for assistance when needed. DON #2 was interviewed on 7/23/15 at 9:58 AM. She stated she and DON #1 were responsible for the fall program. She stated when she started working at the facility, she identified there was a problem with the fall program and she has since tried to implement a program. The DON gave the surveyor the Performance Improvement Project (PIP) for review. The initiation date of the PIP was 6/16/15. The date completed was blank and the status was designated as on-going. Under Plan- Root Cause, the DON had written fall management system/tracking currently not in place. Obstacles- need to formulate fall management system for tracking/prevention /IDT meeting; Projected Outcome-falls to be tracked for appropriate measures, tracked and trended, care plan updates/Resident Care Specialist (RCS) sheet updated with interventions implemented/fall risk identified On the second page, titled DO, under #1 the action item was implement IDT for fall management, driver -nursing, start 6/16/15 and target completion date-ongoing. Resources needed-falls to be reviewed in stand up meeting for appropriate intervention/documentation, complete post fall review with IDT, identify root cause and identify. #2 Action - to track and update RCS sheets and care plans, driver-nursing, start 6/16/15, target completion date ongoing and resources needed-revision of (name of corporation) RCS sheet versus current RCS sheet in use, update care plan (CP) when falls occur with interventions #3 Action Item- In-service education or falls, prevention of falls, incidents/accidents injury Driver-nursing Start 6/16/15, ongoing, Resources- educational data for fall prevention and injury. The DON stated so far, she had been unable to update the sheets used by direct care staff for provision of care and no formal educational sessions for fall prevention had been held. She added all their attention and focus had been placed on returning the facility to compliance. The DON stated the Unit Manager (UM) was responsible on a daily basis for making sure fall prevention interventions are in place. She added the expectation was the UM would make rounds daily and make sure all fall prevention items were in place. The DON was unable to give a reason as to why Resident #46 ' s call bell had not been in place and within the resident ' s reach for 3 observations over 3 days. The DON added if the side rail had been raised during the provision of care on 7/4/15, Resident #46 would not have fallen. The Certified Occupational Therapy Assistant (COTA) was interviewed on 7/23/15 at 10:32 AM. The COTA stated she had placed the diathermy machine into Resident #46 ' s room between 7:00 AM-7:30 AM. She stated on entering the room, the resident ' s over bed table with the dinner bell was beside the resident and within reach. The COTA stated when she left Resident #46 ' s room she made a mistake and had not placed the bell where the resident could reach the bell. She acknowledged without the bell in reach, the resident would not be able to call for assistance. The MDS Coordinator was interviewed on 7/23/15 at 11:53 AM. She stated she was responsible for all quarterly assessments. She added if a resident was assessed as needing side rails, she tries to add side rails to the ADL care plan. The MDS nurse stated the UM was responsible for updating the sheet used by the NAs for provision of resident care. The MDS nurse reviewed the side rail safety review, dated 3/26/15 and stated she had completed the review. She stated according to her assessment and the documentation on the sheet, side rails were indicated and serve as an enabler to promote independence for Resident #46. The MDS nurse added this meant the side rails were used by the resident during incontinent care to help her pull over. The MDS nurse stated she was responsible for placing side rails as an enabler on the ADL care plan and the UM was responsible for placing the side rail information on the NA care sheet. The MDS nurse reviewed the ADL care plan for Resident #46 and stated she had forgotten to add the side rails as an enabler. The MDS nurse stated she knew Resident #46 used side rails. She was aware the resident fell , but was unaware how the fall occurred and she was unaware the side rails were not in an up position. The nurse stated logic would tell you that if the side rails had been up Resident #46 would not have fallen out of bed during incontinent care and the fracture would have been avoided. The fall that resulted in the fall on July 4th could have been prevented if the side rail had been up. The MDS nurse stated the quarterly fall assessments and side rail assessments were behind because the state came in and all efforts had been placed on doing more assessments to capture residents on therapy. The UM for the area where Resident #46 lives was interviewed on 7/23/15 at 12:30 PM. The nurse on the hall or the MDS nurse is responsible for updating care plans after a fall. The UM stated she was unsure if Resident #46 was supposed to have side rails, but she used the side rails for bed mobility. The UM stated she knew the resident had fallen. NA #1 told her she had rolled off the bed during provision of care. The UM stated she had asked the NA if the side rails had been up during care and he had told her no. She stated she had asked him why he had not placed the side rails in an up position during care and received no reply from the NA. The UM stated if the rail had been up, the resident probably would not have fallen. If she had not fallen her arm would not have broken. The nurse stated the broken arm could have been prevented.

Based on staff and witness interviews and record review the facility failed to prevent a nurse aide from physically abusing a resident for 1 of 2 abuse allegations (Resident #5). Immediate jeopardy began on 05/22/15 when nurse aide #1 abused Resident #5. Immediate jeopardy was removed on 05/29/15 at 12:25 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and severely impaired cognitive skills for decision making. The MDS also specified the resident had behavioral symptoms not directed towards others 1 to 3 days a week and required extensive assistance with activities of daily living (ADL). On 05/26/15 at 9:25 AM lab technician #1 was interviewed on the telephone and reported that on 05/22/15 at 5:40 AM she was in the facility walking through the 200 Hall intersection when she heard a loud, angry voice say, "Didn't I tell you not to do that s***, huh, didn't I?" The lab technician stated that she looked immediately toward the direction of the voice and observed nurse aide (NA) #1 standing over Resident #5 who was cowered down leaning to the left. The lab technician stated that Resident #5 was in her wheelchair positioned in the center of the 200 Hall and NA #1 had a tight grip on Resident #5's right wrist, as she spoke the NA shook Resident #5's right wrist to emphasize her words as NA #1 repeated, "Didn't I, didn't I?" Lab technician #1 stated that she watched as NA #1 flung Resident #5's right wrist down in the resident's lap and then slapped Resident #5's right shoulder twice as if she were spanking Resident #5. The lab technician stated that she immediately reported the incident to Nurse #1. The lab technician added that she reported to Nurse #1 that she had observed NA #1 "manhandle" Resident #5. The lab technician reported that after she spoke with Nurse #1 she left the facility and notified her immediate supervisor of the physical abuse. That afternoon, the lab technician stated that she was concerned regarding the incident she had observed and contacted the facility's Administrator. The lab technician stated that the Administrator requested that she email her the details of the witnessed abuse. On 05/26/15 at 12:20 PM the Administrator reported that the abuse allegation was substantiated. The Administrator explained that the incident was witnessed and a statement was obtained. Review of the facility's abuse investigation dated 05/22/15 revealed a document that was emailed to the Administrator on 05/22/15 at 2:49 PM that read in part: "On Friday, May 22, 2015 at 5:40 AM I was walking through the facility to leave. As I approached the intersection of the 200 Hall, I heard a loud, stern feminine voice speaking very loud 'Didn't I tell you not to do that s***? Didn't I tell you that? Huh? Didn't I?' Naturally I looked to my left to see what was going on. I saw Resident #5 in a wheelchair wearing a pink or peach top with a dark sweater or jacket over it, she was cowering her head down towards her left. Nurse aide #1 was standing behind the wheelchair wearing blue scrubs. She had the resident's right wrist in a firm grasp and was shaking it to emphasize her words. NA #1 slung the Resident's arm downward and open hand slapped her twice on the upper arm as if she were spanking a child. I immediately went to tell Nurse #1. On 05/26/15 at 5:00 PM Nurse #1 was interviewed and reported that she was the charge nurse from 11 PM to 7 AM on the morning of 05/22/15. She added that around 6 AM a witness reported that NA #1 had abused Resident #5. Nurse #1 stated that she did not assess Resident #5 for sign or injury. Nurse #1 provided the text message delivered to the DON dated 05/22/15 at 8:23 AM that read in part, I need to let you know that the lab technician reported to me that she saw NA #1 "manhandle " a resident. On 05/27/15 at 9:40 AM NA #1 was interviewed and reported that she assisted Resident #5 the morning of 05/22/15 by getting her dressed and taking her to the dining room for breakfast. NA #1 reported that during care Resident #5 attempted to pinch her. NA #1 stated that she told Resident #5 not to do that. The NA explained that she took Resident #5 to the 200 Hall and left her in the hallway to speak to another resident, when she returned to Resident #5, the resident had pulled her shirt up. NA #1 stated that at times Resident #5 could be aggressive but she pulled the resident's shirt down and denied that she hit or used profanity during the incident. The NA added that after she assisted Resident #5 to the dining room, she was told that a witness made an allegation of abuse against her to Nurse #1. On 05/27/15 at 2:00 PM the Administrator was notified of immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 05/29/15 at 12:25 PM. The following interventions were put into place to remove the immediate jeopardy. Allegation of Compliance F 223: 1. Residents identified to be affected by the alleged deficient practice. On 05/22/15 at 5:40AM, a contract employee reported to Nurse #1 that she had witnessed Nurse Aide #1 physically abuse Resident #5. At 8:23AM, Nurse #1 reported to the Director of Nursing an allegation of abuse involving Resident #5. The facility initiated a 24-hour Report and investigation at 2:50PM when the contracted employee contacted the Administrator. Nurse Aide #1 was suspended on 05/22/15 at 7:00PM. A 5-Working Day Report was submitted on 05/28/15. The findings of the investigation indicated that the allegation was substantiated. The Nursing Assistant was suspended on 05/22/15 at 7:00PM. Resident # 5 was assessed by the facility's Physician's Assistant on 05/27/15 and no injuries were identified as a result of the incident. The physician was notified on 05/27/15, and no additional orders were received as a result of the assessment. 2. Residents with the potential to be affected by the alleged deficient practice. Facility Residents have the potential to be affected by the alleged deficient practice. On 05/27/15, the Social Services Director and Social Services Assistant conducted interviews with those residents whose cognitive level score is 10 or greater to identify concerns related to care and services provided by the staff. Results of the audit revealed one additional allegation. The District Director of Clinical Services has initiated actions on 05/27/15 to include suspension of the identified employee, a 24-Hour Report has been completed, and an investigation has commenced. 3. Systemic Measures The Director of Nursing and Administrator will, upon notification, initiate actions to provide for a resident ' s safety in the event of an allegation of abuse or neglect, and conduct an investigation regarding the allegation according to the facility's Abuse & Neglect Policy and as follows: · Remove alleged staff member from resident care area · Supervisor to immediately notify the Director of Nursing or Administrator of the allegation · Licensed Nurse to assess the resident for potential injury and provide for safety and care · Inform MD if there are any signs/symptoms of injury The Division Director of Clinical Education and the Unit Coordinator have conducted training with facility staff beginning 05/27/15 regarding Abuse & Neglect Prohibition, the requirement that residents are to be free from abuse and neglect, and to report allegations to the Director of Nursing or Administrator to ensure that residents' needs are being met and interventions are put in place to ensure the resident's safety. Facility staff will not be allowed to work until the training is completed. Facility will be provided this education at least annually via the Director of Nursing or Social Services Director. This education will be included in the facility's new hire orientation and newly hired facility staff will not be permitted to assume their floor responsibilities until they have completed this education. On 05/27/15, the Administrator, District Director of Clinical Services, and Division Director of Clinical Education provided education for the Director of Nursing regarding what constitutes an allegation of abuse, removal of the accused individual, ensuring the safety of the resident, submitting a 24-Hour Report, and completing a thorough investigation. Beginning on 05/27/15 all facility employees will be re-educated by the Director of Nursing, Director of Clinical Education, ADON and Unit Coordinator on the Facility Policy for Abuse and Neglect Prohibition and mandated reporting of allegations of resident abuse and neglect. This re-education will also include: · Providing separation and a safe environment for residents while the investigation is completed · Appropriate interventions are care planned and implemented based on the resident's assessment. · No facility employee shall work without receiving this re-education. The Administrator and Director of Nursing will be retrained by the District Director of Clinical Services regarding the facility's Abuse & Neglect policy and the investigative process to include: · Reporting via the 24-Hour Report and 5-working day Report of allegations of abuse or neglect · Interview notes/Statements of staff and residents related to the allegation · Assessment of the resident for potential injuries · Notification of the physician for injuries The following methods of monitoring, tracking, and trending will be implemented as of 05/28/15: · The Director of Nursing will identify individuals who have had two or more allegations of abuse submitted within a calendar year, will monitor care provided and interactions with residents three times per week for four weeks after the second allegation. · The Administrator will review Ambassador Rounds and Concern Forms daily during the morning meeting for any allegations of abuse and will follow up immediately. Immediate Jeopardy was removed on 05/29/15 at 12:25 PM when the facility provided evidence of additional training provided to residents and staff on the importance of preventing all observed, suspected and/or alleged allegations of abuse. Interviews with staff and alert and oriented residents revealed they were trained on when and whom to report allegations of abuse and what actions were required by supervisory nursing staff to protect residents allegedly abused.

Based on observations, staff interviews and record review the facility's Quality Assurance and Assessment Committee failed to maintain implemented procedures and monitor these interventions that the Committee put into place May 2015. The facility alleged substantial compliance with the regulations as of 05/22/15 in the areas of 483.13 (b) policy for implementing the facility's policy for abuse prohibition; 483.13 (c) policy for reporting abuse and 483.35 (i) kitchen sanitation. The continued failure of the facility during two surveys 04/24/15 and 05/29/15 of record demonstrates the facility's inability to sustain an effective Quality Assurance and Assessment Program. Immediate jeopardy began on 05/22/15 when Nurse #1 failed to immediately report witnessed abuse to the Director of Nursing and the facility allowed NA #1 to continue to provide care to Resident #5. The DON had received re-education on the facility's policy and procedure for abuse allegations and failed to initiate a 24 hour report and 50day investigation at the time an allegation was made. Immediate jeopardy was removed on 05/29/15 at 12:05 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: Cross refer F 225, F 226 and F 371 1 a. F 225; Based on staff and Physician's Assistant interviews and record review the facility failed to report to the State an allegation of abuse and investigation results within the required timeframes for 1 of 2 allegations of employee to resident abuse (Resident #171). 1 b. F 226; Based on observations, staff and witness interviews and record review the facility failed to implement protection for a resident after she was physically abused by a nurse aide, and the facility failed to initiate abuse investigations when it was witnessed and reported that Resident #5 had been physically abused and when Resident #171 alleged he had been physically and sexually abused for 2 of 2 allegations of abuse (Resident #5 and #171). 1 c. F 371; Based on observations and staff interviews the facility failed to clean 1 of 2 ice scoop holders, failed to identify and address concerns with the final rinse temperature of the dish machine, failed to remove outdated thickened milk from a pantry refrigerator and failed to clean cookware prior to storing for use. On 05/28/15 at 2:50 PM the Administrator was interviewed and reported that the facility held a Quality Assurance (QA) meeting on 05/12/15 following the facility's annual recertification survey that was completed on 04/24/15. The Administrator explained that she was unable to attend the meeting because she was attending to resident and family but the Director of Nursing (DON) conducted the meeting and reviewed the citations from the annual recertification. The Division Director of Clinical Education (DDCE) was present during the interview and reported that she provided one on one education to the DON regarding abuse allegations and facility's policy on reporting, investigating, protecting and preventing employee to resident abuse. The Administrator and the DDCE both stated that following the education provided for the DON they expected that she would address all allegations of abuse in accordance to facility policy. The Administrator also reported that she implemented a weekly walk-through kitchen inspection to monitor the areas cited on the annual recertification survey as part of the facility's QA process for monitoring kitchen sanitation. The areas of concern identified with kitchen sanitation were discussed with the Administrator and she stated she was unaware that there were still areas not in compliance but expected that all components of kitchen sanitation be corrected. On 05/28/15 at 4:30 PM the Administrator was notified of immediate jeopardy for the Quality Assurance Committee failing to ensure that the Director of Nursing would act in accordance with facility policy for protecting residents from physical abuse and responding as she had been trained to do. The facility provided an acceptable credible allegation of compliance on 05/29/15 at 12:50 PM. The following interventions were put into place to remove the immediate jeopardy. Allegation of Compliance - F520 1. On 5/27/15, the Administrator and Director of Nursing were re-educated by the District Director of Clinical Services regarding the facility's Abuse and Neglect Prohibition policy, including what constitutes an allegation of abuse, proper reporting of allegations of abuse, and thorough investigation of allegations. On 5/28/15, the District Director of Clinical Services conducted re-education for the Administrator on the facility's Quality Assurance and Performance Improvement Program including scheduling, identification of trends or patterns, submission of data, and initiation of quality improvement plans related to the identified areas of opportunity. 2. On 5/29/15, the Administrator and the Quality Assurance Committee were retrained on the Quality Assurance & Performance Improvement Program by a Senior Administrator. The Quality Assurance committee consists of: · Administrator · Director of Nursing · Dietary Manager · Rehabilitation Manager · Maintenance or Environmental Representative · Activities Director · Social Services Director · Human Resource Designee · Business Office Director · Resident Care Management Director · Medical Director 3. The Administrator will present all allegations of abuse, concern forms, and resident council meeting minutes to the Quality Assurance & Performance Improvement committee weekly for four (4) weeks and then monthly thereafter. The Administrator and District Director of Clinical Services will review all allegations to ensure that proper reporting and a thorough investigation have been completed. The next Quality Assurance & Performance Improvement meetings will be conducted weekly for four weeks, then monthly with oversight by District Director of Clinical Services for three months to ensure that all allegations of abuse have been properly reported and investigated. Immediate Jeopardy was removed on 05/29/15 at 12:05 PMM when the facility provided evidence of additional training provided to the Administrator and Quality Assurance Committee members related to the QA system, function of the QA committee and how the QA system monitors for necessary follow up. Interviews with the Administrator and QA Committee members revealed they were knowledgeable of the role the Committee played to prevent repeat deficiencies.

2 Based on staff and witness interviews and record review the facility failed to prevent a nurse aide from physically abusing a resident for 1 of 2 abuse allegations (Resident #5). Immediate jeopardy began on 05/22/15 when nurse aide #1 abused Resident #5. Immediate jeopardy was removed on 05/29/15 at 12:25 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had short and long term memory impairment and severely impaired cognitive skills for decision making. The MDS also specified the resident had behavioral symptoms not directed towards others 1 to 3 days a week and required extensive assistance with activities of daily living (ADL). On 05/26/15 at 9:25 AM lab technician #1 was interviewed on the telephone and reported that on 05/22/15 at 5:40 AM she was in the facility walking through the 200 Hall intersection when she heard a loud, angry voice say, Didn't I tell you not to do that s***, huh, didn't I? The lab technician stated that she looked immediately toward the direction of the voice and observed nurse aide (NA) #1 standing over Resident #5 who was cowered down leaning to the left. The lab technician stated that Resident #5 was in her wheelchair positioned in the center of the 200 Hall and NA #1 had a tight grip on Resident #5's right wrist, as she spoke the NA shook Resident #5's right wrist to emphasize her words as NA #1 repeated, Didn't I, didn't I? Lab technician #1 stated that she watched as NA #1 flung Resident #5's right wrist down in the resident's lap and then slapped Resident #5's right shoulder twice as if she were spanking Resident #5. The lab technician stated that she immediately reported the incident to Nurse #1. The lab technician added that she reported to Nurse #1 that she had observed NA #1 manhandle Resident #5. The lab technician reported that after she spoke with Nurse #1 she left the facility and notified her immediate supervisor of the physical abuse. That afternoon, the lab technician stated that she was concerned regarding the incident she had observed and contacted the facility's Administrator. The lab technician stated that the Administrator requested that she email her the details of the witnessed abuse. On 05/26/15 at 12:20 PM the Administrator reported that the abuse allegation was substantiated. The Administrator explained that the incident was witnessed and a statement was obtained. Review of the facility's abuse investigation dated 05/22/15 revealed a document that was emailed to the Administrator on 05/22/15 at 2:49 PM that read in part: On Friday, May 22, 2015 at 5:40 AM I was walking through the facility to leave. As I approached the intersection of the 200 Hall, I heard a loud, stern feminine voice speaking very loud 'Didn't I tell you not to do that s***? Didn't I tell you that? Huh? Didn't I?' Naturally I looked to my left to see what was going on. I saw Resident #5 in a wheelchair wearing a pink or peach top with a dark sweater or jacket over it, she was cowering her head down towards her left. Nurse aide #1 was standing behind the wheelchair wearing blue scrubs. She had the resident's right wrist in a firm grasp and was shaking it to emphasize her words. NA #1 slung the Resident's arm downward and open hand slapped her twice on the upper arm as if she were spanking a child. I immediately went to tell Nurse #1. On 05/26/15 at 5:00 PM Nurse #1 was interviewed and reported that she was the charge nurse from 11 PM to 7 AM on the morning of 05/22/15. She added that around 6 AM a witness reported that NA #1 had abused Resident #5. Nurse #1 stated that she did not assess Resident #5 for sign or injury. Nurse #1 provided the text message delivered to the DON dated 05/22/15 at 8:23 AM that read in part, I need to let you know that the lab technician reported to me that she saw NA #1 manhandle a resident. On 05/27/15 at 9:40 AM NA #1 was interviewed and reported that she assisted Resident #5 the morning of 05/22/15 by getting her dressed and taking her to the dining room for breakfast. NA #1 reported that during care Resident #5 attempted to pinch her. NA #1 stated that she told Resident #5 not to do that. The NA explained that she took Resident #5 to the 200 Hall and left her in the hallway to speak to another resident, when she returned to Resident #5, the resident had pulled her shirt up. NA #1 stated that at times Resident #5 could be aggressive but she pulled the resident's shirt down and denied that she hit or used profanity during the incident. The NA added that after she assisted Resident #5 to the dining room, she was told that a witness made an allegation of abuse against her to Nurse #1. On 05/27/15 at 2:00 PM the Administrator was notified of immediate jeopardy. The facility provided an acceptable credible allegation of compliance on 05/29/15 at 12:25 PM. The following interventions were put into place to remove the immediate jeopardy. Allegation of Compliance F 223: 1. Residents identified to be affected by the alleged deficient practice. On 05/22/15 at 5:40AM, a contract employee reported to Nurse #1 that she had witnessed Nurse Aide #1 physically abuse Resident #5. At 8:23AM, Nurse #1 reported to the Director of Nursing an allegation of abuse involving Resident #5. The facility initiated a 24-hour Report and investigation at 2:50PM when the contracted employee contacted the Administrator. Nurse Aide #1 was suspended on 05/22/15 at 7:00PM. A 5-Working Day Report was submitted on 05/28/15. The findings of the investigation indicated that the allegation was substantiated. The Nursing Assistant was suspended on 05/22/15 at 7:00PM. Resident # 5 was assessed by the facility's Physician's Assistant on 05/27/15 and no injuries were identified as a result of the incident. The physician was notified on 05/27/15, and no additional orders were received as a result of the assessment. 2. Residents with the potential to be affected by the alleged deficient practice. Facility Residents have the potential to be affected by the alleged deficient practice. On 05/27/15, the Social Services Director and Social Services Assistant conducted interviews with those residents whose cognitive level score is 10 or greater to identify concerns related to care and services provided by the staff. Results of the audit revealed one additional allegation. The District Director of Clinical Services has initiated actions on 05/27/15 to include suspension of the identified employee, a 24-Hour Report has been completed, and an investigation has commenced. 3. Systemic Measures The Director of Nursing and Administrator will, upon notification, initiate actions to provide for a resident ' s safety in the event of an allegation of abuse or neglect, and conduct an investigation regarding the allegation according to the facility's Abuse & Neglect Policy and as follows: · Remove alleged staff member from resident care area · Supervisor to immediately notify the Director of Nursing or Administrator of the allegation · Licensed Nurse to assess the resident for potential injury and provide for safety and care · Inform MD if there are any signs/symptoms of injury The Division Director of Clinical Education and the Unit Coordinator have conducted training with facility staff beginning 05/27/15 regarding Abuse & Neglect Prohibition, the requirement that residents are to be free from abuse and neglect, and to report allegations to the Director of Nursing or Administrator to ensure that residents' needs are being met and interventions are put in place to ensure the resident's safety. Facility staff will not be allowed to work until the training is completed. Facility will be provided this education at least annually via the Director of Nursing or Social Services Director. This education will be included in the facility's new hire orientation and newly hired facility staff will not be permitted to assume their floor responsibilities until they have completed this education. On 05/27/15, the Administrator, District Director of Clinical Services, and Division Director of Clinical Education provided education for the Director of Nursing regarding what constitutes an allegation of abuse, removal of the accused individual, ensuring the safety of the resident, submitting a 24-Hour Report, and completing a thorough investigation. Beginning on 05/27/15 all facility employees will be re-educated by the Director of Nursing, Director of Clinical Education, ADON and Unit Coordinator on the Facility Policy for Abuse and Neglect Prohibition and mandated reporting of allegations of resident abuse and neglect. This re-education will also include: · Providing separation and a safe environment for residents while the investigation is completed · Appropriate interventions are care planned and implemented based on the resident's assessment. · No facility employee shall work without receiving this re-education. The Administrator and Director of Nursing will be retrained by the District Director of Clinical Services regarding the facility's Abuse & Neglect policy and the investigative process to include: · Reporting via the 24-Hour Report and 5-working day Report of allegations of abuse or neglect · Interview notes/Statements of staff and residents related to the allegation · Assessment of the resident for potential injuries · Notification of the physician for injuries The following methods of monitoring, tracking, and trending will be implemented as of 05/28/15: · The Director of Nursing will identify individuals who have had two or more allegations of abuse submitted within a calendar year, will monitor care provided and interactions with residents three times per week for four weeks after the second allegation. · The Administrator will review Ambassador Rounds and Concern Forms daily during the morning meeting for any allegations of abuse and will follow up immediately. Immediate Jeopardy was removed on 05/29/15 at 12:25 PM when the facility provided evidence of additional training provided to residents and staff on the importance of preventing all observed, suspected and/or alleged allegations of abuse. Interviews with staff and alert and oriented residents revealed they were trained on when and whom to report allegations of abuse and what actions were required by supervisory nursing staff to protect residents allegedly abused.

Based on record review and staff interviews, the facility failed to follow their abuse policy and procedures for reporting allegations and investigations of abuse to the state agency and failed to investigate an allegation of misappropriation of property for 2 of 5 sampled residents (Residents #82 and #210). The findings included the following: The facility policy "Abuse & Neglect Prohibition" with a revision date of June 2013 included: *The facility administrator is the Abuse Prevention Coordinator. *The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. *The facility will report such allegations to the state, in accordance with state regulation. *The facility will report all investigation findings to the stated in accordance with state regulations. 1. Resident #82 was readmitted to the facility on [DATE]. The Admission Minimum (MDS) data set [DATE] coded her with long and short term memory deficits, having no behaviors, being nonambulatory, and requiring extensive assistance with most of her activities of daily living skills (ADLs). Review of grievances revealed that on 11/03/14, Resident #82's family filed a written grievance which stated Resident #82 stated that Nurse Aide (NA) #3 "beat on her while changing her or interacting with her." The grievance also stated that NA #3 told Resident #82 that "she was a cry baby (verbal abuse)." An additional note written on the grievance form, from the former Assistant Director of Nursing (ADON), stated this occurred around breakfast that NA #3 "slammed her against the wall & twisted her legs, called her Ms. (NAME REDACTED) & a cry baby." Attached to the grievance were interviews with 3 staff members, an interview with Resident #82, and a reinterview with the family who initially reported the abuse. There was no evidence that the allegation of abuse was reported to the state as required within 24 hours of the allegation and no evidence that a 5 day report of the investigation was reported to the state as required. An interview was conducted with the interim Administrator and the Division Director of Clinical Education on 04/23/15 at 1:50 PM. The Administrator stated that initially the facility would ensure that the resident making an allegation of abuse was removed from threat and interviews would be conducted of appropriate staff, covering questions of who, what where, when and why. He stated that a 24 hour report would be sent to the state and then another report would be sent to the state with the investigation information within 5 days. The Division Director of Clinical Education stated there was no 24 or 5 day report found in the facility with the grievance. On 04/24/15 at 10:10 AM, the Director of Nursing (DON) stated all reports of abuse were given to the Administrator who initiated the investigation piece. The DON stated she followed the instructions of the Administrator and if asked to investigate, she interviewed the resident and follow up with any staff that was on duty at the time of the allegation. She then followed up with her findings with the Administrator. Regarding the grievance of Resident #82, DON stated the former ADON called the DON at home to report family's allegation and she in turn reported it to the former Administrator. The former Administrator instructed the DON to conduct interviews in the morning. DON stated her interviews concluded there were inconsistencies, the resident had a history of [REDACTED]. The District Clinical Director present during this interview stated the former Administrator was the abuse coordinator and was responsible for filing the 24 hour and 5 day reports with the state which was not done. 2. Resident #201 was admitted to the facility on [DATE]. Review of the facility's abuse investigations revealed a 24 hour report submitted to the state which indicated Resident #201 reported that while who was at church, a zip lock bag of jewelry went missing from her room on 03/02/14. The 5 day report submitted to the state by the former Administrator on 03/07/14 indicated that the police had been contacted, the room was searched, staff on the unit were interviewed and there was no conclusion to the missing bag. A copy of the police report revealed items missing included pearl earrings, diamond earrings, gold hoop earrings, Avon bumble bee earrings, crystal earrings and gold ball earrings. The facility was unable to provide information as to who searched the resident's room, what staff were working on that unit, what staff were interviewed, what staff said and or any follow up with the police during the investigation to assure a thorough investigation had been completed. Interview with the Director of Nursing (DON) and the District Clinical Director on 04/24/15 at 10:10 AM revealed all reports of abuse were given to the Administrator who initiated the investigation piece. The DON stated she followed the instructions of the Administrator and if asked to investigate, she interviewed the resident and any staff that was on duty at the time of the allegation. She then followed up with her findings with the Administrator. DON stated that at the time of this incident, the former Administrator took over the investigation. No specific notes regarding the investigation could be located. DON stated she did not conduct any interviews related to the missing jewelry.

Based on observations, staff interviews and record review the facility's Quality Assurance and Assessment Committee failed to maintain implemented procedures and monitor these interventions that the Committee put into place May 2015. The facility alleged substantial compliance with the regulations as of 05/22/15 in the areas of 483.13 (b) policy for implementing the facility's policy for abuse prohibition; 483.13 (c) policy for reporting abuse and 483.35 (i) kitchen sanitation. The continued failure of the facility during two surveys 04/24/15 and 05/29/15 of record demonstrates the facility's inability to sustain an effective Quality Assurance and Assessment Program. Immediate jeopardy began on 05/22/15 when Nurse #1 failed to immediately report witnessed abuse to the Director of Nursing and the facility allowed NA #1 to continue to provide care to Resident #5. The DON had received re-education on the facility's policy and procedure for abuse allegations and failed to initiate a 24 hour report and 50day investigation at the time an allegation was made. Immediate jeopardy was removed on 05/29/15 at 12:05 PM when the facility implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee and resident education and ensure monitoring systems in place are effective. The findings included: Cross refer F 225, F 226 and F 371 1 a. F 225; Based on staff and Physician's Assistant interviews and record review the facility failed to report to the State an allegation of abuse and investigation results within the required timeframes for 1 of 2 allegations of employee to resident abuse (Resident #171). 1 b. F 226; Based on observations, staff and witness interviews and record review the facility failed to implement protection for a resident after she was physically abused by a nurse aide, and the facility failed to initiate abuse investigations when it was witnessed and reported that Resident #5 had been physically abused and when Resident #171 alleged he had been physically and sexually abused for 2 of 2 allegations of abuse (Resident #5 and #171). 1 c. F 371; Based on observations and staff interviews the facility failed to clean 1 of 2 ice scoop holders, failed to identify and address concerns with the final rinse temperature of the dish machine, failed to remove outdated thickened milk from a pantry refrigerator and failed to clean cookware prior to storing for use. On 05/28/15 at 2:50 PM the Administrator was interviewed and reported that the facility held a Quality Assurance (QA) meeting on 05/12/15 following the facility's annual recertification survey that was completed on 04/24/15. The Administrator explained that she was unable to attend the meeting because she was attending to resident and family but the Director of Nursing (DON) conducted the meeting and reviewed the citations from the annual recertification. The Division Director of Clinical Education (DDCE) was present during the interview and reported that she provided one on one education to the DON regarding abuse allegations and facility's policy on reporting, investigating, protecting and preventing employee to resident abuse. The Administrator and the DDCE both stated that following the education provided for the DON they expected that she would address all allegations of abuse in accordance to facility policy. The Administrator also reported that she implemented a weekly walk-through kitchen inspection to monitor the areas cited on the annual recertification survey as part of the facility's QA process for monitoring kitchen sanitation. The areas of concern identified with kitchen sanitation were discussed with the Administrator and she stated she was unaware that there were still areas not in compliance but expected that all components of kitchen sanitation be corrected. On 05/28/15 at 4:30 PM the Administrator was notified of immediate jeopardy for the Quality Assurance Committee failing to ensure that the Director of Nursing would act in accordance with facility policy for protecting residents from physical abuse and responding as she had been trained to do. The facility provided an acceptable credible allegation of compliance on 05/29/15 at 12:50 PM. The following interventions were put into place to remove the immediate jeopardy. Allegation of Compliance - F520 1. On 5/27/15, the Administrator and Director of Nursing were re-educated by the District Director of Clinical Services regarding the facility's Abuse and Neglect Prohibition policy, including what constitutes an allegation of abuse, proper reporting of allegations of abuse, and thorough investigation of allegations. On 5/28/15, the District Director of Clinical Services conducted re-education for the Administrator on the facility's Quality Assurance and Performance Improvement Program including scheduling, identification of trends or patterns, submission of data, and initiation of quality improvement plans related to the identified areas of opportunity. 2. On 5/29/15, the Administrator and the Quality Assurance Committee were retrained on the Quality Assurance & Performance Improvement Program by a Senior Administrator. The Quality Assurance committee consists of: · Administrator · Director of Nursing · Dietary Manager · Rehabilitation Manager · Maintenance or Environmental Representative · Activities Director · Social Services Director · Human Resource Designee · Business Office Director · Resident Care Management Director · Medical Director 3. The Administrator will present all allegations of abuse, concern forms, and resident council meeting minutes to the Quality Assurance & Performance Improvement committee weekly for four (4) weeks and then monthly thereafter. The Administrator and District Director of Clinical Services will review all allegations to ensure that proper reporting and a thorough investigation have been completed. The next Quality Assurance & Performance Improvement meetings will be conducted weekly for four weeks, then monthly with oversight by District Director of Clinical Services for three months to ensure that all allegations of abuse have been properly reported and investigated. Immediate Jeopardy was removed on 05/29/15 at 12:05 PMM when the facility provided evidence of additional training provided to the Administrator and Quality Assurance Committee members related to the QA system, function of the QA committee and how the QA system monitors for necessary follow up. Interviews with the Administrator and QA Committee members revealed they were knowledgeable of the role the Committee played to prevent repeat deficiencies.

Based on facility and medical record reviews and interviews with physicians and staff the facility failed to obtain verification and approval prior to transferring and transcribing an order for [REDACTED]. Immediate Jeopardy was identified 02/08/2011 at 1:25 PM and began on 01/01/2011 when Licensed Nurse (LN) #1 failed to contact the physician for clarification and approval of a physician's orders [REDACTED]. The facility remains out of compliance at a lower scope and severity of "D" (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of employee education and monitoring of placed systems. The findings are: Lexi-comp's Drug Information Handbook, 8th edition, included the following information on [MEDICATION NAME] (an Antimetabolite used [MEDICAL CONDITIONS] and for treatment of [REDACTED]. "High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error. Errors have occurred (resulting in death) when oral [MEDICATION NAME] was administered as 'daily' dose instead of the recommended 'weekly' dose." "Mechanism of Action/Effect: The MOA (mechanism of action) in the treatment of [REDACTED]." "Dosing [MEDICAL CONDITION] arthritis: Oral: 7.5 mg (milligram) once weekly or 1.5 mg every 12 hours for 3 doses/week (per week), not to exceed 20 mg/week." "Adverse Reactions Note: (in part) Pneumonia, Pharyngitis (painful inflammation of throat or pharynx), renal dysfunction, vomiting, fever, reddening of skin, rash, hyperpigmentation of skin, ulcerative stomatitis (inflammation of mouth tissue), Leukopenia (decrease in disease-fighting cells), [MEDICAL CONDITION] (decrease in blood clotting platelets), and malaise." Resident # 1 was admitted to the facility 11/10/2008 with [DIAGNOSES REDACTED]. Resident #1 also had a history of [REDACTED]. A handwritten "REPORT OF CONSULTATION" in the medical record revealed Resident #1 was seen by Rheumatology 12/30/2010 for [DIAGNOSES REDACTED]. Treatment is complicated by several co-morbidities including [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) on [MEDICAL TREATMENT] and severe Diarrhea." Multiple medications were recommended for treatment including "[MEDICATION NAME] 10 (ten) mg (milligram) po (by mouth) 1 (one) day / (per) week." The prescribed medications included the notation "only if agreeable c (with) (name of facility physician)." The handwritten "PHYSICIAN'S TELEPHONE ORDERS" dated 01/01/2011 at 12:00 PM included "[MEDICATION NAME] 10 mg po qd (every day) X (times) one week" to be administered for [MEDICAL CONDITION] Arthritis. The names' of the facility physician and the consulting physician were written of the order followed by the name and signature of Licensed Nurse (LN) #1 indicating that she (LN #1) had received the physician's orders [REDACTED].# 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 01/01/2011 physician's orders [REDACTED]." The MAR bore initials on January 2, 3, 4, 5, 6, and 7, 2011 indicating that [MEDICATION NAME] 10 mg was administered. January 8th on the MAR indicated NURSE'S NOTE" section stating that Resident #1 refused all medications. A 01/07/2011, no noted time, Encounter Note revealed Resident #1 was seen by the facility Physician's Assistant (PA) for complaints of sore throat, ear pain, and malaise (general discomfort). The note read in part "history of endstage (sic) [MEDICAL CONDITION]. He was attending [MEDICAL TREATMENT] this morning, but had to be taken off due to complaints of feeling poorly." The PA noted that Resident #1 spoke with a "hot potato" voice and that "he is complaining of a sore throat, sore mouth, pain in his ears, and shortness of breath." The PA diagnosed Resident #1 with an Upper Respiratory Infection and Pharyngitis and noted the following treatment plan: [REDACTED]. Start (antibiotic) due to pharyngitis and respiratory infection." The PA's note gave no reference to Resident #1 receiving [MEDICATION NAME]. A 01/08/2011 3:00 PM Nurse's Note revealed Resident #1 was medicated for complains of "severe throat pain" and itching and burning in the groin area. A 01/08/2011 6:00 PM Nurse's Note revealed Resident #1 requested to go to the hospital and was assessed by Licensed Nursing staff. Resident #1 was assessed with [REDACTED]. Resident #1's vital signs included a temperature of 100.4, heart rate of 100, blood pressure of 140/78, respirations of 20 with 86% Oxygen saturation (percentage of Oxygen saturation in blood). Documentation further revealed Resident #1 was refusing to leave supplemental Oxygen in place. The Physician's Assistant (PA) was notified and orders were obtained to send Resident #1 to the hospital via Emergence Medical Services (EMS). The 01/08/2011 (no noted time) "Resident Transfer Form" completed by the facility listed "Vomiting Blood" as the reason for Resident #1's transfer to the hospital Emergency Department (ED). The transfer form noted that Resident #1 had a temperature of 100.4 degrees, an Oxygen saturation of 86 %, and that the resident had trouble swallowing due to "mouth sore." Nurse's Notes from the hospital ED, from arrival on 01/08/2011 at 7:53 PM to 01/09/2011 at 01:44 AM when admitted for hospitalization , revealed Resident #1 arrived at the ED via ambulance with complaints of not feeling well, coughing with brown green mucus, and Oxygen saturation of 82 % prior to placement of Oxygen at the facility and while in route via EMS. The nursing assessment noted "Appears distressed, uncomfortable, behavior is agitated, restless. Complains of pain all over. Pain currently is 10 (ten) out of 10 on a pain scale. Quality of pain is described as aching." "Breath sounds are diminished bilaterally. Patent/caregiver reports the patient having vomiting (sic) blood. Blisters noted on penis on scrotum severe excoriation, with minimal bleeding noted around the scrotal area and glands penis, excoriation noted on buttocks and peri area." Resident #1 was noted as having a temperature of 101.2 degrees and an Oxygen saturation of 94 % with supplemental Oxygen in place at two (2) liters via nasal cannula. The nurse's Pneumonia screening read "Cough present with congestion present with Dyspnea (shortness of breath)." Physician documentation from the hospital ED, dated 01/09/2011 at 12:05 AM, noted that Resident #1 presented to the hospital with complaints of "Nausea/Vomiting." The physical examination conducted by the ED physician noted "Abdomen/GI (Gastro Intestinal): Positive for vomiting." The physician documented that Resident #1 was to be admitted with a preliminary ED [DIAGNOSES REDACTED]. The hospital admission History and Physical for Resident #1, completed 01/09/2011 at 01:17 AM by the admitting physician, included the following assessment findings "1. Pneumonia. Aspiration pneumonia versus healthcare-associated pneumonia. 2. [MEDICAL CONDITIONS]. 3. [MEDICAL CONDITION] secondary to pneumonia and [MEDICAL CONDITION]. 4. Altered mental status. 5. Leukopenia and rule [MEDICAL CONDITION]." A "MEDICATION VARIANCE REPORT" dated 01/18/2011, provided by the facility, indicated that an error occurred 01/02/2011 through 01/07/2011 in which Resident #1 was administered the wrong dose of [MEDICATION NAME] for treatment of [REDACTED].#1. As a result of the error Resident #1 received [MEDICATION NAME] 10 mg by mouth daily for six (6) days. The variance report noted "consult note confusing" as the cause of error. The outcome of the error noted on the report read: "An error occurred that may have contributed to or resulted in temporary resident harm or required initial or prolonged hospitalization ." The hospital Discharge Summary completed 02/08/2011 included the following [DIAGNOSES REDACTED]. Acute [MEDICAL CONDITION] 2.[MEDICAL CONDITION] syndrome, likely due to pneumonia 3. Pancytopenia (abnormal depression of all the cellular elements of blood resulting from depression of bone marrow activity), "felt due to [MEDICATION NAME] toxicity." 4. End Stage [MEDICAL CONDITION]. The documented summary of Resident #1's hospitalization read in part: "admitted to the hospital 1 (one) month ago. He was admitted with pneumonia and [MEDICAL CONDITION], brought on by pancytopenia. This was felt to be due to [MEDICATION NAME] for a chronic rheumatologic condition. He was septic, received ventilator support, broad-spectrum antibiotics, and fluids. He developed complications with stomatitis." "His condition, though severe and serious, has stabilized, and he is planned for discharge." During an interview 02/07/2011 at 11:45 AM the facility Director of Nursing (DON) reported on 01/18/2011 at approximately 08:00 AM the facility physician made her aware that Resident #1, discharged to the hospital 01/08/2011, had received [MEDICATION NAME] 10 mg by mouth daily from 01/02/2011 through 01/07/2011. The DON stated that the physician requested that she pull resident #1's medical record and review the [MEDICATION NAME] order. The DON stated she recognized an error when she reviewed the order transcribed/written by Licensed Nurse (LN) #1 and the 12/30/2010 physician's orders [REDACTED]. The DON stated LN #1 read, wrote, and transcribed the physician's orders [REDACTED].#1 receiving a higher than intended dosage. The DON stated LN #1 did not contact the facility physician or the consulting/prescribing physician for approval and/or clarification prior to writing and transcribing the [MEDICATION NAME] order. The DON reported that the end result of LN #1's failure to obtain verification and approval of the [MEDICATION NAME] order resulted in an error that may have contributed to or result in Resident #1's hospitalization on [DATE]. On 02/07/2011 at 12:15 PM an interview was conducted with Resident #1's physician (also the facility Medical Director). The physician stated that [MEDICATION NAME] 10 mg daily for treatment of [REDACTED]. The physician stated he would have expected the nurse to question the order and call the facility physician or extenders on-call for approval and verification prior to writing and transcribing the [MEDICATION NAME] order. The physician stated it would have also been appropriate to clarify the order with the prescribing physician. On 02/07/3011 at 1:54 PM an interview was conducted with LN #1, responsible for writing and transcribing Resident #1's [MEDICATION NAME] physician's orders [REDACTED]. LN #1 stated on 01/01/2011 she removed the Rheumatology consultation report from the "Doctor's Book," utilized by the facility for non-urgent communicate, and proceeded to "take off" the orders. LN #1 reported she read the physician's orders [REDACTED]. LN #1 stated she looked up [MEDICATION NAME] on the computer and saw directions for the medication to be given weekly which gave rise to the "thought" that the dose and/or frequency was "unusual." LN #1 stated she spoke to the Pharmacist and faxed the Rheumatology consultation report with the original [MEDICATION NAME] order to the pharmacy to be reviewed. LN #1 stated she did not question her interpretation of the physician's orders [REDACTED]. LN #1 stated she did not know why she did not contact the physician for approval and/or clarification prior to writing and transcribing the [MEDICATION NAME] order. LN #1 stated she did not know why she did not call the physician. The interview revealed "after a few days" on the [MEDICATION NAME] Resident #1 voiced complaints of a sore mouth and throat. LN #1 stated Resident #1 had voiced complaints previously and that she did not relate the sore mouth/throat to the [MEDICATION NAME]. The interview further revealed on 01/07/2011 LN #1 referred Resident #1 to the facility Physician's Assistant (PA) after receiving report from the [MEDICAL TREATMENT] nurse that the resident was not feeling well. Resident #1 was assessed by the PA and orders were received for Antibiotics to treat a Respiratory Infection and Pharyngitis. On 02/8/2011 at 3:05 PM an interview was conducted with Resident #1's Rheumatologist. The Rheumatologist stated Resident #1 was seen in his office 12/30/2010 and orders were written for [MEDICATION NAME]. The physician stated that his order was intended to read "[MEDICATION NAME] 10 mg po 1 day per week." The Rheumatologist stated the order was written as a "recommendation" to be implemented if approved by the resident's physician and Nephrologist. The Rheumatologist confirmed that he had handwritten the orders and noted "only if agreeable with (facility physician's name)" on the consultation report which was returned to the facility with the resident. The Rheumatologist reported he was contacted, date unknown, by the Nephrologist regarding Resident #1's receipt of [MEDICATION NAME] 10 mg daily for six days and hospitalization . The Rheumatologist stated that [MEDICATION NAME] given as 10 mg daily for six days was a "[MEDICAL CONDITION] dose" which would result in bone morrow suppression and toxicity allowing the set-up of infection, mouth ulcers and sloughing of mouth tissues, and affects on the kidneys and liver. The Rheumatologist stated the excessive [MEDICATION NAME] dosing could have had a "large" impact on Resident #1's condition and may have lead to his hospitalization . The interview further revealed the Rheumatologist or another in his group were available at all times and calls were welcome and encouraged regarding clarification of orders and/or concerns. The Rheumatologist stated he was not contacted by facility staff regarding clarification of Resident #1's [MEDICATION NAME] order of 12/30/2011. During a follow-up interview, 02/09/2011 at 4:35 PM, the DON reported the facility utilized a "MD (Medical Doctor) Book" for non-urgent communications with the facility Physician, Nurse Practitioner (NP), and PA. The DON stated on 12/30/2010 Resident #1 returned from his Rheumatology appointment sometime after 4:00 PM with the consultation report and physician's orders [REDACTED]. The DON stated the consultation sheet was placed in the MD Book for the NP or PA to review and write the orders on their next visit. The DON stated the PA or NP were in the building four to five days weekly and were scheduled but did not come in on 12/31/2010 to review records or see residents. The DON stated LN #1 pulled the consultation report on 01/01/2011 and processed the order for Resident #1's [MEDICATION NAME]. The DON stated this was the routine procedure for processing consultations and follow-ups unless "now or stat" (immediate attention) were specified. Multiple attempts were made to contact the Nephrologist without success. The Administrator was notified of Immediate Jeopardy on 02/08/2011 at 1:25 PM. The facility provided a credible allegation of compliance on 02/10/2011 at 11:45 AM. The following interventions were placed by the facility to remove the Immediate Jeopardy: Corrective action has been accomplished for alleged deficient practice related to standards of practice involving a licensed nurse did not obtain the physician's verification and approval prior to transcribing orders from consulting physician recommendations. Licensed Nurse #1 was suspended on 1/18/11 pending an investigation being completed involving Resident #1. Resident #1's order was transcribed prior to receiving the attending physician's approval of the orders recommended by the consulting physician. Licensed Nurse #1 received one on one inservice education on 1/24/11 by Director of Nursing regarding procedure for notification of physician prior to initiation of consulting physician orders [REDACTED]. Director of Nursing observed Licensed Nurse #1 during Medication Administration on 1/24/11. Weekly documentation review of charting completed by Licensed Nurse #1, has and will continue, to be completed by the Director of Nursing weekly for four weeks and then monthly for three months. Current residents have the potential to be affected by the same alleged deficient practice related to standards of practice involving physician approval of consulting physician recommendations. Between 1/18/11 - 1/25/11 the Director of Nursing audited 100% of the medical records for residents currently residing in the facility for physician consultations that occurred from 12/1/10 - 1/25/11. On 2/8/11 consultation reports received between 1/25/11 - 2/8/11 were reviewed by the Director of Nursing for accuracy of transcription, timely initiation, and physician prior approval of recommendations. On 1/25/11 discrepancies were reviewed by the Quality Assessment and Assurance Committee and will continue to be reviewed weekly for four weeks and then monthly for three months for any trending patterns. The Committee will review the effectiveness of the plan based on outcomes/trends identified. Unit Managers will continue to audit consultation reports Monday through Friday for accuracy and timeliness of transcription. The Weekend Supervisor will review consultation reports on Saturday and Sunday for timeliness and accuracy of transcription, and prior physician approval. Discrepancies will be reported to the physician who wrote the consultation for evaluation and any new orders. This audit will continue weekly for four weeks and then monthly for three months. Then the audits will be reviewed quarterly. Measures put into place to ensure that alleged deficient practice does not recur include: 1/19/11 and 1/20/11 inservices were conducted by the Director of Nursing and the consultant pharmacist (RPH) for licensed nurses. An additional session was held on 1/22/11 by the Staff Development Coordinator. One remaining PRN/Casual nurse received training on 2/9/11 and one nurse is on medical leave and will receive required education prior to returning to work. Content of the inservice education conducted included: 1. Monitoring of High Risk Medications 2. Signs and Symptoms to observe for involving high risk medications 3. Excessive doses or Black Box Warnings 4. Importance of following physician orders 5. Importance of notifying physician for change of condition 6. Importance of timely review and initiation of recommendations from consultations with physician approval 7. Review of most common medication errors with failure to follow Five Rights of Medication Administration 8. When in question of any medication to contact the prescribing physician 9. Facility practice to assure that two licensed nurses note and verify physician orders 10. Importance of assuring that high-risk medication information is placed in a notebook at all nurses stations. 11. Facility practice to receive physician approval of consultation orders on the day of the consultation and note and verify these orders. 12. Available resources to review if a medication is questionable, i.e. pharmacy library on Omniview, Physician Desk Reference, referring physician, attending physician, and region, division, and field support resources. 13. Staff educated to document any observations of signs or symptoms of medication toxicity and report to the physician immediately. Documentation can occur on the 24-hour report, change of condition report, behavior monitoring form, and anti-coagulant report. On 1/19/11 and then ongoing the Director of Nursing, Assistant Director of Nursing, and Unit Managers reviewed physicians' consultation and any new orders weekly, and will continue to verify, that order transcription is accurate, has been noted and verified by two nurses. New physicians' telephone orders were, and will continue to be, compared to the Medication/Treatment Administration record for accuracy of transcription. The physician was, and will continue to be, notified of any discrepancies. Audits were reported to Quality Assurance and Assessment Committee for trending evaluation. The audits will be reviewed weekly for four weeks at Quality Assessment and Assurance Committee meeting and any necessary changes to the corrective action will be made based on trending analysis from the audit. The audits will then be reviewed by the Committee monthly for three months for any necessary changes based on trending data. Then the Committee will review quarterly. On 1/19/11 and then ongoing, Medication Administration Records were, and will be, audited by the Unit Managers and Assistant Director of Nursing weekly to determine medication variances with staff follow-up and re-education weekly, and/or disciplinary action, as appropriate. Discrepancies and medication variances were, and will continue to be, reported to the physician. Audits will be reviewed weekly for four weeks at the Quality Assessment and Assurance Committee meetings for any necessary changes to the corrective action based on trending analysis. The Committee will review the data monthly for three months, then quarterly and make recommendations based on the trending data. On 1/19/11 an emergency Quality Assessment and Assurance Committee meeting and Medication Management and Advisory Committee (MMAC) meeting was held with Medical Director and Pharmacy Consultant present. The Quality Assessment and Assurance Committee approved this action plan during the 1/19/11 meeting. The Regional Vice President of Operations, Regional Clinical Director, Division Director of Clinical Services or other Region/Division Team member will review the Committee's minutes and plans developed to ensure compliance as well as to assist with further development of the Committee. Immediate Jeopardy was removed on 02/10/2011 at 3:45 PM. The credible allegation of compliance was validated regarding in-services and training through interviews with Licensed Nursing staff form first, second, and third shifts and review of material and staff sign-in logs. One Licensed Nurse, currently on leave, to be in-serviced prior to first shift worked. Medication reference materials were observed at the Nurse's Stations and available for use. No additional residents were prescribed [MEDICATION NAME] thus medical records for other residents on high risk medications such as [MEDICATION NAME] and [MEDICAL CONDITION] medications were reviewed for unnecessary medications. Facility records regarding audits and monitoring, follow-ups, as well as Quality Assurance were in place and were reviewed.

Based on medical record reviews, physician and staff interviews the facility failed to monitor and adjust a [MEDICATION NAME] dosage for Resident #2 and failed to obtain verification and approval of a [MEDICATION NAME] order for Resident #1 resulting in administration of unnecessary medication for two (2) of seventeen (17) residents sampled for unnecessary medications. (Resident #1,2). Immediate Jeopardy was identified 02/08/2011 at 1:25 PM and began on 11/29/2010 when facility staff failed to obtain a PT/INR ([MEDICATION NAME] Time/International Normalized Ratio to measure blood clotting ability) and adjust a [MEDICATION NAME] dosage for Resident #2 resulting in hospitalization with an INR greater than twelve (12). The facility was also in Immediate Jeopardy from 01/01/2011 for failure to contact a physician for clarification and approval of [MEDICATION NAME] (a high risk medication) resulting in Resident #1 receiving five (5) times the intended dosage and an extended hospitalization . The facility remains out of compliance at a lower scope and severity of "D" (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of employee education and monitoring of placed systems. The findings are: 1. Lexi-comp's Drug Information Handbook, 8th edition, included the following information on [MEDICATION NAME] (an Antimetabolite used [MEDICAL CONDITIONS] and for treatment of [REDACTED]. "High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error. Errors have occurred (resulting in death) when oral [MEDICATION NAME] was administered as 'daily' dose instead of the recommended 'weekly' dose." "Mechanism of Action/Effect: The MOA (mechanism of action) in the treatment of [REDACTED]." "Dosing [MEDICAL CONDITION] arthritis: Oral: 7.5 mg (milligram) once weekly or 1.5 mg every 12 hours for 3 doses/week (per week), not to exceed 20 mg/week." "Adverse Reactions Note: (in part) Pneumonia, Pharyngitis (painful inflammation of throat or pharynx), renal dysfunction, vomiting, fever, reddening of skin, rash, hyperpigmentation of skin, ulcerative stomatitis (inflammation of mouth tissue), Leukopenia (decrease in disease-fighting cells), [MEDICAL CONDITION] (decrease in blood clotting platelets), and malaise." A June 2007 policy and procedure, provided by the facility, titled "Physician Orders" included instructions for Licensed Nursing staff to verify accurate dosage and frequency when receiving physician's orders [REDACTED]. Resident # 1 was admitted to the facility 11/10/2008 with [DIAGNOSES REDACTED]. Resident #1 also had a history of [REDACTED]. A handwritten "REPORT OF CONSULTATION" in the medical record revealed Resident #1 was seen by Rheumatology 12/30/2010 for [DIAGNOSES REDACTED]. Treatment is complicated by several co-morbidities including [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) on [MEDICAL TREATMENT] and severe Diarrhea." Multiple medications were recommended for treatment including "[MEDICATION NAME] 10 (ten) mg (milligram) po (by mouth) 1 (one) day / (per) week." The prescribed medications included the notation "only if agreeable c (with) (name of facility physician)." The handwritten "PHYSICIAN'S TELEPHONE ORDERS" dated 01/01/2011 at 12:00 PM included "[MEDICATION NAME] 10 mg po qd (by mouth every day) X (times) one week" to be administered for [MEDICAL CONDITION] Arthritis. The names' of the facility physician and the consulting physician were written of the order followed by the name and signature of Licensed Nurse (LN) #1 indicating that she (LN #1) had received the physician's orders [REDACTED].# 1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The 01/01/2011 physician's orders [REDACTED]." The MAR bore initials on January 2, 3, 4, 5, 6, and 7, 2011 indicating that [MEDICATION NAME] 10 mg was administered. January 8th on the MAR indicated NURSE'S NOTE" section stating that Resident #1 refused all medications. A 01/07/2011 08:00 AM Nurse's Note in the medical record revealed Resident #1 voiced complaints of a sore throat and difficulty swallowing and was medicated for discomfort. A 01/07/2011, no noted time, Physician's Assistant (PA) Encounter Note revealed Resident #1 was seen complaints of sore throat, ear pain, and malaise (general discomfort). The note read in part "history of endstage (sic) [MEDICAL CONDITION]. He was attending [MEDICAL TREATMENT] this morning, but had to be taken off due to complaints of feeling poorly." The PA noted that Resident #1 spoke with a "hot potato" voice and that "he is complaining of a sore throat, sore mouth, pain in his ears, and shortness of breath." The PA diagnosed Resident #1 with an Upper Respiratory Infection and Pharyngitis and noted the following treatment plan: [REDACTED]. Start (antibiotic) due to pharyngitis and respiratory infection." The PA's note gave no reference to Resident #1 receiving [MEDICATION NAME]. A 01/08/2011 3:00 PM Nurse's Note revealed Resident #1 was medicated for complains of "severe throat pain" and itching and burning in the groin area. A 01/08/2011 6:00 PM Nurse's Note revealed Resident #1 requested to go to the hospital and was assessed by Licensed Nursing staff. Resident #1 was assessed with [REDACTED]. Resident #1's vital signs included a temperature of 100.4, heart rate of 100, blood pressure of 140/78, respirations of 20 with 86% Oxygen saturation (percentage of Oxygen saturation in blood). Documentation further revealed Resident #1 was refusing to leave supplemental Oxygen in place. The Physician's Assistant (PA) was notified and orders were obtained to send Resident #1 to the hospital for evaluation and treatment via Emergence Medical Services. The 01/08/2011 (no noted time) "Resident Transfer Form" completed by the facility listed "Vomiting Blood" as the reason for Resident #1's transfer to the hospital Emergency Department (ED). The transfer form noted that Resident #1 had a temperature of 100.4 degrees, an Oxygen saturation of 86 %, and that the resident had trouble swallowing due to "mouth sore." Nurse's Notes from the hospital ED, from arrival on 01/08/2011 at 7:53 PM to 01/09/2011 at 01:44 AM when admitted for hospitalization , revealed Resident #1 arrived at the ED via ambulance with complaints of not feeling well, coughing with brown green mucus, and Oxygen saturation of 82 % prior to placement of Oxygen at the facility and while in route via Emergency Medical Services. The nursing assessment noted "Appears distressed, uncomfortable, behavior is agitated, restless. Complains of pain all over. Pain currently is 10 (ten) out of 10 on a pain scale. Quality of pain is described as aching." "Breath sounds are diminished bilaterally. Patent/caregiver reports the patient having vomiting (sic) blood. Blisters noted on penis on scrotum severe excoriation, with minimal bleeding noted around the scrotal area and glands penis, excoriation noted on buttocks and peri area." Resident #1 was noted as having a temperature of 101.2 degrees and an Oxygen saturation of 94 % with supplemental Oxygen in place at two (2) liters via nasal cannula. The nurse's Pneumonia screening read "Cough present with congestion present with Dyspnea (shortness of breath)." Nurse's notes revealed, while in the ED, Resident #1 was ordered and received medications to reduce his elevated temperature and intravenous antiemetics (treatment for [REDACTED]. Further review of Nurse's Notes revealed multiple laboratory tests (lab/labs) were ordered and conducted in the ED including a CBC (Complete Blood Count diagnostic for [MEDICAL CONDITION], infection, and other diseases) and BMP (Basic Metabolic Panel for evaluation of kidney function, blood sugar, and electrolytes). BMP lab results from Resident #1, collected in the ED 01/08/2011 at 8:20 PM, reflected abnormal values consistent with his [DIAGNOSES REDACTED]. CBC lab results, collected in the ED 01/08/2011 at 8:20 PM, reflected multiple abnormal results including: ? WBC (White Blood Cell) results 2.8 - below the normal reference range of 3.6 to 11.1 (may be decreased with some medications including [MEDICATION NAME], severe infections, and bone marrow failure). ? RBC (Red Blood Cell) results 4.08 - below the normal reference range of 4.70 to 6.10 (may be decreased with [MEDICAL CONDITION]). ? Platelet Count results 93 - below the normal reference range of 165 to 353 (may be decreased blood clotting ability). ? Lymphocytes (immune response white cells) results 0.3 - below the normal reference range of 1.1 - 2.7 (decrease indicates immune suppression). Physician documentation from the hospital ED, dated 01/09/2011 at 12:05 AM, noted that Resident #1 presented to the hospital with complaints of "Nausea/Vomiting." The physical examination conducted by the ED physician noted "Abdomen/GI (Gastro Intestinal): Positive for vomiting." The physician documented a reviewed of Resident #1's vital signs, the nurse's assessment/notes, and lab test results and noted the need for further "work-up and treatment" in the hospital. The physician documented that Resident #1 was to be admitted with a preliminary ED [DIAGNOSES REDACTED]. The hospital admission History and Physical for Resident #1, completed 01/09/2011 at 01:17 AM by the admitting physician, read in part "complaints of nausea, vomiting, altered mental status, [MEDICAL CONDITION] (deprived of adequate oxygen), and productive cough since one (1) day." "Patient (Resident #1) is complaining of sore throat and also had shortness of breath." "He had brownish green-colored expectoration with cough. His initial Oxygen saturation was 82% on room air and chest x-ray showing right lower lobe infiltrates." The physician's review of systems read in part: "He also has high-grade fever." "Fatigue and generalized weakness present. Also gets joint pains due to [MEDICAL CONDITION] arthritis. There was also decrease in physical activity." "Also has skin rash/[MEDICAL CONDITION] over face and bilateral lower extremities. Also having brownish pigmentation of bilateral lower extremities." The physician's admission physical examination included in part: "HEENT (Head, Ears, Nose, and Throat): [MEDICATION NAME] mucosa (inner lining of mouth) dry and [MEDICATION NAME] [DIAGNOSES REDACTED] (redness)." "LUNGS: Decreased air entry bilaterally. Crackles (abnormal lung sound) audible over right lower lung field. Occasional bilateral wheezes audible." The physician noted his assessment finds as "1. Pneumonia. Aspiration pneumonia versus healthcare-associated pneumonia. 2. [MEDICAL CONDITIONS]. 3. [MEDICAL CONDITION] secondary to pneumonia and [MEDICAL CONDITION]. 4. Altered mental status. 5. Leukopenia and rule [MEDICAL CONDITION]." A "MEDICATION VARIANCE REPORT" dated 01/18/2011, provided by the facility, indicated that an error occurred 01/02/2011 through 01/07/2011 in which Resident #1 was administered the wrong dose of [MEDICATION NAME] for treatment of [REDACTED].#1. As a result of the error Resident #1 received [MEDICATION NAME] 10 mg by mouth daily for six (6) days. The variance report noted "consult note confusing" as the cause of error. The outcome of the error noted on the report read: "An error occurred that may have contributed to or resulted in temporary resident harm or required initial or prolonged hospitalization ." The hospital Discharge Summary completed 02/08/2011 revealed Resident #1 was admitted [DATE] for "[MEDICAL CONDITIONS]" and was expected to discharge 02/09/2011. The summary revealed consultations with Nephrology, Critical Care, Cardiology, Infectious Disease, and Hematology were involved with Resident #1's care and treatment during hospitalization . Discharge [DIAGNOSES REDACTED]. 1. Acute [MEDICAL CONDITION] 2.[MEDICAL CONDITION] syndrome, likely due to pneumonia 3. Pancytopenia (abnormal depression of all the cellular elements of blood resulting from depression of bone marrow activity), "felt due to [MEDICATION NAME] toxicity." 4. End Stage [MEDICAL CONDITION]. The documented summary of Resident #1's hospitalization read in part: "admitted to the hospital 1 (one) month ago. He was admitted with pneumonia and [MEDICAL CONDITION], brought on by pancytopenia. This was felt to be due to [MEDICATION NAME] for a chronic rheumatologic condition. He was septic, received ventilator support, broad-spectrum antibiotics, and fluids. He developed complications with stomatitis." "His condition, though severe and serious, has stabilized, and he is planned for discharge." During an interview 02/07/2011 at 11:45 AM the facility Director of Nursing (DON) reported on 01/18/2011 at approximately 08:00 AM the facility physician made her aware that Resident #1, discharged to the hospital 01/08/2011, had received [MEDICATION NAME] 10 mg by mouth daily from 01/02/2011 through 01/07/2011. The DON stated that the physician requested that she pull resident #1's medical record and review the [MEDICATION NAME] order. The DON stated she recognized an error when she reviewed the order transcribed/written by Licensed Nurse (LN) #1 and the 12/30/2010 physician's orders [REDACTED]. The DON stated LN #1 read, wrote, and transcribed the physician's orders [REDACTED].#1 receiving a higher than intended dosage. The DON stated LN #1 did not contact the facility physician or the consulting/prescribing physician for approval and/or verification prior to writing and transcribing the [MEDICATION NAME] order. The DON reported that the end result of LN #1's failure to obtain verification and approval of the [MEDICATION NAME] order resulted in an error that may have contributed to or result in Resident #1's hospitalization on [DATE]. The DON confirmed Resident #1 was administered [MEDICATION NAME] from 01/02/2011 through 01/07/2011. . On 02/07/2011 at 12:15 PM an interview was conducted with Resident #1's physician (also the facility Medical Director). The physician stated a Nephrologist (Kidney specialty) contacted him on 01/17/2011 to report concerns that nursing home staff administered "too much [MEDICATION NAME]" to Resident #1. The physician stated the Nephrologist felt that Resident #1's problems and 01/08/2011 hospitalization was a direct result of receiving [MEDICATION NAME] 10 mg daily from 01/02/2011 through 01/07/2011. The physician stated that [MEDICATION NAME] 10 mg daily for treatment of [REDACTED]. The physician stated he would have expected the nurse to question the order and call the facility physician or extenders on-call for approval and verification prior to writing and transcribing the [MEDICATION NAME] order. The physician stated it would have also been appropriate to clarify the order with the prescribing physician. On 02/07/3011 at 1:54 PM an interview was conducted with LN #1, responsible for writing and transcribing Resident #1's [MEDICATION NAME] physician's orders [REDACTED]. LN #1 stated on 01/01/2011 she removed the Rheumatology consultation report from the "Doctor's Book," utilized by the facility for non-urgent communicate, and proceeded to "take off" the orders. LN #1 reported she read the physician's orders [REDACTED]. LN #1 stated she looked up [MEDICATION NAME] on the computer and saw directions for the medication to be given weekly which gave rise to the "thought" that the dose and/or frequency was "unusual." LN #1 stated she spoke to the Pharmacist and faxed the Rheumatology consultation report with the original [MEDICATION NAME] order to the pharmacy to be reviewed. LN #1 stated she did not question her interpretation of the physician's orders [REDACTED]. LN #1 stated she did not know why she did not contact the facility physician for approval and/or clarification prior to writing and transcribing the [MEDICATION NAME] order. LN #1 stated she did not know why she did not call the physician. The interview revealed "after a few days" on the [MEDICATION NAME] Resident #1 voiced complaints of a sore mouth and throat. LN #1 stated Resident #1 had voiced complaints previously and that she did not relate the sore mouth/throat to the [MEDICATION NAME]. The interview further revealed on 01/07/2011 LN #1 referred Resident #1 to the facility Physician's Assistant (PA) after receiving report from the [MEDICAL TREATMENT] nurse that the resident was not feeling well. Resident #1 was assessed by the PA and orders were received for Antibiotics to treat a Respiratory Infection and Pharyngitis. On 02/8/2011 at 3:05 PM an interview was conducted with Resident #1's Rheumatologist. The Rheumatologist stated Resident #1 was seen in his office 12/30/2010 and orders were written for [MEDICATION NAME]. The physician stated that his order was intended to read "Metotrexate 10 mg po 1 day per week." The Rheumatologist stated the order was written as a "recommendation" to be implemented if approved by the resident's physician and Nephrologist. The Rheumatologist confirmed that he had handwritten the orders and noted "only if agreeable with (facility physician's name)" on the consultation report which was returned to the facility with the resident. The Rheumatologist reported he was contacted, date unknown, by the Nephrologist regarding Resident #1's receipt of [MEDICATION NAME] 10 mg daily for six days and hospitalization . The Rheumatologist stated that [MEDICATION NAME] given as 10 mg daily for six days was a "[MEDICAL CONDITION] dose" which would result in bone morrow suppression and toxicity allowing the set-up of infection, mouth ulcers and sloughing of mouth tissues, and affects on the kidneys and liver. The Rheumatologist stated the excessive [MEDICATION NAME] dosing could have had a "large" impact on Resident #1's condition and may have lead to his hospitalization . The interview further revealed the Rheumatologist or another in his group were available at all times and calls were welcome and encouraged regarding clarification of orders and/or concerns. The Rheumatologist stated he was not contacted by facility staff regarding clarification of Resident #1's [MEDICATION NAME] order of 12/30/2010. On 02/08/2011 at 4:35 PM an interview was conducted with the Pharmacist responsible for receiving, verifying, and processing the 12/30/2010 [MEDICATION NAME] order for Resident #1. The interview revealed on 01/01/2011 the Pharmacy received the original Rheumatology Consult order and the Physician's Telephone Order prescribing [MEDICATION NAME] 10 mg po (by mouth) qd (every day) for 1 (one) week to be dispensed for Resident #1. The Pharmacist stated, per pharmacy policy, all orders prescribing [MEDICATION NAME] for daily administration and/or dosages of twenty (20) mg or more weekly required approval from a physician. The Pharmacist stated on 01/01/2011 at 1:40 PM he contacted the facility Nurse Practitioner (NP), advised her of the Rheumatology Consult order for [MEDICATION NAME], and explained the Pharmacy policy. The Pharmacist stated he requested and was given approval from the NP to dispense "[MEDICATION NAME] 10 mg po qd for 1 week" for Resident #1. During an interview, 02/09/2011 at 11:00 AM, the facility PA stated she saw Resident #1 on 01/08/2011 for Pharyngitis and Respiratory Infection and prescribed an antibiotic. The interview revealed Resident #1 complained of a sore throat, sore mouth, and shortness of breath. The PA stated prior to prescribing the antibiotics she reviewed Resident #1's medications and record for antibiotic use but did not review or recognize the [MEDICATION NAME] order. The PA stated she did not recall being aware that Resident #1 receiving [MEDICATION NAME] at the time of the encounter. During a follow-up interview, 02/09/2011 at 4:35 PM, the DON reported the facility utilized a "MD (Medical Doctor) Book" for non-urgent communications with the facility Physician, Nurse Practitioner (NP), and PA. The DON stated on 12/30/2010 Resident #1 returned from his Rheumatology appointment sometime after 4:00 PM with the consultation report and physician's orders [REDACTED]. The DON stated the consultation sheet was placed in the MD Book for the NP or PA to review and write the orders on their next visit. The DON stated the PA or NP were in the building four to five days weekly and were scheduled but did not come in on 12/31/2010 to review records or see residents. The DON stated LN #1 pulled the consultation report on 01/01/2011 and processed the order for Resident #1's [MEDICATION NAME]. The DON stated this was the routine procedure for processing consultations and follow-ups unless "now or stat" (immediate attention) were specified. Multiple attempts were made to contact the Nephrologist without successful. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 also had a [MEDICAL CONDITION] stoma. Review of the facility's policy and procedure for Anticoagulant Therapy, revisied June 2008, included in part; initiate and order anticoagulant therapy labs per physician's orders [REDACTED]. Review of a Physician Note dated 11/20/10 revealed Resident #2 had a PICC (Peripherally Inserted Central Catheter) line in the left arm and was receiving [MEDICATION NAME] (Intravenously administered antibiotic) for [MEDICAL CONDITION]-resistant Staphylococcus Aureus (MRSA) infection. Resident #2 developed swelling in his upper left arm about twenty four (24) hours ago. An ultrasound of the left upper arm showed a [MEDICAL CONDITIONS] that does not involve the tip of the PICC line. PLAN: [MEDICATION NAME] for six (6) weeks, continue the [MEDICATION NAME] until the International Normalized Ratio (INR - used to determine the clotting tendency of blood. Normal range 2.0 - 3.0), is between two (2) and three (3). He (Resident #2) is at high risk for mortality and morbidity. A review of a handwritten physician order [REDACTED]. Review of the Anticoagulant Therapy Flow Sheet, used by the facility to track [MEDICATION NAME] orders, PT/INR orders and PT/INR results, revealed the following laboratory values and corresponding physician orders: ? 11/21/10: INR 1.5. Continue [MEDICATION NAME] 10 mg by mouth daily and [MEDICATION NAME] 100 mg SQ daily continue [MEDICATION NAME] until INR is between 2 and 3 and recheck INR daily. ? 11/22/10: INR 3.3. Stop [MEDICATION NAME] and [MEDICATION NAME] 10 mg. Start [MEDICATION NAME] 9 mg by mouth daily and repeat PT/INR on 11/26/10. ? 11/24/10: INR 5.0. Hold [MEDICATION NAME] for 2 (two) days and recheck INR on 11/26/10. ? 11/26/10: INR 3.0. Start [MEDICATION NAME] 8 mg by mouth every day and check PT/INR on 11/29/10 to maintain levels within appropriate parameters. ? 11/29/10: Current dose for [MEDICATION NAME] 8 mg daily, a strike-out mark through the PT/INR result boxes and a strike-out mark through the new order box. No documentation of PT/INR. ? 12/07/10: INR >7.5. A telephone order received from the GNP dated 12/07/10 at 3:40 p.m. read in part; Hold [MEDICATION NAME] 8 mg on Tuesday 12/07/10. Give two (2) 5mg = 10 mg Vitamin K (reverses the effects of [MEDICATION NAME]) times one (1) dose. Check PT/INR at 9:00 p.m. on 12/07/10. If INR is greater than 3.0 call the physician on call. If INR is less than 3.0 report to GNP or PAC (Physician Assistant-Certified) in the morning and check PT/INR on 12/08/10. A telephone order received from the GNP dated 12/07/10 at 5:00 p.m. read; "Give Vitamin K 10 mg (2 5mg tabs) now." A handwritten order from the GNP dated 12/07/10 (no documentation of time) read; "Send to ER (emergency room ) for Eval (evaluation) re (regarding) toxic INR, hemoptysis/decreased (downward arrow) B/P." A review of resident #2's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Also noted on the November MAR indicated [REDACTED]. Review of Resident Transfer Form dated 12/07/10 (no documentation of time) indicated Resident #2's INR was > 7.5. Vitamin K 20 mg given by mouth and his Blood Pressure went from 110/72 to 100/62. Bleeding was noted from the resident's PICC line site and [MEDICAL CONDITION] stoma. The GNP in the facility assessed and gave an order to send Resident #2 to the ED (Emergency Department). A review of the emergency room (ER) report dated 12/07/10 revealed the resident presented to the ER with bleeding from his [MEDICAL CONDITION] stoma and PICC line site beginning 12/07/10. Multiple bruises were noted over his upper extremities. Laboratory tests obtained while in the ER revealed an INR of >12. The patient was given Vitamin K 10 mg (milligrams) intravenously and 2 (two) units of Fresh Frozen Plasma (FFP). Resident #2 was admitted to the medical floor of the hospital with admitting [DIAGNOSES REDACTED]. A review of Resident #2's Discharge Summary Report from the hospital dated 12/08/10 revealed a discharge [DIAGNOSES REDACTED]. Hospital course revealed Resident #2 achieved hemostasis (bleeding stopped) and all active bleeding resolved with FFP transfusion. The resident also received 1 (one) unit of Packed Red Blood Cells (PRBC) for moderate worsening [MEDICAL CONDITION] due to acute bleeding. Resident #2 was discharged from the hospital and returned to the facility on [DATE]. On 02/08/11 at 3:20 p.m. LN # 3 was interviewed and revealed she is 1 (one) of 4 (four) LNs documenting on the Anticoagulant Therapy Flow Sheet and performing PT/INR testing. It is her process to transcribe PT/INR orders onto the flow sheet and place in the notebook. Each day she will look in the book and at doctor's orders for changes in anticoagulation therapy and new PT/INR orders. The interview further revealed LN #3 was unable to state a cause for the missed lab. Interview with the facility's GNP (Geriatric Nurse Practitioner) on 02/09/11 at 8:50 a.m. revealed it is her expectation for nurses to call her with INR results. Stated she was unsure how the INR test of 11/29/10 was missed. The interview further revealed she was notified of Resident #2's bleeding from the tracheotomy stoma and PICC line. Vitamin K 10 mg by mouth was ordered for a total of 2 (two) doses. An interview on 02/09/11 at 10:15 a.m. with LN # 2 revealed she took the telephone order from the GNP on 11/26/10, transcribed the order to check PT/INR on Monday 11/29/10 onto the Anticoagulant Therapy Flow Sheet and placed it in the notebook. The interview further revealed the facility's process is to transcribe changes in [MEDICATION NAME] dosages, results of recent PT/INR, and new orders for follow-up PT/INR with the date on the Anticoagulant Therapy Flow Sheet. The flow sheet is placed in the notebook under the correct date. PT/INR to be drawn on 11/29/10 would be placed under the 29 tab. LN # 2 revealed someone must not have moved the flow sheet to the 29 tab and stated a PT/INR should have been drawn on 11/29/10. An interview on 02/10/11 at 8:05 a.m. with the Director of Nursing (DON) revealed PT/INRs are documented in a notebook. The notebook is a "working" book divided into date tabs where the flow sheet is placed when an INR needs to be drawn. A duplicate of the flow sheet resides in the resident's chart. When the physician order [REDACTED]. The flow sheet remained under the 26th tab until 12/07/10 when the resident started bleeding. The DON further revealed she was notified on 12/07/10 when the resident started bleeding which was the first indication that something was not right. The DON also stated the PT/INR machine was working correctly on 12/07/10 and if a resident's INR is > 7.5 the machine will read "> 7.5" and not the actual value. On 12/08/10 the Assistant Director of Nursing (ADON), Unit Managers and LN's responsible for completing PT/INRs met and reviewed the laboratory protocol and the Anticoagulation Therapy protocol, completed a 100 percent (100 %) audit on residents receiving anticoagulation therapy. The Administrator was notified of Immediate Jeopardy on 02/08/2011 at 1:25 PM. The facility provided a credible allegation of compliance on 02/10/2011 at 11:45 AM. The following interventions were placed by the facility to remove the Immediate Jeopardy: Corrective Action has been accomplished for Resident #1 and Resident #2 Resident #1 was discharged to the hospital on [DATE] with complaints of sore throat, fever, oral thrush, and blood tinged mucous. Resident #1 was admitted to the hospital. The facility was contacted on 1/18/11 by the Medical Director who indicated that resident #1 may have received inaccurate dosing of a medication. An investigation was initiated by the facility on 1/18/11, which revealed that the resident received an excessive dose of a high risk medication. Resident #1 discharged from the hospital on [DATE] to another skilled nursing facility A PT/INR was completed for Resident #2 on 12/7/10 with the INR results being greater than 7.5. The Unit Manager received subsequent orders from the nurse practitioner on 12/7/10 to administer Vitamin K. Vitamin K was administered on 12/7/10 by a licensed nurse. The resident's physician was notified and made the decision to transfer the resident to hospital for evaluation. Resident was admitted to the hospital with [REDACTED]. Resident #2 received fresh frozen plasma and red blood cell transfusion with improvement in his hemoglobin and hematocrit and INR and was discharged back to the facility on [DATE]. Resident #2 readmitted to the facility on [DATE], and [MEDICATION NAME] dosing resumed on 12/9/10 with PT/INR monitoring per physicians' orders. Corrective Action taken for all residents with the potential to receive unnecessary medication or have inadequate monitoring of medications. On 12/8/10 current residents receiving anticoagulant therapy were identified with 100% of identified charts audited by the Director of Nursing and Unit Managers to verify that laboratory diagnostic testing was obtained and the physician was notified of the results. On 12/8/10 the Director of Nursing and unit secretaries audited current resident charts for physician orders, which included laboratory testing to verify completion of labs that were ordered from 10/1/10 through 12/8/10. The physician(s) were notified of any discrepancies identified with new orders received. On 2/8/11 the Director of Nursing and Unit Managers audited 100% of current residents receiving anticoagulant therapy to include review of the.physician orders [REDACTED].