Every finding on record at The Pavilion at Creekwood

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services.The facility failed to ensure RN A and RN B administered Resident #1's blood pressure medication, clonidine 0.1 mg PRN, according to the physician ordered parameters on 08/08/26,08/15/26,08/20/26, 08/22/26, and 08/23/26.This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse side effect. Findings included: Review of Resident #1's MDS assessment, dated 06/20/26, reflected was an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a BIMS score of 15 indicating cognition was intact. Resident #1's diagnoses included hypertension (is a long-term medical condition where blood pushes too forcefully against artery walls). Review of Resident #1's care plan dated 06/01/26 revealed: Problem: [Resident #1] receives antihypertensive medications and is at risk for hypertensive/hypotensive complications rule out diagnosis of hypertension. Goal: [Resident #1] will not experience any complications related to blood pressure through next review period. Approach: Administer medications as ordered: Norvasc (a prescription calcium channel blocker used to treat high blood pressure (hypertension) and chest pain (angina) carvedilol (medication used to treat high blood pressure, heart failure, and left ventricular dysfunction after a heart attack), Clonidine [medication used to treat high blood pressure and attention deficit hyperactivity disorder] and Losartan [used to treat high blood pressur]). Monitor and record blood pressure/pulse before medication administration and report abnormal findings to physician. Review of Resident #1's physician's order dated 10/16/25 reflected: 1. Clonidine HCl tablet; 0.1 mg; amt: 1 tablet; oral Special Instructions: Give 1 tablet every 6 hours as needed for SBP (systolic blood pressure) >160 As Needed. 2. Vitals check Q Shift call Cardiology if heart rate is below 50 BP less than 90/60 and if BP (blood pressure) is more than 170/90 Every Shift First, Second, Third 06/16/2026.Record review of Resident#1 July 2026 TAR revealed blood pressure on 07/29/26-173/81 mmhg , no PRN clonidine was documented as administered and no documentation that the physician was notified.Record review of Resident #1's August 2026 TAR revealed the following blood pressure:-On 8/8/26-163/93 mmhg08/15/26-162/84 mmhg08/20/26-165/86mmhg08/22/26-165/83 mmhg and 08/23/26- 162/87mmhg and PRN clonidine was not administered on all these dates.Interview on 08/28/26 at 9:20 AM, Resident #1 stated she had been given her morning medications, and it included her blood pressure medications. She said her blood pressure get checked before medications are administered and she is shown the findings of her blood pressure, but she does not recall whether the nurses administer her PRN clonidine 0.1mg.Interview on 08/28/26 at 12:54 PM, RN A revealed she worked with Resident #1 on weekends. She said she was the one that worked with Residnet#1 on 08/08/26,08/15/26,08/20/26,08/22/26 and 08/23/26. She said she was aware she was supposed to administer clonidine 0.1mgs as needed for systolic blood pressure above 160 mmhg. RN A stated she could not recall whether she had administered Prn medications during those days the SPB was high. She said when she checked Resident#1 blood pressure in the morning she would let the MA know of the findings and tell her to administer her morning medications. She said she was aware she was supposed to recheck the blood pressure. She said she was supposed to document the administration of the PRN medication and the rechecked blood pressure. RN A stated the risk of not administering PRN medications when SPB was above 160 was blood pressure could go up and could lead to stroke.Interview on 08/28/26 at 1:48 PM, RN B revealed she had worked with Resident #1 on 07/29/26. She said she was aware she was supposed to administer clonidine 0.1mgs as needed for systolic blood pressure above 160 mmhg and if BP was above 170/90, she should contact the cardiologist. RN B stated she could not recall whether she told the medication aide to administer the morning medications or she administered Prn medications. She said she could not recall notifying the cardiologist as per the orders. RN B stated the risk of not administering PRN medications when SPB was above 160mmhg was blood pressure could go up and could lead to heart attack. She said failure to notify the doctor it could affect the Resident#1's blood pressure management. Interview and record review on 08/28/26 at 2:10 PM, ADON C stated she was not aware that Resident #1 had missed any PRN blood pressure medications. ADON C stated both RN A and RN B were responsible for care and medication administration for Resident #1.ADON C stated all nursing staff should follow doctor's orders, administer PRN medications, recheck blood pressure and notify physicians and document in the progress notes. ADON C stated the management are responsible for checking the vitals that are triggered in red and follow up with nurses, but she think those dates with high parameters were missed. ADON C stated if staff do not follow the doctor's orders to administer PRN medications and notify the doctor of high parameters the risk is high blood pressure. Interview on 08/28/26 at 3:05 PM, the DON stated the MA, and nurses are responsible for checking blood pressure before administering blood pressure medication. She said if the MA checks and the blood pressure is out of the parameters set by the physician, they should let the nurse know and the nurse should recheck and administer PRN medication. The DON said her expectation was nurses should follow doctor's orders. She said when the nurses checked the blood pressure and it was out of parameters; they were supposed to administer PRN medication and document on the TAR or in the nurse's progress notes. The DON stated she expected all nursing staff to ensure they are following physician's orders and in not doing so placed residents at risk of decline in general health and well-being, and uncontrolled blood pressure. The DON stated her and ADON were responsible for following up to ensure the physician orders were being followed ,and they check every morning on vitals, and she thinks it was missed. Record review of the facility's Medication Management Program policy, review dated 01/15/25, reflected: . 3. Licensed nurses will evaluate, assess, monitor, document and report the effectiveness of the medication regimen that includes all medications and supplements prescribed to treat illness, disease process, or enhance the patient's/resident's quality of life.3. Prior to administering medications, the nurse is responsible for:A. Obtaining and recording any necessary vital signs.B. Noting any changes on the MAR.I. If a PRN medication is administered, the authorized staff documents thepurpose for administration and response.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of five residents (Resident #1) reviewed for quality of life. CNA A and CNA B failed to transfer Resident #1 in accordance with the facility's policy when they failed to ensure her right wheelchair brake was locked and secured prior to completing a mechanical lift transfer. This failure could place residents at risk for accidents/injuries, including falls.Findings included: Record review of Resident #1's Face Sheet, dated 06/01/26, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses including dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), muscle wasting and atrophy (the loss of muscle mass that can occur due to various factors), and unsteadiness on feet (trouble keeping one's balance). Record review of Resident #1's MDS Assessment, dated 04/24/26, reflected she had a BIMS score of 02, indicating she had severe cognitive impairment. Resident #1 was identified as needing substantial/maximum assistance (indicating the helper did more than half the effort) for chair/bed-to-chair transfers. Record review of Resident #1's Physician's Orders, dated 06/01/26, reflected she required a mechanical lift for transfers, with the assistance of two individuals. Record review of Resident #1's Care Plan, dated 06/01/26, reflected she required a mechanical lift for transfers due to lower extremity weakness and/or modified weight bearing status. Observation on 06/01/26 at 10:15AM of a mechanical lift transfer for Resident #1 from her bed into her wheelchair, conducted by CNA A and CNA B, reflected prior to Resident #1 being transferred out of bed via mechanical lift, CNA B advised CNA A that the wheelchair brake on the right side of Resident #1's wheelchair was broken and would not lock. CNA A advised CNA B to hold the wheelchair securely during the transfer, since the right wheelchair brake would not lock. CNA B did as advised, and CNA A and CNA B proceeded with the mechanical lift transfer without incident, with the right side of Resident #1's wheelchair brake unlocked. Observation of Resident #1's wheelchair on 06/01/26 at 11:29AM (along with the Maintenance Director) revealed both sides of Resident #1's wheelchair were able to be securely locked. There were no noted concerns regarding the functionality of Resident #1's wheelchair. During an interview with CNA A on 06/01/26 at 11:00AM, she stated during the mechanical lift transfer for Resident #1, CNA B advised her that the wheelchair brake on the right side of Resident #1's wheelchair was broken and would not lock. CNA A stated she advised CNA B to hold the wheelchair securely during the transfer. She stated this was standard practice (one person would work the mechanical lift while the other person held the wheelchair securely) and wheelchair brakes were not required to be locked during mechanical lift transfers. She stated following the mechanical lift transfer, the Maintenance Director adjusted the wheelchair brakes, and now both were in proper working order. CNA A stated she worked PRN at the facility for the past two years, and had not been trained on mechanical lift transfers. She stated she never had any incidents involving mechanical lift transfers while at the facility. During an interview with CNA B on 06/01/26 at 11:10AM, she stated during the mechanical lift transfer for Resident #1, the wheelchair brake on the right side of Resident #1's wheelchair was different than the brake on the left side of the wheelchair. She stated the wheelchair brake was not moving into place correctly at the time of the mechanical lift transfer. She stated upon voicing this to CNA A, she was advised to hold the wheelchair securely during the transfer. CNA B stated she did as advised, and the mechanical lift transfer was completed without the right side of Resident #1's wheelchair being locked. CNA B stated the expectation was for wheelchairs to be completely locked prior to performing mechanical lift transfers. She stated she and CNA A should have stopped the transfer and notified maintenance and/or therapy of the issue, so the wheelchair brake could be fixed prior to completing the transfer. She stated she had been in-serviced on mechanical lift transfers at the facility, but she only worked at the facility for one week which was why she followed the instruction of CNA A. CNA B stated the risk of not locking both wheelchair brakes prior to a mechanical lift transfer was the potential for the wheelchair to move and cause the resident to fall. During an interview with the Administrator on 06/01/26 at 11:18AM, he stated he was notified of the incident involving Resident #1's right wheelchair brake not being locked during the mechanical lift transfer. He stated the expectation was for wheelchair brakes to be securely locked prior to mechanical lift transfers being completed. He said the risk of not locking both wheelchair brakes prior to a mechanical lift transfer was the potential for the wheelchair to move and cause the resident to fall. The Administrator stated nursing and therapy staff completed annual in-services on mechanical lift transfers; evidence of in-servicing for CNA A was requested at that time but was not provided. During an interview with the Maintenance Director on 06/01/26 at 11:29AM, he stated he was notified that the right side of Resident #1's wheelchair was unable to be locked during a mechanical lift transfer this morning. He stated he fixed Resident #1's wheelchair, and both sides were now able to be securely locked. Record review of the facility's Mechanical Lifts: General Guidelines policy, dated 05/05/23, reflected, .I. Prepare equipment by:. 3.) Ensure the receiving surface is stable and locked.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and disposal of for 3 (hall 300, 400 hall, and 200 hall) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure Resident #47's Trelegy elipta (a disposable, dry-powder inhaler) was dated after opening and before storage in the medication cart. The facility failed to ensure Resident #90's Breo elipta (in haler used to treat asthma) was dated after opening and before storage in the medication cart The facility failed to ensure of Resident #58's unopened Lantus SoloStar (disposable, prefilled, long-acting insulin) which required refrigeration per manufacturer's guidelines was observed stored unrefrigerated. These failures could place residents at risk of medication errors, reduced therapeutic effectiveness, unsafe administration and potential adverse outcome due to improper storage of medication.Findings included: Resident #47 Review of Resident #47's Quarterly MDS Assessment, dated 03/02/2026, reflected a [AGE] year-old female and had a BIMs score of 12 indicated moderate cognitive impairment. The resident had diagnoses which included Asthma, (a chronic, non-curable inflammatory lung disease causing airway obstruction, characterized by wheezing, chest tightness, coughing, and shortness of breath). Review of Resident #47's Comprehensive Care Plan, Edited: 04/06/2026 reflected: [NAME] is at risk for respiratory distress/SOB due to Dx of: COPD, ACUTE/CHRONIC RESP FAILURE Interventions included Administer medications as ordered. Monitor adverse reaction. Contact MD if noted. Review of Resident #47's active physician orders Dated 04/7/2026 reflected: Trelegy Ellipta blister with device(a disposable, dry-powder inhaler); 100-62.5-25 mcg; amt:1puff; inhalation Special Instructions: Rinse mouth with water after each use Once A Day start date 02/05/2026. Observation on 04/12/2026 at 9:10 AM, of the 300 Hall Nurses Cart with RN B revealed, Resident #47's Trelegy Ellipta did not have an opening date. During an interview on 04/12/2026 at 9:12 AM, RN B stated she was unaware Resident #47's Trelegy Ellipta labeled to expire 6 weeks after opening required to be dated after opening. She stated the nurses were responsible for ensuring all medication in the cart was dated. She stated that she had been inserviced on medication labeling and storage. Resident #90 Review of Resident #90's Quarterly MDS Assessment, dated 02/06/2026, reflected a [AGE] year-old female and had a BIMs score of 07 considered severe cognitive impairment. The resident had diagnoses which included Asthma (a chronic, non-curable inflammatory lung disease causing airway obstruction, characterized by wheezing, chest tightness, coughing, and shortness of breath). Review of Resident #90's Comprehensive Care Plan, Date Initiated: 04/02/2026 reflected Resident #90 is at risk for respiratory distress/SOB due to Dx of: COPD Interventions included Administer breathing treatments as ordered. Keep Nebulizer mask/tubing bagged when not in use. Review of Resident #90's active physician orders dated 04/7/2026 reflected: Breo Ellipta blister(a once-daily prescription maintenance inhaler used to treat asthma) with device; 200-25mcg/dose; amt: 1; inhalation Special Instructions: Rinse Mouth with water after each use Once A Day order start 04/02/2026. Observation on 04/13/2026 at 9:13 AM, of 200 hall nurses cart 200 Hall Nurses Cart with RN D revealed, Resident #90's Breo Ellipta had no opening date. During an interview on 04/13/2026 at 9:15 AM, RN D stated she was unaware Resident #90's Breo Ellipta labeled to expire 6 weeks after opening required to be dated after opening. She stated the nurses were responsible for ensuring medication in the cart was dated after opening. She stated the risk to the resident was medication error and someone could take the medication. She stated that she had been in serviced on medication labeling and storage. Resident #58 Review of Resident #58's Quarterly MDS Assessment, dated 03/20/2026, reflected a [AGE] year-old male and had a BIMs score of 07 considered severe cognitive impairment. The resident had diagnoses which included Diabetes Mellitus (a chronic metabolic disorder characterized by high blood sugar (glucose) due to inadequate insulin production). Review of Resident #58's Comprehensive Care Plan, Date Initiated reflected: Resident #58's is Immunodeficient r/t: Malnutrition risk. Interventions included: Administer meds as ordered. Review of Resident #58's active physician orders dated 04/7/2026 reflected: Lantus Solostar U-100 Insulin (insulin glargine) insulin pen; 100 unit/mL (3 mL);amt: 40 units; subcutaneous start order 03/17/2026. Review of the Lantus SoloStar Step-by-Step guide (www.Lantus.com) reflected, .HOW TO STORE YOUR UNOPENED LANTUS SOLOSTAR PEN .Before opening, store Lantus in the refrigerator (36 F to 46 F) . Observation on 04/12/2026 at 9:14 AM, of the 400 Hall Nurses Cart with RN C revealed, Resident #58's unopened Lantus which required refrigeration before opening per manufacturer's guidelines was observed stored unrefrigerated in the medication cart. During an interview on 04/12/2026 at 9:17 AM, RN C stated Resident #58's unopened Lantus should be stored in the refrigerator until it is opened and dated. She stated the nurses were responsible for ensuring all medication in the cart were dated after opening. She stated the risk to the resident was the insulin would loose it effectiveness when used to treat the residents blood sugar levels. She stated that she had been in serviced on medication labeling and storage. During an interview on 04/14/26 at 1:04 PM, the DON stated nurses were responsible for ensuring medication was dated after opening and medication that required refrigeration's like unopened insulin were refrigerated. She stated the ADON audited the medication carts weekly, then the pharmacy consultant checks the medication room, and the medication cart every month. She stated if medication were supposed to be refrigerated it should be refrigerated because the medication could lose its effectiveness. She stated that the nurses and medication aides had been in serviced on medication storage. Review of the facility's policy Medication Storage Revised 4/17/2024 reflected the following: .Medications and biologic biologicals are stored safely securely and properly following manufacturer's recommendations or those of the suppliers in accordance with state and federal laws the facility will store all drugs and biological in locked compartments under proper temperature and other appropriate environmental controls to preserve the integrity. Facility staff should monitor and record the temperature of refrigerator and freezer twice a day. The medication and biologicals supply is only accessible to licensed nursing personnel, pharmacy, pharmacy personnel or authorized staff members.Medication Refrigerators: 36 - 46-degree F or 2 - 8 Degree C.

Based on observation, interview, and record review, the facility failed to establish a system of records of receipt and dispositon of all controlled drugs in sufficient detail to enable an accurate reconciliation for 3 of (200 hall, 300 hall, and 400 hall) of 4 medication carts reviewed for pharmacy services. The facility failed to ensure proper storage and disposal of Resident #60's Tylenol#3-300 mg (controlled medication) by taping a narcotic medication and storing it in medication cart. The facility failed to ensure proper storage and disposal of Resident #68's hydrocodone 5-325mg (controlled medication) by taping a narcotic medication and storing it in medication cart. The facility failed to ensure proper disposal Resident #120's lorazepam 0.5mg (controlled medication) Resident discharged [DATE]. This failure could place residents at risk of drug diversion, medication error, and risk of pills contamination due to broken seals. Findings included: Resident #60 Review of Resident #60's Comprehensive MDS Assessment, dated [DATE], reflected Resident #60 was admitted on [DATE], he was a [AGE] year-old male, and had a BIMs score of 15 indicated he was cognitively intact. The resident had diagnoses which included Type 2 diabetes mellitus with foot ulcer (a serious, high-risk condition, affecting up to one-third of diabetics and potentially leading to infections, hospitalization, or amputation). Review of Resident #60's Comprehensive Care Plan, initiated [DATE], Edited: [DATE] reflected: Resident #60's is at risk for pain/discomfort r/t IMPAIRED MOBILITY, DIABETIC WOUND WITH OSTEOMYELITIS (a serious, often bacterial, infection of the bone or bone marrow, resulting in swelling, pain, and potentially bone destruction). Interventions included Administer medication as ordered, assess pain/discomfort every shift on a scale of 1-10. Review of Resident #60's active physician orders Dated:[DATE] reflected acetaminophen-codeine - Schedule III tablet (controlled medication); 300-30 mg; amt: 1 TABLET; oral Every 4 Hours - PRN Order start [DATE]. Observation on [DATE] at 9:14 AM, of the 400 Hall nurses' medication cart with RN C, revealed Resident #60's Tylenol #3-300mg had 4 broken seals on the blister pack secured with clear tape. The damaged blister packs had the pills still inside at the time the surveyor inspected the medication cart. During an interview on [DATE] at 9:17 AM, RN C stated she did not see Resident #60's Tylenol #3-300mg blister pack seals were broken during the count. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics at change of shift. She stated that the risk of a damaged blister would be potential for drug diversion and contamination of the medication. She stated discharged residents' medication should be removed from the medication cart as soon as the resident discharged . She stated the risk to the residents was medication error because a discharged resident medication could be accidentally administered to another resident. She stated she had been in service on medication storage. Resident #68 Review of Resident #68's Quarterly MDS Assessment, dated [DATE] reflected the resident was a [AGE] year-old male, had a BIMs score of 12 indicated he was moderately cognitively impaired. The resident had diagnoses which included Diabetes Mellitus. Review of Resident #68's Care Plan edited: [DATE] reflected: Resident #68 is incontinent of Bowel and Bladder. Intervention included Give pain meds PRN, monitor effectiveness. Monitor for complaints of verbal and non-verbal signs of pain during urination. Review of Resident #68's active physician orders Dated:[DATE] reflected hydrocodone 5-325mg amt:1 tablet; oral every 4-PRN. Observation on [DATE] at 9:13 AM, of the 200 Hall nurses' medication cart with RN D, revealed Resident #68's hydrocode 5-325mg had 2 broken blister seals on the blister pack. The damaged blister pack had the capsule still inside at the time the surveyor inspected the medication cart. During an interview on [DATE] at 9:15 AM, RN D stated she was unaware Resident #68's hydrocodone 5-325mg blister pack seal was broken. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated that the risk of a damaged blister would be potential for drug diversion and contamination of the medication. She stated she had been inserviced on medication storage. Resident #120 Review of Resident #120's Quarterly MDS Assessment, dated [DATE], reflected the resident#120 is a [AGE] year-old female. admission date [DATE] and discharged [DATE]. Section A Coded 13 indicated resident was deceased . Review of Resident #120's Comprehensive Care Plan, revealed no care plan problem goals, or intervention related to the medication. Resident#120 was discharged [DATE]. Review of Resident #120's physician orders reflected lorazepam - Schedule IV tablet (controlled medication); 0.5 mg; amt: 1 tablet; oral Special Instructions: One PO/SL q6 hours PRN anxiety/restlessness Every 6 Hours - PRN. Observation on [DATE] at 9:10 AM, of the 300 hall nurses' cart with RN B, indicated Resident # 120's Lorazepam 0.5mg (controlled medication) who had been discharged [DATE] was stored and available in the medication cart. During an interview on [DATE] at 9:12 AM, RN B stated Resident # 120's Lorazepam 0.5mg (controlled medication) should have been removed from the cart when she discharged . She stated the risk was a medication error because a discharged residents medication could be accidentally administered to another resident and potential for drug diversion. She stated she had been inserviced on medication storage. During an interview on [DATE] at 3:29 PM, the DON stated her expectation was that the nurses would not tape narcotics blister packs. She stated narcotics with broken seals should be wasted and witnessed by two nurses. She stated the discharged residents' medication should be removed from the medication cart as soon as the resident discharged . She stated having discharged residents' medication in the medication cart could lead to a medication error. She stated the pharmacy consultant audits the medication rooms and the medication carts monthly. She stated the risk to the residents of taping narcotics was contamination and medication error. She stated the nurses had been inserviced on medication storage. Review of the facility's policy Medication Storage Revised [DATE] reflected the following: Medications and biologic biologicals are stored safely securely and properly following manufacturer's recommendations or those of the suppliers in accordance with state and federal laws the facility will store all drugs and biological in locked compartments under proper temperature and other appropriate environmental controls to preserve the integrity.Once any medication or biologicals package is opened, the facility should follow manufacturers/suppliers' guidelines with respect to expiration dates of opened medications.All scheduled medications and other drugs subject to abuse are stored in a separate permanently of affixed area and are under double lock.Outdated contaminated and deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from the stocks pulled off according to procedures for medication distraction and reorder from the pharmacy replacements as needed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: There was a box of dinner rolls that was opened and unsealed in the walk-in deep freezer. There was a bag of lettuce heads that was opened, unsealed, without a label and use-by date in the walk-in refrigerator. There was a bag of mixed salad greens that had been previously opened and partially used, wrapped in clear plastic wrapping without a label and use-by date in the walk-in refrigerator. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.Findings included:1. Observation on 4/12/2026 at 9:22 AM, revealed there was a 11.25-lb box of dinner rolls on a shelf in the walk-in freezer. The dinner rolls were in the original packaging, a clear plastic bag inside of the box. The box was opened from the top and the plastic bag holding the rolls was open. A white sticker on the box read 4/7/2026.2. Observation on 4/12/2026 at 9:25 AM in the walk-in refrigerator revealed a clear plastic bag of lettuce heads stored unsealed without a use-by date on the packaging.3. Observation on 4/12/2026 at 9:26 AM in the walk-in refrigerator revealed a bag of mixed salad greens, previously opened and partially used, without a label or use-by date. The mixed salad greens were observed to be wrapped several times in clear plastic wrap. During an interview on 4/12/2026 at 9:29 AM, the Morning Cook, reported every morning she would check to ensure all food stored in the kitchen was labeled and dated. She observed the dinner rolls, lettuce heads, and mixed lettuce greens. She stated she would throw the food items away. She reported the risk posed to residents by undated and exposed food could cause cross contamination. During an interview on 4/14/2026 at 12:00 PM with the Dietary Manager, she reported she was made aware of the food items in the kitchen that were exposed to air and not dated. She reported that food should have been closed and labeled/dated. She reported the Morning [NAME] threw away the dinner rolls after surveyor identified. She reported the risk to residents was potential freezer burn and contaminated food. She reported that foodborne illness is a potential risk. She reported she conducted an in-service that same day with all kitchen staff on food safety, storage, and labeling. Record review of the facility policy titled Food Safety in Receiving and Storage, dated 10/15/2025, reflected in part: tightly reseal opened packages to prevent contamination or place food in covered containers. Containers holding food or food ingredients that are removed from their original packages are identified with the common name of the food.

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one of six residents (Resident #79) reviewed for resident rights. The facility did not ensure LVN A knocked on the door before entering Resident #79's room or announced herself. These failures could place residents at an increased risk of diminished quality of life.Findings included: Resident #79 Record review of Resident #79's Quarterly MDS Assessment, dated 03/07/2026, reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. The resident had a BIMS score of 9 which indicated moderate cognitive impairment. Diagnoses included: Unspecified dementia (severe decrease in memory and intellectual functioning that can occur in the later stages of Parkinson's), Type II Diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), and Hypertension (blood pressure is consistently too high, which can strain the heart and blood vessels). Resident #79 required extensive assistance for bed mobility, transfer, and toilet use. Review of Resident #79's Comprehensive Care Plan, dated 2/27/2026, reflected Resident #79 required the use of side rails (positioning bar) for turning and repositioning with an intervention of keeping the call light within reach. The plan also identified the resident as a fall risk with an intervention of keeping the call light within reach at all times. Resident #79's care plan identified she had impaired visual function with an intervention stating staff would announce self by name, position, and call resident by her name. During an observation and interview on 4/12/2026 at 10:13 AM, Resident #79 reported her incontinent brief was wet and needed changed. She reported she had not told anyone because she could not find her call button. Her call button was observed on a nightstand. Resident #79 stated she was not sure who put the call button there and could not reach it. During an interview with LVN A on 4/12/2026 at 10:17 AM, LVN A was told Resident #79 expressed she needed to be changed and could not call for assistance because her call light was out of reach. LVN A stated she would send a CNA to help the resident. LVN A was asked to accompany surveyor to Resident #79's room to see her call light placement. LVN A walked into the room and placed the call light on the resident's stomach and walked out. LVN A was observed walking into the resident's room without knocking or announcing herself to the resident. LVN A did not say anything to the resident. LVN A stated staff are required to knock on every resident's door and say their name so that the resident would know who you were and not get confused. During an interview with the DON on 4/14/2026 at 10:45 AM , she reported staff are expected to knock/announce who they were as they entered a resident room. She reported not doing so would be an invasion of privacy and potential dignity issue. Record review of facility's policy and procedures Call Lights, Responding to, dated 5/5/2023, revealed staff knock on the patient or resident room door before entering to promote privacy and dignity.

Based on observation, interview, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #79 and Resident #28) of six residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #79 and #28's rooms were in a position that was accessible to the residents. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #79 Record review of Resident #79's Quarterly MDS Assessment, dated 03/07/2026, reflected a [AGE] year-old female, originally admitted to the facility on [DATE]. The resident had a BIMS score of 9 which indicated moderate cognitive impairment. Diagnoses included: Unspecified dementia (severe decrease in memory and intellectual functioning that can occur in the later stages of Parkinson's), Type II Diabetes (a condition where the body can't properly use sugar for energy, leading to high blood sugar and possible complications), and Hypertension (blood pressure is consistently too high, which can strain the heart and blood vessels). Resident #79 required extensive assistance for bed mobility, transfer, and toilet use. Review of Resident #79's Comprehensive Care Plan, dated 2/27/2026, reflected Resident #79 required the use of side rails (positioning bar) for turning and repositioning with an intervention of keeping the call light within reach. The plan also identified the resident as a fall risk with an intervention of keeping the call light within reach at all times. During an observation and interview on 4/12/2026 at 10:13 AM with Resident #79, she reported her incontinent brief was wet and needed changed. She reported she had not told anyone because she could not find her call button. Her call button was observed on a nightstand. Resident #79 stated she was not sure who put the call button there and could not reach it. During an interview with LVN A on 4/12/2026 at 10:17 AM, surveyor spoke to LVN A in the hallway and explained Resident #79 expressed she was needing changed and could not call for assistance because her call light was out of reach. LVN A stated she would send a CNA to help the Resident. LVN A was asked to accompany surveyor to Resident #79's room to see her call light placement. LVN A walked into the room and placed the call light on the resident's stomach and walked out. Resident #28 Record review of Resident #28's, admission MDS assessment dated [DATE], reflected a [AGE] year-old female, admitted to the facility on [DATE]. Resident 28's BIMS score was not completed on the assessment. Diagnoses included: senile degeneration of brain (the age-related, progressive, and irreversible loss of brain cells (neurons) and cognitive function) and essential primary hypertension (chronic high blood pressure that does not have a single, identifiable medical cause). Record review of Resident #28's Comprehensive Care Plan, dated 3/28/2026, reflected Resident #28 required assistance for bed mobility, toileting, transfers, and ambulation. During an observation and interview on 4/12/2026 at 10:04 AM, with Resident #28, she reported she needed her incontinence brief changed. She reported she had been waiting at least an hour. She reported she was unable to call anyone for help because she could not reach her call button. The resident's call button was observed on the floor on the side of the resident's bed, out of reach. Resident #28 said it fell off her bed earlier this morning. During an interview with LVN A on 4/12/2026 at 10:07 AM, she reported resident's use their call button if they need incontinence assistance. She stated everyone's call light should be within reach. She reported when she gave Resident #28's medications she had to pick up her call button from the floor. LVN A reported Resident #28 knocks the call button off her bed. LVN A picked the call button up and placed it back on Resident #28's bed within her reach. During an interview with the DON on 4/14/2026, she reported resident call light buttons are expected to be within reach. She stated everyone was responsible for that. She reported if a resident was unable to access their call button, they would not be able to call for assistance. Record review of facility's policy and procedures Call Lights, Responding to, dated 5/5/2023, revealed ensure the call light is placed within patient's/resident's reach.

Based on interview and record review, the facility failed to conduct a Comprehensive Assessment within 14 calendar days after admission, as well as at least once every 12 months, for one (Resident #28) of five residents reviewed for Comprehensive Assessments and timing. The facility failed to ensure a Comprehensive MDS Assessment for Resident #28 was completed within 14 days after her admission to the facility. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.Findings included: Review of Resident #28's Face Sheet, dated 04/14/26, reflected she was a [AGE] year-old female, who was admitted to the facility on [DATE], with diagnoses including senile degeneration of brain (the age-related, progressive, and irreversible loss of brain cells (neurons) and cognitive function) and essential primary hypertension (chronic high blood pressure that does not have a single, identifiable medical cause). Review of Resident #28's electronic medical record on 04/14/26 reflected no evidence that an MDS Assessment had been completed. During an interview with the MDS Coordinator on 04/13/26 at 10:55 AM, she stated Resident #28 originally admitted to the facility as a respite resident on 03/27/26 and was only supposed to reside at the facility for four days. Resident #28's family then extended the respite stay twice (the second extension resulted in Resident #28 residing at the facility for more than 14 days). The MDS Coordinator stated she was not made aware that Resident #28's respite stay had been extended the second time, which was why her MDS Assessment was not completed within the required timeframe. The MDS Coordinator stated upon finding out that Resident #28's respite stay had been extended for the second time, she immediately initiated an admission MDS Assessment (which was still in the process of being completed) and notified admissions/administration to communicate with her any time a respite stay was extended. The MDS Coordinator stated the risk of MDS Assessments not being completed in the required timeframe was the potential for improper billing and funding. Review of the facility's Minimum Data Set (MDS) policy, dated 09/28/23, reflected, .Facilities are required to complete a comprehensive assessment of each resident within 14 calendar days after admission to the facility, when there is a significant change in the resident's status, and not less than once within 366 days.

Based on interview and record review the facility failed to ensure residents was free of any significant medication error of 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure accurate transcription of Resident #1's prednisone orders (medication used to reduce inflammation and suppress the immune system, and severe illness flare-ups resulting in a missed medication dose. The failure resulted in a medication error and placed the resident at risk for adverse clinical outcomes, worsening the resident's condition or potential harm due to omission of the prescribed medication. Findings include: Record review of Resident #1's MDS Assessment, dated 03/04/26, reflected a [AGE] year-old male, admitted [DATE].No BIMS score was recorded, indicating no interview was conducted. No diagnosis was recorded in the MDS, resident was at the facility from 03/02/2026 - 03/04/2026. Record review of Resident #1's hospital records reflected he was admitted at the hospital from [DATE] to 03/02/2026, his diagnosis included Interstitial lung disease (lung disease that progresses and causes severe respiratory failure causes chronic inflammation and scarring (fibrosis) in lung tissue, impairing oxygen transfer and often leading to chronic or exertional hypoxia (low oxygen). Record review of Resident #1's active care plan, Baseline Care Plan, created 03/03/2026, reflected Resident #1 requires oxygen. Interventions included Administer oxygen as ordered, Observe for S/S of SOB, decreased perfusion (insufficient oxygen delivery to tissues). Report significant changes to the MD. Record review of Resident #1's discharge orders dated 03/02/2026 reflected: Take Prednisone (used to reduce inflammation and suppress the immune system, treating conditions like asthma, allergies, arthritis, skin diseases, and severe illness flare-ups ) 16 tablets (80 milligrams total) by mouth daily for two days, then 14 tablets (70 milligrams total )daily for 14 days, then 12 tablets (60 milligrams total) daily for 14 days, then 10 tablets (50 milligrams total) daily for 14 days, then 8 tablets (40 milligrams total) daily for 14 days, then 6 tablets (30 milligrams total) daily for 14 days and then 4 tablets (20 milligrams total) daily for the 14 days, then 2 tablets (10 milligrams total) for 14 days, then 1 tablet (5 milligrams total) dealing for 14 days. Last taken 80 milligrams on March 2nd, 2026, at 8:24 AM. Start taking on March 3rd 2026. Record review of Resident #1's physician orders reflected prednisone was not transcribed on the physician orders and Medication Administration record on admission. Further review revealed the medication was not administered as ordered on 03/03/2026 resulting in a missed dose. Record review of Resident #1's March 2026 MAR reflected prednisone orders had start date of 03/04/2026. There was no prednisone orders dated 03/03/2026. Record review of Resident #1's records revealed the facility had completed medication error for the missed medication on 03/03/2026. During an interview on 04/13/2026 at 11:45 AM, the ADON- revealed Resident #1 was admitted on [DATE] at 4:30 PM. She stated the next day there was a note in her office from the nurse that admitted Resident #1 to please enter the prednisone order, but she did not see the note and there was no communication that it was her responsibility to enter the order. She stated the order was entered in PCC by another nurse manager. She stated Resident #1's FM spoke to her about medication but did not mention prednisone. She stated on 03/03/2026 she went to do rounds and Resident #1's FM informed her that he had not received his medication. She stated she had not audited his admission medication to see if there were any missing medications. She stated the risk to the resident was a missed dose and ineffective treatment. She stated she was suspended pending investigation and was still on suspension. During an interview on 04/13/2026 at 11:50 AM, LVN E revealed she was Resident #1's nurse when he admitted and the day he was transferred to the hospital. She stated LVN F assisted with entering medication in the computer. She stated she recalled the prednisone order was confusing and LVN F contacted the ADON to assist with entering the medications. She stated she was not aware the resident missed any medication because the medication aides administer medication and if there was medication that was missing the medication aide would notify her but on 03/03/2026 she was not notified of Resident #1 missing medication. During an interview on 4/14/2026 at 12:10PM , LVN H revealed Resident #1 admitted on [DATE] in the evening. She stated LVN F left her note to assist in entering the prednisone orders. She stated she entered the orders on 03/03/2026 but populated on the MAR order the next day 3/04/2026. She stated she was not sure why he did not get the medication on 03/03/2026. She stated she was not aware that he missed the dose until she heard about it recently. She stated the ADONs audits all new admission orders to make sure all orders were transcribed. She stated the risk to the resident was medication error and up to death depending on the medication missed. During an interview on 04/13/2026 at 12:40 PM, the FM revealed Resident #1 was admitted to the facility on Monday 03/02/2026 around 4 PM. She stated on Tuesday 03/03/2026 he missed a dose of prednisone. She stated she was notified that there was confusion of how the orders were written from the hospital and the nurse needed to verify with the facility MD. She stated she spoke with the nurse and the ADON, and he got his prednisone on 03/04/2026. She stated the missed dose might have caused him to have a drop in oxygen level on 03/03/2026 when he was transferred to the hospital. During an interview on 04/14/2026 at 12:45 PM, LVN F revealed she assisted with entering Resident #1's admission orders. She stated order verification was done by LVN E. She stated she entered all the orders in but had an issue with the prednisone orders because it titrates and she did not know who to enter the order in PCC. She stated that she communicated with the ADON that she needed assistance with entering the prednisone orders. She stated she gave report to the oncoming night nurse she could not enter the prednisone orders and circled the orders that were not entered. She stated the risk of not transcribing the orders on admission could result in medication errors and depending on the medication it could have adverse effects on the residents to include hospitalization. During an interview on 04/14/2026 at 3:45 PM, the DON revealed Resident #1's prednisone order was not transcribed to the MAR on admission. She stated all new admission orders were audited and verified by the ADON the following morning after admission to make sure there was nothing omitted. She stated she was not sure why the audit was not done. She stated the ADON was suspended pending investigation. The DON stated the failure to accurately transcribe the order contributed to the missed dose and medication error. She stated all physician orders should be promptly and accurately transcribed to the MAR to ensure medications are administered as prescribed. During an interview on 04/14/2026 at 3:45PM, the MD revealed a chart review because Resident #1 was there for a short time and because of the missed dose. She stated the resident had been on a high dose of steroids and intravenous medication for over a month so it was not a new start for the steroids so it would have been sensitive to the medication. She stated he was readmitted for pneumonia which was not related to the missed dose. She stated when there was an issue with order clarification the nurses would call for a one-time order, so the resident does not miss the dose. She stated the risk of not transcribing admission orders was medication error and missed doses. Review of the facility's policy Medication Management Program Revised 1/ 5/2025 reflected the following: The facility's Medical Director will have an active role in the oversight of medication management, achieved in a variety of ways including medical record reviews, consultation, recommendations from pharmacy consultants and/or recommendations through the Quality Assurance and Performance Improvement process.2. Licensed Independent Practitioners, licensed nurses, consulting pharmacists, and pharmacy service providers collaborate and review medication orders to ensure medical and clinical necessity and appropriateness. The primary mechanism for this validation is an initial and ongoing medication reconciliation process.

Based on observations, interviews and record review, the facility failed to ensure residents with pressure ulcers and at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #2, #3 and #4) of six residents reviewed for treatment/services for pressure ulcers.1. The facility failed to ensure pressure was offloaded from Resident #2's unstageable deep tissue injury on his left heel on 08/05/25. 2. The facility failed to ensure Resident #3's right heel air boot was in place to relieve and reduce pressure to a healing wound on 08/05/25.3. The facility failed to ensure pressure was offloaded on Resident #4's healing surgical incision site on her lower leg on 08/05/25.This failure placed residents at risk of worsening pressure and delayed healing, as well as discomfort and pain. Findings included:1. Record review of Resident #2's Face Sheet dated 08/06/25 reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. Resident #2's diagnoses included metabolic encephalopathy (a condition where brain dysfunction arises from a chemical imbalance in the blood caused by an underlying medical condition or illness), diabetes mellitus (a chronic condition where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), atherosclerotic heart disease (plaque buildup in the arterial walls of the heart), muscle wasting and atrophy (loss of muscle mass and strength).Record review of Resident #2's admission MDS dated [DATE] reflected a BIMS score of 13, which indicated moderate cognitive impairment. He had no psychosis, delirium or rejection of care issues. Resident #2 had range of motion impairment on both sides of his lower extremities. Resident #2 was dependent on the physical assistance of staff for transfer and substantial/maximal assistance for bed mobility. Resident #2 was at risk of developing pressure ulcers and he had one unhealed and unstageable pressure injury presenting as a deep tissue injury upon admission. Resident #2 required pressure ulcer/injury care and applications of ointments/dressings. Record review of Resident #2's care plan dated 07/25/25 reflected, [Resident #2] has a DTI to his left heel related to immobility; At risk for Pressure Injury related to: impaired mobility, incontinence, diabetes, kidney failure, heart failure and fragile skin. Approaches included, Use pillows, pads, or other pressure-reduction devices to offset pressure from bony prominences.Record review of Resident #2's initial wound care visit dated 07/20/25 reflected he had an unstageable deep tissue injury of the left heel of undetermined thickness with a two-to-four-month time frame for healing, a goal to decrease the ulcer area, with approaches that included offloading. Resident #2's wound size was 7cmx10cmx not determinable, 70 cm in surface area, no exudate, skin with purple/maroon discoloration, blood filled blister, no pain and no signs/symptoms of infection. Recommendations included to float heels in bed, reposition per facility protocol and off-load wounds. A second visit was completed on 08/06/25 and the wound care doctor noted the resident's wound measurement were the same as the week prior and the wound progress was not at goal due to need more time. There was no pain or signs of infection on the second visit. Record review of Resident #2's physician order dated 07/25/2025 reflected, Elevate/Float Heels while in bed; Right plantar DTI- apply skin prep to area daily.Record review of Resident #2's nursing progress note dated 07/30/2025 reflected, Left heel DTI measuring 7cm x10cm- skin intact with purple/ maroon discoloration (blood filled blister), current wound care order continues. Resident continues wearing air boots in air boots as prescribed.An observation of Resident #2 on 08/05/25 at 2:08 PM, revealed Resident #2's feet were not offloaded and his heels were placed directly on a pillow at the foot of his bed. An interview with the DON on 08/05/25 at 2:09 PM, revealed she observed Resident #2 and he did not have his feet properly offloaded. An interview with LVN E on 08/05/25 at 2:12 PM, revealed he was the charge nurse from 6a-2p for Resident #2. He stated he had not touched Resident #2's feet that shift so he did not know who placed his feet and heels directly on a pillow. LVN E stated he was the one who had completed wound care on Resident #2's heel that shift, but he was not sure if he required air boots and he was only there to provide the wound care and did not check to see if they were offloaded properly. He checked Resident #2's chart and verified air boots were ordered to be in use. Record review of new physician's order dated 08/05/25 (after investigator intervention), reflected, Z-flex boots to offload heels while in bed, Frequency: Every Shift.Record review of Resident #2's revised care plan (completed after investigator intervention), reflected the care plan was updated by the facility and reflected he was resistant to care. The care plan update on 08/06/25 reflected, Problem Start Date: 08/06/2025-[Resident #2] has behaviors AEB: resident unsafely puts himself into bed and doesn't apply boots to protect his heels- Approach: Document non-compliance in clinical record.Record review of Resident #2's nursing progress notes since his admission on [DATE], reflected no entries related to him being non-compliant with wearing any heel protectors/air boots. 2. Record review of Resident #3's Face Sheet dated 08/06/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #3's diagnoses included metabolic encephalopathy (a condition where brain dysfunction arises from a chemical imbalance in the blood caused by an underlying medical condition or illness), muscle wasting and atrophy (loss of muscle mass and strength) and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, leading to damage to brain cells). Record review of Resident #3's admission MDS dated [DATE] reflected a BIMS score of 08, which indicated moderate cognitive impairment. Resident #3 had no psychosis, delirium or rejection of care issues. She was dependent on the physical assistance of staff for transfer and substantial/maximal assistance for bed mobility. Resident #3 was at risk of developing pressure ulcers/injuries but had no pressure ulcers documented as being present at the time of the assessment, as well as no venous or stasis ulcers. Resident #3 also had no other ulcers, wounds or skin problems indicated. Record review of Resident #3's care plan dated 07/07/25 reflected, 1) [Resident #3] is at risk for Pressure Injury related to: impaired mobility, incontinence, decreased cognition, kidney failure and fragile skin, 2) [Resident #3] has a current wound/disruption of skin surface: blood filled, blister Skin tear to RLL. Approaches included, Use pillows, pads, or other pressure-reduction devices to offset pressure from bony prominences.Record review of Resident #3's physician orders reflected, Offload right heel when resident is in bed every shift (start date 07/03/2025 -open ended).Record review of Resident #3's nursing progress note dated 07/16/25 reflected, Wound update- blister to right heel dry with blister surface continuing to slough off, application of betadine continues to area daily and offloading of heels. Wound surface area decreasing in size.An observation of Resident #3 on 08/05/25 at 1:50 PM, revealed she was in bed asleep. Resident #3's feet were observed to have no heel protectors or air boot on. All wound dressings were observed to be in place and was dated 08/05/25. An interview and observation on 08/05/25 at 2:03 PM, with LVN B revealed Resident #3 should have air boots on her feet and went to the resident's room to find them. She located the air boots on the floor in the closet and then placed them onto Resident #3's feet. She stated she looked in the chart and verified there was a physician's order to place air boots on the resident's right foot while in bed. She stated she had done the wound care earlier and had offloaded one foot one a pillow. LVN B stated even though Resident #3's heel was floated on a pillow; she still should have had her air boots on because there was an order to wear them to prevent skin breakdown. She said the air boots helped keep Resident #3's heel lifted off the mattress and have no pressure placed on it. LVN B said the resident's heel was not mushy, it was drying out. LVN B stated a mushy heel was a concern in that it could turn into a wound quickly in a couple hours if there was pressure on it. LVN B stated even with the use of Betadine to dry the heel out, if it was left on the mattress or pillow, then skin would start to go backwards in healing and get soft again. An observation of Resident #3 on 08/06/25 at 12:00 PM, (after investigator intervention) revealed she had two air boots one on her right and left feet. An interview with Resident #3's family member on 08/06/25 at 12:00 PM, revealed the resident got the wound on her right heel because she had neuropathy and was rubbing her heel skin on the mattress most likely because it felt good to itch it. The family member stated the wound did not appear to be getting better because the resident would indicate through grimacing at time during visits that it was hurting. The family member stated the air boots that were presently on Resident #3's feet she had never seen before and noted the roommate [Resident #4] was currently wearing the heel protectors she was used to Resident #3 wearing. She did not know why those were now being used for her roommate. 3. Record review of Resident #4's Face Sheet dated 08/06/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included acute osteomyelitis- left ankle and foot (a bone infection, usually bacterial, that develops over a short period, often within two weeks), pain, peripheral vascular disease (a circulation disorder that affects blood vessels outside of the heart and brain), muscle wasting and atrophy (loss of muscle mass and strength), methicillin resistant staphylococcus aureus infection (a type of staph that can be resistant to several antibiotic), diabetes mellitus (a chronic condition where the body doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), neuropathic arthropathy (a condition where a joint breaks down due to nerve damage) and dementia (a decline in mental ability severe enough to interfere with daily life).Record review of Resident #4's admission MDS dated [DATE] reflected a BIMS score of 03, which indicated severe cognitive impairment. She had no signs or symptoms of psychosis, delirium, or rejection of care. Resident #4 had range of motion limitations on both sides of her lower extremities. Resident #4 was dependent on staff for all transfers and needed substantial/maximal assistance for bed mobility. Resident #4 was at risk of developing pressure ulcers/injuries and had one Stage 2 pressure ulcers that was present upon admission. She also had other ulcers, wounds and skin problems which included an infection of the foot. Resident #4 required pressure ulcer/injury care, applications of ointments/medications other than to feet and application of dressings to feet (with or without topical medications).Record review of Resident #4's care plan dated 07/15/25 reflected, [Resident #4] has a surgical incision s/p I&D to left plantar surface. Interventions did not include a discussion of offloading her feet/legs. Record review of Resident #4's physician wound care orders reflected, 1) Left plantar: Cleanse with NS, Pat dry, Apply calcium alginate with silver to wound bed cover with dry dressing daily (start date 07/25/2025-open ended), 2) Elevate/Float Heels while in bed Every Shift (start date 07/28/2025-open ended).Record review of Resident #4's initial H&P completed by the attending physician on 07/15/25, reflected, Patient on IV antibiotic for underlying left foot osteomyelitis with MRSA positive. An observation and interview of Resident #4 on 08/05/25 at 10:51 AM, revealed she said her left foot was where the wound was. The wound was observed to be wrapped and under a sock and her foot was not offloaded from the bed. Resident #4 stated she was not in any pain and did not know how the wound on her foot occurred. Her ability to articulate her thoughts was limited due to cognition. An interview with CNA C on 08/05/25 at 2:06 PM, revealed she was the CNA for Resident #3 and Resident #4 and they had just moved to the hall about a week prior. She stated both residents had wounds on their feet and their heels should be offloaded as a result. She stated she did not know about any air boots that were used for Resident #3. An interview with the wound care nurse (WC LVN D) on 08/06/25 at 1:15 PM, revealed she felt all residents' feet should be offloaded when they were in bed. She stated heel protectors such as air boots were used, Because we are trying to relieve pressure or residents' at risk for pressure, I want one on them because we don't want breakdown, pillows move when we offloaded, but it you put those boots on, they are not going anywhere. WC LVN D stated the charge nurses should be monitoring to ensure these interventions were in place and they were supposed to check it off on the MAR/TAR as being observed. WC LVN D stated, Therapy is notorious for not putting the air boots back on. An interview with LVN A on 08/06/25 at 1:45 PM, revealed air boots and heel protectors were important to reduce the friction a resident has with their skin on the bed. She stated if an offloading device was not in place and missing, the CNA should tell the charge nurse who would come and put it on. LVN A stated, however, that the nurses should be rounding too and should check to see that their assigned residents' feet were being offloaded. She stated if a resident's foot was not offloaded, they would develop a deep tissue injury on their heel, and that is when we get wounds, which we don't want.An interview with the DON on 08/06/25 at 2:20 PM, revealed monitoring for heel protectors such as air boots was the responsibility of the wound care nurse, and if the wound care nurse was not there, then it was to be done by the charge nurses.Review of the facility's policy titled, Wound Care Policies and Procedures-Pressure Ulcers in Adults revised 06/01/15 reflected, .5. Mechanical Loading and Support Surface Guideline.Use devices that relive or reduce pressure on the heels.

Based on interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Residents #1) of five residents reviewed for quality of care. The facility failed to apply a dressing to cover Resident #1's recently infected wound (non-pressure related) on her left foot, when she was observed with it exposed to air on 08/05/25. |This failure could place residents with wounds at risk of a decline in their healing progression as well as at risk for infection and discomfort. Findings included:Record review of Resident #1's Face Sheet dated 08/06/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's diagnoses included dementia (a general term for a decline in mental ability severe enough to interfere with daily life), fracture of right femur (upper leg/thigh), malnutrition, atherosclerotic heart disease (plaque buildup in the arterial walls of the heart), peripheral vascular disease (a circulation disorder that affects blood vessels outside of the heart and brain), local infection of the skin and subcutaneous tissue (the deepest layer of skin, primarily composed of fat and connective tissue), muscle wasting and atrophy (the wasting or thinning of muscle tissue)-multiple sites, dysphagia (difficulty swallowing) and pain.Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15 and no sign/symptoms of delirium, psychosis or rejection of care issues. Resident #1 had no range of motion issues and used a wheelchair for mobility. Resident #1 required substantial/maximal assistance for transfers and moderate assistance for bed mobility. Resident #1 had occasional pain which occasionally interfered with sleep and therapy activities with an intensity during the assessment period of three (out of ten). Resident #1 was at risk of developing pressure ulcers but had none at the time of the assessment. She had no other skin conditions and had applications of ointments/medications other than to feet.Record review of Resident #1's care plan initiated 06/20/25 and last updated 07/30/25 reflected Problem start date 07/21/25: [Resident #1] has a non-pressure ulcer on left foot between great toe and 2nd toe. Interventions included, Wound care as ordered. See treatment record.Record review of Resident #1's nursing progress noted dated 07/18/2025 and written by LVN A reflected, Resident noted with an open area on the left foot between the big toe and the second biggest. Area inflamed and small amount of exudate noted. MD notified new order to start Bactrim 800mg 1 tab BID x 10 days and wound care consult. Order noted, MAR updated initial dose given from E-Kit.Record review of Resident #1's Initial Wound Evaluation and Management Summary dated 07/20/25 reflected she had a non-pressure wound of the left, first toe-full thickness due to trauma/injury by footwear and was over ten days in duration and was noted to be present upon admission per staff. The healing potential was fair with an estimation of one to two months to heal. The care goal was to decrease necrosis (death of tissue within a wound) and ulcer area by offloading, optimizing moist wound healing, education and counseling and serial debridement. The wound was 2x2x0.1cm with a surface area of 4.00 cm, exudate was light serous with 30% thick adherent devitalized necrotic tissue. There was 10% slough and 60% granulation tissue with no signs of infection. A surgical debridement (a wound care approach where dead or damaged tissue is removed repeatedly over time to promote healing) procedure was completed to remove necrotic tissue and establish the margins of viable tissue. As a result of this procedure, the nonviable tissue in the wound bed decreased from 40 percent to 10 percent. A second visit from the wound doctor occurred on 08/06/25 where Resident #1's wound had decreased in size and was 1.8 x 1.5 x 0.1 cm with a surface area of 2.70 cm and wound progress was noted to be improved as evidenced by decreased surface area with no pain and no signs of infection. The Dressing Treatment Plan reflected: Primary Dressing- 1) Add Collagen Powder once daily and as needed if saturated, soiled, or dislodged for 30 days; 2) Sodium Hypochlorite Gel (Anasept) once daily for 30 days and as needed: if saturated, soiled or dislodged for 30 days; Secondary Dressing: 1) Add Gauze Island w/ bdr once daily and as needed: if saturated, soiled, or dislodged for 30 days.Record review of Resident #1's physician order dated 07/30/25 reflected, Dressing Treatment Plan: Primary Dressing-Collagen powder apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days; Sodium hypochlorite gel (anasept) apply once daily and as needed: if saturated, soiled, or dislodged for 30 days. Secondary Dressing- Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged for 30 days.An observation of Resident #1 on 08/05/25 at 12:14 PM, revealed she was in the facility's courtyard with a family member being pushed in a wheelchair. Her feet were observed to not have any socks or shoes on either foot. Resident #1's left foot had an open wound about a quarter in size next to her great big toe and second toe. An interview with LVN A on 08/05/25 at 2:30 PM, revealed she was the charge nurse for Resident #1 from 6A-2P and was responsible for completing any wound care on her hall, since the wound care nurse was not at the facility that day. LVN A stated there was no dressing on Resident #1's wound on her foot because when she went to round on the resident earlier in the morning, she was indicating her foot was in pain so she took the dressing off her wound and gave her a pain pill. LVN A stated she decided to keep the dressing off and leave the wound open to air while the pain medication worked. LVN A stated, But then it got very busy and I was running back and forth. She stated Resident #1's family member then arrived for a visit and wanted to take the resident around the facility and outside. When the family left, LVN A stated that was when she covered Resident #1's wound with a dressing. LVN A stated Resident #1 had gangrene on her foot and the wound was supposed to always be covered, but she thought that since the resident was in pain earlier, leaving it off for a while would be okay. LVN A stated she should have tried to apply a dressing, however, when she initially removed it. LVN A stated having an open gangrene wound not covered with a dressing could place Resident #1 at risk for infection. She stated Resident #1 had just finished a round of antibiotics for an infection in that area. A record review of Resident #1's MAR reflected no pain medication was administered to her on the 6a-2p shift on 08/05/25, however, there was a follow up pain assessment by LVN A initialed at 9:30 AM from an earlier pain medication administration by the overnight nurse at 5:27 AM indicating it had been effective and her pain was controlled. A follow up interview with LVN A on 08/06/25 at 1:45 PM, revealed on 08/05/25, what had actually happened was when she got to work, she got her report from the overnight nurse and then around 6:30 am, one of her residents became unresponsive and she had to assess her and send her out to the hospital. LVN A also stated the facility was down one CNA for the halls she covered, so they had four instead of five, for 70 residents. While she was dealing with the other resident's emergency, she was walking down the hall and could hear Resident #1 crying so she went in to check on her. She said Resident #1 was saying leg my leg.my leg. LVN A said the dressing on her foot looked too tight so she took it off but then had to deal with the crisis related to the other resident on the hall and she was rushing to call 911. Then after that, another resident's family member came to visit and had an issue that LVN A had to deal with so we don't have any complaints, and then Resident #1's family member arrived for a visit. LVN A stated the family member about the dressing being off because she wanted to wheel her around the facility and go outside. LVN A stated, I said just tell me when you come back.Yesterday was so frustrating, usually when we work with four aides only, we have to help them feed, transfer and yesterday with two families present, I had to make sure those residents were okay. I didn't leave [Resident #1's] on purpose. LVN A confirmed the antibiotic that Resident #1 had just finished was for the infected wound on her foot and it was to be covered because, Anything in the air can get into the wound and infect it. An interview with the wound care nurse (WC-LVN D) on 08/06/25 at 1:15 PM, revealed Resident #1's wound started as a scratch between her toes and it was not gangrene, however, she did not know what the wound care doctor was considering it. She stated it was a split between the toes that occurred and due to the resident's poor circulation it worsened. WC LVN D stated her expectation was that LVN A should have provided Resident #1 pain medication if needed and redressed the wound immediately. Review of the facility's policy titled, Wound Care-Performing a Dressing Change revised June 2015 reflected, Policy- A dressing change will follow specific manufacturer's guidelines and general infection control principles; Procedures: .4. Assess the wound .6. Apply a cover dressing-date and initial cover dressing, place time reference on it.

Based on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 45 medication administration opportunities with 11 errors resulting in a 24% medication error rate, for 2 of 6 residents (Residents #52 and #65) reviewed for medication administration. 1. The facility failed to ensure MA A administered a medication as ordered to Resident #52 by crushing Nifedipine ER (used to treat hypertension (high blood pressure) and angina (chest pain)); a medication that should not be crushed. 2. The facility failed to ensure MA B administered Resident #65 medication per physician orders, medications scheduled at 7 am were administered at 11:18 am This deficient practice placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions. The findings included: Record review of Resident #52's admission record dated 02/26/2025 revealed an admitted [DATE] with diagnoses which included Muscle wasting and atrophy, Dysphagia, HTN, hypertensive heart disease without heart failure, schizophrenia, and Type 2 diabetes mellitus. Record review of Resident #52's quarterly assessment MDS dated [DATE] revealed Resident #52 had a BIMS score of 05, indicating severe cognitive impairment. Record review of Resident #52's care plan edited on 12/26/24 revealed, resident had hypertension, goal will not experience any complications r/t blood pressure through next review period, approach, Administer medications as ordered. Record review of Resident #52's physicians orders dated February 2025 revealed the physician prescribed for Resident #52 to receive the following medications: Famotidine 10 mg 2 tablets Divalproex sprinkle 125 mg 2 capsules Benztropine 1 mg 1 tablet Atenolol 50 mg 1 tablet Clopidogrel 75 mg 1 tablet Glimepiride 2 mg 1 tablet Nifedipine ER 60 mg 1 tablet, NOT TO CRUSH Observation on 02/26/25 at 11:01 AM, revealed MA A crushed and administered the following medications to Resident #52: Famotidine 10 mg 2 tablets Divalproex sprinkle 125 mg 2 capsules Benztropine 1 mg 1 tablet Atenolol 50 mg 1 tablet Clopidogrel 75 mg 1 tablet Glimepiride 2 mg 1 tablet Nifedipine ER 60 mg 1 tablet In an interview with MA A on 12/24/25 at 11:04 am, MA A stated the resident always took crushed medications and he had been taking Nifedipine ER crushed. MA A stated per the medication instructions, the medication was not supposed to be crushed. She stated the medication was extended-release meaning required to be released gradually, and if it was crushed the medication could be absorbed at once which could lead to medication overdose or side effects. MA A stated she would inform the charge nurse to get the medication switched. Record review of Resident #65's admission record dated 02/26/25 revealed an admitted [DATE] with diagnoses which included, Cognitive communication deficit, chronic kidney disease stage 3, dementia, psychotic disturbance, mood disturbance, and anxiety, osteoarthritis, vitamin deficiency, hyperlipidemia, HTN acute on chronic diastolic (congestive) heart failure, pain, personal history of malignant neoplasm of prostate (cancer of the prostate gland) and Type 2 diabetes mellitus. Record review of Resident #65's quarterly assessment MDS dated [DATE] revealed Resident #65 had a BIMS score of 07 indicating severe cognitive. Record review of Resident #65's physicians orders dated February 2025 revealed the physician prescribed Resident #65 to receive the following medications: Amlodipine 5 mg at scheduled to be administered at 7am Isosorbide mono ER 30 mg scheduled to be administered at 7am Finasteride 5 mg scheduled to be administered at 7am Memantine 10 mg scheduled to be administered at 7am Montelukast 10 mg scheduled to be administered at 7am Nebivolol 5 mg scheduled to be administered at 7am Pantoprazole 40 mg scheduled to be administered at 7am Tamsulosin 0.4 mg scheduled to be administered at 7am Clopidogrel 75 mg scheduled to be administered at 7am Aspirin 81 mg scheduled to be administered at 7am Observation on 02/24/25 at 11:18 AM revealed MA B administered the following medications to Resident #65. Amlodipine 5 mg 1 tablet Isosorbide mono ER 30 mg 1 tablet Finasteride 5 mg 1 tablet Memantine 10 mg 1 tablet Montelukast 10 mg 1 tablet Nebivolol 5 mg 1 tablet Pantoprazole 40 mg 1 tablet Tamsulosin 0.4 mg 1 tablet Clopidogrel 75 mg 1 tablet Aspirin 81 mg 1 tablet In an interview on 02/26/25 at 11:05 AM with MA B, she stated she did administer the medications late mainly because there was a lot of residents to administer medications to who were scheduled at the same time. MA A stated she was supposed to follow the five rights of medication administration; that was the right medication, time, dosage, patient, and route. MA A stated she had informed the DON not getting the medication completed on time, and so far, nothing had been done. MA A stated Resident #65 was on blood pressure medications thus requiring the medications to be administered on time to prevent increase in blood pressure. MA A stated last month, the staff was in-serviced on making sure the medications were administered on time. In an interview on 02/26/25 at 02:22 PM with the DON, she stated MA B had informed her regarding the medications being late and the issue will be addressed in the management meeting. The DON stated she expected the staff to follow the medication administration protocol of administering medications one hour before and one hour after the scheduled time, and following the physician orders. The DON stated MA A was not supposed to crush extended-release medications because it would alter the potency of the medications. The DON stated the staff were in-serviced on medication administration on 2/21/25. Review of the facility's policy undated, titled management medication program, reflected The facility implements the management medication program to meet the pharmaceutical needs of the patients and residents, according to the established standards of practice and regulatory requirements.Preparing for medication pass.7. Medications are administered not more than one (1) hour before to one (1) hour after the designated medication pass time. Administering the medication pass.F. Crush oral medications in accordance to the facility policy.

Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances residents had and ensure that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for one (Resident #99) of five residents reviewed for grievances. The facility failed to document any attempts to resolve Resident #99's grievance when she expressed concern that CNA G refused to provide incontinent care. This failure could place residents at risk of a diminished quality of life and unmet care needs. Findings included: Review of Resident #99's Face Sheet, dated 02/26/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including diverticulitis of large intestine with perforation and abscess with bleeding (a serious condition that can occur when a small pouch in the colon wall becomes inflamed and/or infected) and anxiety disorder (a mental health condition that involves excessive fear, worry, or dread). Review of Resident #99's MDS Assessment, dated 12/23/24, reflected she was cognitively intact. Resident #99 was identified as being occasionally incontinent of bladder and frequently incontinent of bowel. Review of Resident #99's Care Plan, dated 12/26/24, reflected she was identified as being incontinent of bladder and bowel. A documented approach for this care area was for staff to assist with toilet use and provide incontinent care as indicated. Review of Grievance Reports from 01/01/25 to 02/24/25 reflected no evidence that a grievance related to the allegation made by Resident #99 had been filed. During an interview with Resident #99 on 02/24/25 at 2:00PM, she stated within the past several weeks, there was a singular instance when CNA G, who worked the night shift, refused to change her brief. Resident #99 stated she told ADON E about the issue, and ADON E stated she would take care of it. During a telephone interview with ADON E on 02/24/25 at 2:53PM, she stated Resident #99 did tell her about an instance in which CNA G refused to change her brief on an overnight shift. She stated Resident #99 felt as though this was a customer service issue; she did not report feeling as though she had been abused or neglected. ADON E stated she spoke with CNA G regarding this customer service issue and the need to provide timely incontinent care, but she did not file a formal grievance. ADON E stated looking back, she should have filed a grievance on behalf of the resident. During an interview with the Administrator on 02/24/25 at 3:30PM, he stated prior to today (02/24/25), he had not been made aware of the incident in which CNA G allegedly refused to provide incontinent care for Resident #99. The Administrator stated once ADON E became aware of the alleged incident, she should have filed a grievance form on behalf of Resident #99. The Administrator stated the risk of a grievance not being filed included the facility not being able to investigate and resolve resident concerns/complaints. The surveyor attempted to contact CNA G via telephone on 02/24/25 at 4:22PM. The surveyor left a voice message requesting a return telephone call. Review of the facility's Complaints/Grievances Process policy, dated 11/06/23, reflected, .Procedures: 1. Grievances/Complaints are accepted by the following, but not limited to: A. Administrator B. Department manger or his/her designee C. Supervisors D. Unit Managers E. Ombudsman 2. Upon receipt of the grievance the receiver completes all appropriate sections of electronic Grievance form under Portal Links or a paper form .

Based on interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #99) of 40 resident reviewed for pharmacy services. The facility failed to ensure the 400 Hall nurses' medication cart had an accurate narcotic count for Resident #99. This failure could place residents at risk for medication errors, drug diversion, and delays in medication administration. Findings included: Record review of Resident# 99's face sheet dated 02/26/25 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Admitting diagnoses included diverticulitis of large intestine with perforation and abscess with bleeding, cough, depressive episodes, allergy, GERD, without bleeding, nausea with vomiting, sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection ), anemia, unspecified and HT Record review of Resident #99's Admission MDS Assessment, dated 12/23/24, reflected the resident BIMS score of 15 indicating no cognitive impairment. Record review of Resident #99's care plan did not indicate the resident was taking pain medications. Record review of Resident #99's physician's orders dated February 2025, reflected an order for the resident to receive Hydrocodone-Acetaminophen Oral Tablet 10-325 MG. Give 1 tablet by mouth every 6 hours as needed for pain. Acetaminophen with codeine #3 (Tylenol with codeine #3). Give 1 tablet by mouth every 4 hours as needed for pain. Record review of Resident #99's medication administration record reflected, Hydrocodone-Acetaminophen Oral Tablet 10-325 MG was last administered on 01/22/25 and Acetaminophen with codeine #3 was last administered on 2/15/25. Review of the narcotic log for Resident #99 reflected the count sheet for Acetaminophen with codeine was 19 and the medication card contained 20 tablets and the narcotic sheet for Hydrocodone-Acetaminophen 10-325 MG was 20 and the card contained 19 tablets. In an interview on 02/26/25 at 10:35 AM with LVN C, she stated she had not administered any pain medication to Resident #99. LVN C stated she was switched to work on the hall after the start of the shift and ADON D was the one who completed the narcotics count with the night nurse. LVN C stated she did not complete a narcotic count after taking over the cart from the ADON D. LVN C stated she would inquire from the ADON if she administered the pain medication. LVN C stated she last worked on the hall on 02/24/25 and she did not realize the count was wrong. LVN C stated she was supposed to make sure the name of the resident, the medication and the count all matched. LVN C stated with any narcotics discrepancies, she was expected to report immediately to the DON. In an interview on 02/26/25 at 10:42 AM with ADON D, she stated she had not administered any pain medication to Resident #99. ADON D stated when she completed the count during the change of shift, the count was correct, but per the records, did not reveal to be correct. Then the ADON stated she would inform the DON of the discrepancy. The ADON stated during narcotic count she was supposed to check and make sure the medication and number of the narcotics in the narcotic sheet were a match. In an interview on 02/26/25 at 10:56 AM with Resident #99, she stated she was not in pain, and she had not taken any pain medication on 02/26/25. Resident #99 stated she took a hydrocodone-Acetaminophen 10-325 mg tablet about two weeks ago due to pain from surgery, and since then she had not taken any pain medication. An interview on 02/26/25 at 2:35 PM with the DON revealed she had been made aware of the narcotic discrepancy on hall 400 nurse medication cart, and she was already in the process of in-servicing the staff. The DON stated she talked with Resident #99, and the resident stated she had taken Norco and not Tylenol #3 when she had requested for a pain medication about two weeks ago. The DON stated when she talked with the nurse on duty, the nurse had given the resident the Norco and signed in the wrong narcotic sheet. The DON stated the charge nurse had failed to realize the inconsistency and get it corrected timely. The DON stated she expected the charge nurse to make sure the medication, the resident name and narcotic count matched when they completed narcotic count during shift change to prevent narcotics discrepancy. Review of the facility's policy undated and titled medication management program reflected, . Security and Safety Guidelines . 9. Controlled substances are accounted for each patient/resident on a Controlled Substance Record . A. Substances are counted by authorized staff members at each change of shift. B. Drug count discrepancies are reported immediately for the Director of Nursing or designee.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one (Resident #99) of five residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #99. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services. Findings included: Review of Resident #99's Face Sheet, dated 02/26/25, reflected she was a [AGE] year-old female who admitted to the facility on [DATE], with diagnoses including diverticulitis of large intestine with perforation and abscess with bleeding (a serious condition that can occur when a small pouch in the colon wall becomes inflamed and/or infected) and anxiety disorder (a mental health condition that involves excessive fear, worry, or dread). Review of Resident #99's MDS Assessment, dated 12/23/24, reflected she was cognitively intact. Review of Resident #99's electronic medical records on 02/25/25 reflected no evidence that a baseline Care Plan had been completed. During an interview with MDS Coordinator F on 02/26/25 at 10:10AM, she stated she was responsible for completing baseline Care Plans for residents within 48 hours of their admission to the facility. She confirmed there was no evidence to suggest that a baseline Care Plan for Resident #99 had been completed following her admission. MDS Coordinator F stated the risk of not completing a baseline Care Plan for a resident within the required timeframe was that the facility would receive a citation from the State. Review of the facility's Care Plan Process, Person-Centered Care policy, dated 05/05/23, reflected, .Procedures: .1: Develop and implement the baseline person-centered care plan within 48 hours of a resident's admission .

Based on observations, record reviews, and interviews the facility failed to ensure that a resident who was diagnosed with a mental illness or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for one (Resident #1) of 5 residents reviewed for services for mental/psychosocial concerns, in that: LVN O failed to follow the facility's suicide policy when Resident #1 made an outcry of self-harm on 01/01/25. An IJ was identified on 01/03/25. The IJ template was provided to the facility on [DATE] at 5:09 PM. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This deficient practice placed residents with suicidal ideations at risk for not being monitored effectively and could affect other residents with psychiatric diagnoses in the nursing facility. Findings included: Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed she was [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included: stroke, Alzheimer's disease, CVA/TIA/Stroke, depression cognitive communication deficit. Her BIMS was a 05 indicating sever cognitive impairment. Section E indicated that Resident #1's had no potential indicators of psychosis. Section N indicated that Resident #1 was taking antidepressants. Review of Resident1's Care Plan, with an edited date of 12/07/24 reflected the following: - Focus section: [Resident Name] is taking Psychotropic Drug and is at risk for adverse consequences R/T receiving psychotropic medication for the treatment of: Use Problem Start Date: 01/09/2024 diagnosis of DEPRESSION. - Focus section: Resident has impaired cognition with expected decline in cognitive impairment over a period of time as a natural progression of the disease process Goal Target Date: 03/08/2025. Review of Resident #1's Physician Orders for December 2024 reflected the following orders: - Fluoxetine 20mg MG, - Remeron Tablet 7.5 MG (Mirtazapine), - Depakote Tablet delayed release 125MG (Divalproex Sodium), - Donepezil 10 mg, and Psych evaluation and TX as indicated (active order since 01/06/2024). Review of Resident #1's nurses' note from 12/01/24 through 01/05/25 reflected the following: 01/01/2025 [Recorded as Late Entry on 01/01/2025 08:55 PM] [LVN O]. This nurse found patient sitting in wheelchair beside her bed screaming Help me. Nurse asked patient what the problem was, and patient stated she wanted to get the hell out of here. Nurse explained to patient that she cannot go anywhere without the doctor's consent. Patient stated she wanted to kill herself so she would be sent to the hospital. Nurse explained that I would not allow her to do anything to hurt herself. Patient stated she feels she is being held here against her will. Nurse advised that she would need to talk with the doctor about her going home. Patient is refusing her pain med, her regular meds and the clonazepam. [MD] notified of above, no new orders at this time. Will continue to monitor patient closely. 01/01/2025 [Recorded as Late Entry on 01/02/2025 03:45 PM] [LVN O] This nurse notified patient's [FM/RP] of patients status and the fact that she wants to kill herself. states that she cannot handle her and that she gets physically sick when dealing with her. Nurse advised [FM/RP] that we are watching her closely and will notify her of any changes. [FM/RP] stated understanding. An observation on 01/02/25 at 12:20 PM revealed that Resident#1 was observed repositioning herself from right to left and adjusting covers and her pillow. Resident #1 did not respond when HHSC Surveyor attempted to speak to her. An observation and interview on 01/03/25 at 10:30 AM revealed Resident #1 was observed laying her in her bed, the resident stated she felt better but wanted to sleep. In an interview on 01/02/25 at 2:06 PM Resident #1's FM/RP stated on the evening of 01/01/25 the facility notified her that the resident was screaming. FM stated, for my personal health I could not deal with her so I asked the facility could they not sedate her?. The FM stated that about two weeks ago the resident medication dosage was lowered and whenever there were changes in residents' medication the resident got more agitated. The FM stated that happened while she was at the assisted living, they lowered her medication, and the resident was screaming about several hours she calmed the resident over the phone. She stated that she was aware the resident slept a lot, but the resident had always been sleepy even before transferring to the facility. In an interview on 01/03/25 at 1:17 PM with CNA H (works 6AM-2PM Monday - Friday) revealed she knew Resident #1 and knew she screamed often and always wanted to go back to bed as soon as staff got her out bed for meals or activities. CNA H stated she was not aware that Resident #1 had mentioned she wanted to kill herself the other day (01/01/25) and was notified the day after . CNA H stated that if a resident mentioned they wanted to harm themselves, she would report it immediately to the nurse. CNA H stated that failing to monitor a resident with suicidal ideation could result in the resident hurting themselves. In an interview on 01/02/25 at 3:17 PM LVN S stated that during her shift change, it was not reported to her from LVN T that Resident #1 had stated she was going to kill herself . LVN S stated that she was notified Resident #1 had made suicide outcry to LVN O by the DON during her shift. LVN S stated that when she came in for her shift, staff got the resident up for breakfast and on the resident request staff put her back to bed and the resident had remained in bed for most of her shift. LVN S stated that if a resident made statements to hurt themselves, she would assign a CNA to monitor the resident, the call doctor who would send to the emergency room or have psych come assess the resident. LVN S stated she would also notify DON, ADON, Administrator and family. LVN S stated that items that residents could use to hurt themselves included call light chords, bedside tables and telephone cords. LVN S stated that failing to monitor a resident with suicidal ideation could result in the resident hurting themselves. In an interview on 01/02/25 at 3:50 PM LVN T stated when he received report from LVN O, he was not told that Resident #1 had mentioned she wanted to kill herself but that she had a new order for Clonazepam. LVN T stated that when he started his shift, Resident #1 was already asleep and remained asleep during his shift. LVN T stated that if a patient had suicidal ideation, he would immediately notify the DON, physician, Administrator, and family. LVN T stated that he would implement interventions per physician orders. LVN T stated that staff would complete 15 mins checks and monitor residents for up to three days. LVN T stated he did not monitor the resident for suicide ideation because he did not know that the resident had said she wanted to kill herself. LVN T stated if patient is not monitored the risk remains, they can kill themselves. In an interview on 01/02/25 at 2:40 PM with LVN O, revealed that on 01/01/25 during the evening shift, Resident #1 had said a lot of things. LVN O stated that Resident #1 had stated she wanted to get the hell out of here and wanted to kill herself. LVN O stated that Resident #1 had wanted to go to the hospital and wanted her (LVN O) to give her (Resident #1) medication to sleep so she would not wake up. LVN O stated that the Resident #1 wanted to get out of bed and to kill herself. LVN O stated she called Resident #1's daughter who said she could not deal with the resident and did not want to talk to her. LVN O stated that she was not able to get ahold of Resident #1's husband and Resident #1 felt that her husband had abandoned her. LVN O stated that she stayed with the resident the whole time during her shift. LVN O stated when she went to another resident, she left the resident with nurse LVN T. LVN O stated she did not notify the DON or the Administrator because she was more concerned with making sure Resident #1 did not hurt herself. LVN O stated she texted the MD about what the resident said, and he responded okay and gave her orders to renew clonazepam. When asked about the facility's suicide policy, LVN O did not say anything. In an interview on 01/02/25 at 4:33 PM, the Social Worker revealed she was notified about Resident #1's statement of wanting to kill herself, after psych services had assessed Resident #1. Social Worker stated she went to assess Resident #1 but Resident #1 did not want to talk . Social did not state who contacted psych services. Social Worker stated that if a resident verbalized the intent to harm themselves, she would have called the psych service provider to have the resident assessed, to ensure the was safe to remain in the building and if not, the resident would be transferred to the hospital. Social Worker stated that she believed the policy was to have the resident on 15-minute checks until the resident was seen by psych services. Social worker stated that her understanding was the staff reached out to the doctor. Social worker stated that if the residents was not properly assessed it can be serious that resident could hurt themselves. In an interview of 01/02/25 at 1:13 PM the DON stated she was not notified by LVN O that Resident #1 stated she wanted to kill herself. The DON stated HHSC Surveyor had made her ware of Resident #1's claim. The DON stated that her expectation was that LVN O followed policy which was to put the resident on 15-minute checks. The DON stated if LVN O would have called her (DON) then DON would have walked LVN O through on what to do. In an interview on 01/02/25 at 3:34 PM, the MD stated he received a message from LVN O stating that Resident #1 had refused medication and wanted to kill herself so she could go to the hospital. The MD stated that he told LVN O okay. HHSC Surveyor asked MD what he meant by okay and he stated he meant okay to send the resident to the hospital, because the resident had refused to take medication, and threatened to kill herself. The MD stated that the facility had a policy that if a resident verbalized, they wanted to hurt themselves, the resident would be sent to the hospital to be evaluated unless psych was available to evaluate the resident. The MD stated that he did not have knowledge of Resident #1 wanting to her hurt herself in the past. The MD stated he was aware that Resident #1 had a family issue that was causing the resident to become agitated. Review of policy Suicide Prevention and precaution management dated 05/2023 reflected the following: Policy Statement: The Facility will provide and/or arrange for transfer to the safest, practicable living environment for all patients/residents who voice suicidal thoughts, attempt suicide, or cause self-injury. The highest level of emotional and physical well-being of the patients/residents will be promoted using all available resources including but not limited to Physicians, Psychologists, Social Service Directors, Counselors, Psychiatrists, Inpatient psychiatric therapy, and family meetings. The Facility will complete a brief suicide ideation assessment on new admissions with a history of suicidal ideations that includes the following: Brief Suicide Intent Scale: A. On a scale of 1 to 10 how strong is your desire to kill or harm yourself? B. Have you thought about how you would kill or harm yourself? C. Have you ever tried to kill or harm yourself in the past? D. Does the individual have the means available to kill or harm themselves or others? 2. The above will be documented in the clinical record. Should the brief assessment scale reveal concerns related to the mental stability of the resident/patient, the staff will immediately notify the primary physician. The staff will also immediately notify the Administrator, DON, and Social Service Director who will visit with the patient/resident to determine if adequate safety can be provided by the facility. 3. If a patient/resident, who is voicing suicidal thoughts or attempts suicide, is a danger to self or others, additional interventions will be initiated including: A. Physician, Psychiatrist/Counselor/Psychologist and family are notified immediately. If the patient/resident doesn't have a psychiatrist, then a referral is made at this time. B. Suicide precautions are implemented immediately if a resident is deemed to be a threat to themselves or others to preserve the well-being of the patient/resident. to address the risk factors presented by the resident/patient. 5. Suicide precautions include the following: A. The resident/patient will eat on the unit without sharp utensils The Physician should be notified immediately of suicide ideations and for further orders. C. If it is determined that the facility cannot provide a safe environment due to the suicidal ideations of the resident/patient will be transported to an acute care setting for evaluation and treatment. 4. Suicide precautions will be implemented immediately for any resident/patient that presents with a significant level of depression or suicidal preoccupation and will be used Until evaluation or transfer can occur, certain items such as belts, drawstring pants, shoes with laces, sheets, etc. may be prohibited if they present a potential danger for the resident/patient. C. Call light cord is removed from patient/resident room. If available, a bell or other signaling device is given to replace the call light. D. Medication nurse observes patient/resident swallowing all medications and checks oral cavity to establish that patient/resident has swallowed all medications. E. If available, a wander device is placed on the patient's/resident's wrist or ankle. F. Patient's/Resident's door remains open when staff is not providing direct bedside care. Curtains are not drawn so as to obstruct immediate observation of the patient/resident from the hallway. G. A minimum of two staff members is assigned to escort patient/resident to any appointment/ activity outside of the facility. H. A licensed nurse will assess the resident/patient at least every four hours and document the assessment in the medical record. I. Family or responsible party will be notified of the suicide precautions. 6. For residents requiring one-to-one supervision: A. The resident/patient will be assigned a one-to-one staff member who will remain within six (6) feet of the resident/patient and always maintain constant visual contact with the resident/patient. B. During waking hours, the resident/patient will reside in a designated area. C. During sleeping hours, the resident/patient will sleep in an area where close observation can be maintained in accordance with 6.a. above. D. The employee assigned to the patient will document every fifteen (15) minutes the observation of the resident/patient. 7. A physician order is required to discontinue suicide precautions. 8. Follow-up interventions: A. Develop behavioral interventions for Care Plan. B. Provide ongoing support and reassurance by all staff. C. The patient/resident continues to attend psychiatric/counselor/psychological appointments until formally discharged . 9. Documentation guidelines: A. When a physician orders suicide precautions, documentation is completed at least every fifteen (15) minutes and more often if needed. B. Documentation includes date, time, the reason the patient/resident is placed on suicide precautions, patient/resident responses and behaviors, additional safeguards and supervision of patient/resident, the search for and removal of items that may be used in a suicide attempt and time family was contacted. C. Date, time and reasons suicide precautions were discontinued, and signature. 10. Record that the Patient/Resident was checked every fifteen minutes for suicide precautions. Staff documents this by signing their initials in the column for their shift. This was determined to be an IJ on 01/03/25 at 5:09PM. The Administrator was notified and provided with the IJ template. A Plan of Removal was requested. The facility's plan of removal was accepted on 01/05/25 at 8:27 AM and included the following: [Facility Name] Plan of Removal F742 1/3/25 Resident #[1] was assessed by psychiatry services on 1/2/25 and resident was not deemed a threat to herself, per psychiatry provider transfer to hospital not appropriate at this time and resident agreed. Social Services Director completed a suicide ideation assessment on 1/3/25 and resident was not deemed a threat to herself. Resident #[1] will continue to follow up with psychiatry while remaining in the facility A review of the facility activity report and the 24hour reports from 1/1/25 were reviewed by the Director of Nursing/Designee to identify additional residents that have voiced suicidal ideation. None were identified. Licensed Nurses and Social Services Director will be re-educated by the Director of Nursing/Designee by 1/4/25 on suicidal precaution management including : If a resident voices or indicates in some manner suicidal ideations the licensed nurse will implement 1:1 supervision immediately and notify the social Services Director. If a safe environment cannot be maintained with 1:1 supervision, the resident will be transported to an acute care setting for evaluation and treatment. The Social Services Director will complete the Columbia Suicide Severity Rating Scale in the medical record Should the assessment reveal concerns, the Social Services Director will immediately notify the administrator, DON and primary physician for further orders. Licensed Nurses not receiving this education by 1/4/25 will receive it prior to their next scheduled shift. The Director of Nursing/designee will review the 24hour report and facility activity report in clinical morning meeting Monday - Friday beginning 1/5/25 to identify residents who have voiced or are indicating in some manner suicidal ideations and validate assessments and notifications were completed. This will be completed by the weekend supervisor on the weekends. Ad Hoc QAPI was held on 1/3/25. The Medical Director was notified of the Immediate Jeopardy and contents of this plan on 1/3/25. The facility's implementation of the IJ Plan of Removal was verified on 01/05/25 through the following: Review of Resident #1's Psychiatric Subsequent assessment dated [DATE] reflected the following: Staff reported current symptoms of loss of interest and psychomotor agitation. Patient stated I'm fine. When asked about current/recent sx of depression patient reported to have made statement regarding self-harm the night prior to exam, at this time patient denies any current suicide ideation, thoughts of self-harm or thought of believing she would be better dead. Primary treating dx. Anxiety, secondary dx. Major depressive disorder recurrent. Review of the Suicide Ideation Assessment completed by the Social Worker, dated 01/03/25 reflected that Resident #1 was not deemed a threat to herself. Resident #1 will continue to follow up with psychiatry while remaining in the facility. An observation on 01/04/25 at 2:30 PM revealed Resident #1 was sleeping in bed. Review of the facility's inservice titled Suicide Prevention and Precaution Management dated 01/02/25, presented by the DON reflected: review policy, including who to notify interventions needed If a resident voices or indicates in some manner suicidal ideations the licensed nurse will implement 1:1 supervision immediately and notify the social Services Director. If a safe environment cannot be maintained with 1:1 supervision, the resident will be transported to an acute care setting for evaluation and treatment. The Social Services Director will complete the Columbia Suicide Severity Rating Scale in the medical record Should the assessment reveal concerns, the Social Services Director will immediately notify the administrator, DON and primary physician for further orders. 63 staff (16 LVNs, 24 CAN, 8 RN, MD, Activity Director, Housekeeping Supervisor, 5 Med Aides, Social Worker Assistant, ADON, 2 MDS Nurses and the Social) had signed the inservice. Interviews were conducted on 01/05/25 from 1:10 PM to 4:57 PM with staff from various shifts. The staff included CNA A, LVN G, CNA H, CNA I, RN J, LVN K, LVN L, LVN M, CNA N, LVN O, and LVN P. All staff were able to verbalize policy, including who to notify and interventions needed If a resident voices or indicates in some manner suicidal ideations the licensed nurse will implement 1:1 supervision immediately and notify the social Services Director. If a safe environment cannot be maintained with 1:1 supervision, the resident will be transported to an acute care setting for evaluation and treatment. In an interview on 01/05/25 at 4:45 PM with the DON revealed she had reviewed the facility activity report and the 24hour reports from 1/1/25. The DON stated the purpose of the review was to identify additional residents that have voiced suicidal ideation. The DON stated no new residents were identified. The DON stated she would be responsible for reviewing the 24hour report and facility activity report in clinical morning meeting Monday - Friday beginning 01/05/25, the purpose was to identify residents who have voiced or are indicating in some manner suicidal ideations and validate assessments and notifications were completed. The DON stated that during the weekend, will be completed by the weekend supervisor on the weekends An interview was attempted on 01/05/25 at 4:26 PM with the Medical Director. The Medical Director did not return the call of the Surveyor. An IJ was identified on 01/03/25. The IJ template was provided to the facility on [DATE] at 5:09 PM. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents and injury for 1 of 3 residents (Resident #3) reviewed for accidents and supervision. CNA A and RN B failed to ensure that Resident #3 was not left alone in the shower chair in his room. As a result, Resident #3 fell out of the shower chair, obtaining a hematoma to his head and being sent to the hospital. On 01/03/25 at 5:00 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of, neglect, serious injury, and death. Findings included: Record review of Resident #3's admission MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included stroke, hemiplegia (paralysis on one-side of the body) or hemiparesis (weakness on one side of the body), and aphasia (condition that affects the ability to verbally communicate). Resident #3 had a BIMS score of 11 meaning his cognition was moderately impaired. The MDS further reflected Resident #3 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers was required for the resident to complete the activity) on staff for tub/shower transfers. Record review of Resident #3's Progress notes dated 11/04/24 reflected: 11/04/24 at 9:46 PM At 7:17 PM RN B was verbally notified by CNA A that resident had an unwitnessed fall. She briefly stated she had just given him a shower; she then used the rolling shower chair to move patient from the bathroom closer to the bed. She stated she needed assistance and left the resident unattended for no greater than 5 minutes to get assistance to aid in transferring resident back to bed. Resident was then found lying on the floor face down. Resident was observed by RN conscious with a noticeable medium sized, swollen bump on the left side of his forehead. Resident was manually transferred to bed with the assistance of two CNA staff members. Vital signs were obtained Blood Pressure: 156/78 Heart Rate: 102 Respirations: 20, Oxygen level:96% Room Air. A head-to-toe assessment was completed with no visible new injuries other than the swollen forehead. Resident denied feeling any pain or discomfort but stated he did not remember just having a fall. ADON, Physician, and family notified. EMS was called for assistance, ambulance services arrived, report was given; and resident was transferred to the hospital for further observation. Written by RN B. Record review of Resident #3's care plan dated 10/14/24 and revised on 11/05/24 reflected he was at risk for falls due to impaired mobility on the left side, diabetes, incontinence, and decreased cognition. Facility interventions included: 11/05/24 - Staff education 10/14/24 - Encourage resident to use environmental devices such as hand grips, handrails, etc. Keep call light in reach at all times. Keep personal items and frequently used items within reach. Orient to changes in environment such as new furniture, room changes, etc. Provide an environment free of clutter. Provide proper, well-maintained, slip resistant footwear. 10/14/24 Resident requires assistance with activities of daily living. Facility interventions included: Transfers - Assist of 1-2 Bathing - Assist of 1 The care plan did not address fall risks related to showers chairs. Record review of the facility's Provider Investigation Report dated 11/11/24, for Resident #3 reflected: 11/04/24 7:15 PM Resident had a fall from his shower chair to the floor. The resident had a hematoma on the left side of his head. The resident was given a shower in a shower chair by CNA A. When the shower was over, CNA A dried off the resident and wrapped him up in towels and wheeled him to the side of his bed. She locked the wheels to the shower chair and then CNA A left the room to get another CNA to help transfer. When CNA A got back to the room, the resident had fallen out of the shower chair to the floor. Family and physician notified, resident assessed for pain and injury and sent to hospital for treatment. Staff were interviewed, and CNA A was suspended pending investigation. Resident fall risk assessment was updated, care plan updated. Staff in-serviced over abuse and neglect. Employee corrective action. Nursing staff was re-educated on fall management and not leaving residents unattended. 11/5/24 Interview with CNA A CNA A said on Monday night 11/04/24 she and another CNA used the hoyer lift to transfer the resident into the shower chair. The other CNA left, and CNA A gave the resident a shower. When CNA A finished the shower, she dried him off. CNA A said she placed three towels around the resident and then wheeled him (in the shower chair) to the side of his bed. She said she locked the wheels and told the resident she was going to get a CNA to help transfer him. CNA A said when she got back in the room a couple minutes later, the resident had fallen to the floor, and she left the room and went and got the nurse. Review of an in-service, Fall Prevention and Major Injuries, dated 11/05/24 reflected: Do not leave resident by themselves unsupervised in shower chair .Ensure to see the falling star on the door that is to let you know the resident is at risk for falls. Check POC (plan of care) for how the resident is transferred. 30 nursing staff were in-serviced. CNA A was not in-serviced. RN B was in-serviced. Review of an in-service, Abuse and Neglect, dated 11/05/24 reflected 32 staff were in-serviced. CNA A and RN B were not in-serviced. The findings of the investigation were unconfirmed. Record Review of the Corrective Action Form for CNA A, dated 11/08/24, reflected CNA A was in-serviced regarding not leaving a resident unassisted and fall risk. There was no documentation provided to show CNA A was in-serviced on neglect prior to 01/03/25. The facility provided their Mitigation Plan for the incident following the calling of the Immediate Jeopardy. The Mitigation Plan dated 11/05/24 reflected: What corrective action(s) will be accomplished for those residents found to have been affected by the alleged deficient practice: Practice issue is to be free of accident/hazards/Supervision and devices. Resident was sent to hospital 11/4/24 at approximately 7:17 PM for evaluation and returned to the facility on [DATE] at approximately 8:00 PM with a diagnosis of hematoma. Resident's fall risk assessment was updated to reflect current status and fall interventions were in place per the care plan. Residents' physician was notified for medication evaluation and a follow up appointment was made per ER discharge recommendations. Nursing staff was re-educated on the fall management policy and to not leave residents unattended. Staff involved was suspended pending investigation and incident was reported to HHSC. How other residents who have the potential to be affected by the alleged deficient practice are identified: Residents who require assistance with showering had the potential to be affected. Residents who had a fall in the past 14 days were to be reviewed by DON and/or designee to validate root cause had been identified and appropriate intervention was implemented. This was to be completed by 11/06/24. How the corrective action would be monitored to ensure the deficient practice would not recur: Licensed nurses would be re-educated on Root Cause Analysis, how to conduct a thorough investigation for a resident who falls to determine the root cause of the fall and implementation of an appropriate intervention to prevent further falls with care plan and profile updates to reflect new interventions. This education would be presented by the Director of Nursing and/or Designee and would be completed by 11/06/24. Re-education was provided on Abuse and Neglect and completed on 11/05/24. Facility Administrator would be responsible for the overall implementation and validation of this plan. Facility Medical Director will be informed of this plan and given progress updates. What quality assurance program will be put into place: Fall Incident reports would be reviewed monthly for trends by the Director of Nursing/designee. Leadership would conduct random rounds 3 times a week to validate fall risk interventions were in place and that residents were not left unattended during bathing. These reviews would be presented to the Quality Assurance and Performance Improvement Committee for review and recommendations for 3 months. Any discrepancies would be addressed at time of discovery. An interview on 01/02/25 at 11:07 AM with the family of Resident #3 revealed the resident had been discharged . The family member said she was notified by the facility that the resident had a fall after being left on the shower chair because the staff was not able to transfer him without help. The family member said they did not understand why the resident was left unattended. An interview on 01/03/25 at 12:30 PM with CNA A revealed on 11/04/24 she gave Resident #3 a shower in a shower chair. She said she needed to put him to bed, but no one was there to help her, and no one was answering the call light. CNA A said she left the resident in the shower chair and went to look for help to get him to bed. She said while she was gone (maybe two minutes) he fell out of the shower chair onto the floor. CNA A said she did not see the resident fall. She said she did not know if the resident usually had problems sitting in a shower chair because she did not usually take care of him. CNA A said the resident was not wobbly in the shower chair. CNA A said neglect was leaving a resident unattended and that she neglected Resident #3 when she left him in the shower chair unattended. CNA A said she was in a hurry and had another resident waiting on her. She said she had an in-service on neglect at the end of December 2024. She said she was not sure if she had received an in-service about leaving residents unattended but thought maybe she did. She said she did receive in-services after the incident, and she had not left any other residents unattended in a shower chair. An interview on 01/03/25 at 12:15 PM with RN B revealed she was working on 11/04/24 when Resident #3 fell . She said she was in a room and overheard 2 CNAs talking and she heard the word fall. The CNAs told her that Resident #3 fell out of the shower chair. RN B said CNA A had stepped away for a few minutes to get help to transfer him and he fell . RN B said the resident had a hematoma on his head and she sent him out to the hospital. RN B said Resident #3's left side was flaccid and he had muscle spasms. She said he had no control over the left side of his body and had a history of sliding out of a low bed because he was not able to use the left side of his body. She said staff had to stay with Resident #3 while he was in a chair because he would lean to his left side. RN B said neglect was a staff not doing something for a resident that they were supposed to do and it caused harm. She said she did not know when her last in-service for neglect was and that she had been at the facility for 3 months. RN B said Resident #3 was not neglected when he was left unattended because CNA A was trying to get help for him. RN B said she had not received any in-services about not leaving resident unattended in a shower chair. She said leaving a resident unattended could result in falls and harm. She said she did not remember receiving any in-services after the incident. An interview on 01/03/25 at 1:30 PM with the DON regarding Resident #3 revealed she was on vacation when the resident fell . She said she was told that he fell in the shower room. She said Resident #3 did not have problems sitting in a chair. She said neglect was failure to provide basic needs to the resident. The DON said CNA A neglected the resident when she stepped away and left Resident #3 alone. The DON said in-services on neglect and not leaving residents unattended had been completed with staff. She said a resident left unattended placed them at risk for falls and injuries. An interview on 01/03/25 at 1:35 PM with the Administrator regarding Resident #3 revealed CNA A gave the resident a shower, wheeled him to bed, locked the wheels, and left to go get help, (instead of using the call light) because the resident was a two person assist. The Administrator said neglect was not doing something you know you are supposed to do and in-services on neglect were provided to staff about every week. He said in this instance, CNA A did not neglect Resident #3 because she locked the wheels, covered him with towels. She was trying to get assistance with the resident. The Administrator said CNA A did not use the correct intervention. The Administrator said residents left unattended were at risk for falls and injuries. He said he had completed in-services with staff about not leaving residents unattended. An follow-up interview at 01/04/25 at 10:25 AM with the DON revealed CNA A was not listed on the facility in-services because she was provided a 1:1 in-service. The DON said that the care plan for Resident #3 did not include information regarding not being left alone in a shower chair because staff were in-serviced that no resident could be left alone in a shower chair. The DON said leadership was conducting random rounds three times a week to validate that residents are not left unattended during bathing. Record review of the facility's Abuse, Neglect, Exploitation, or Mistreatment policy, not dated, reflected: POLICY: 1. The facility's Leadership prohibits neglect . 6. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. This was determined to be an IJ on 01/03/25 at 5:00 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 11/04/24 at 5:09 PM and a Plan of Removal was requested. The following Plan of Removal was submitted by the facility and was accepted on 01/05/25 at 08:27 AM and reflected the following: Resident #3 was sent to the ER for assessment and treatment on 11/4/24 and returned the same day with new orders. Resident #3's fall risk assessment was updated upon return and new interventions implemented and care planned. CNA A received disciplinary action and 1:1 education by the Director of Nursing on fall management including not leaving residents unattended during bathing by 11/06/24. A review of fall risk evaluations will be completed by the Director of Nursing/Designee on current residents to validate the assessments are accurate. Identified residents without a current fall risk evaluation will have one completed by 01/04/25 with appropriate interventions implemented, care planned and placed in the resident profile. A review of the falls from the previous 14 days to assess root cause and appropriate interventions was completed by the Director of Nursing/Designee by 11/06/24. Nursing Staff were re-educated by the Director of Nursing/Designee on 11/5/24 on Fall Management Policy and not leaving residents unattended during bathing including: Fall risk evaluations are completed by the licensed nurse at admission, readmission, quarterly and with significant change in condition. Fall interventions are updated as needed with fall risk evaluation update, care planned and placed in resident profile for nursing staff reference. Resident care needs are updated with change and documented in care plans and resident profiles for nursing staff reference. Administrator and Director of Nursing were reeducated on Abuse and Neglect by the Clinical Consultant on 01/04/25. Nursing Staff were reeducated on Abuse & Neglect by the Director of Nursing/designee by 01/04/25. Nursing Staff and new hires not receiving this education by 11/06/24 will receive it prior to their next scheduled shift. The Director of Nursing/Designee will review fall risk evaluations for new admissions and readmissions in clinical morning meeting Monday - Friday, to validate accuracy and thoroughness and validate care plans and resident profiles have been updated as appropriate. This will be completed by the weekend supervisor on the weekends. The Director of Nursing/Designee will review fall risk evaluations weekly following the MDS calendar to validate accuracy and thoroughness and validate care plans and resident profiles have been updated as appropriate. The Director of Nursing/Designee will validate resident care needs have been care planned and documented in resident profiles following the MDS calendar weekly. The Director of Nursing/designee continued to complete rounds 3 times a week to verify appropriate fall interventions are in place and residents are not being left unattended during bathing. An Ad Hoc QAPI was held on 11/06/24. The Medical Director was notified of the contents of this plan on 11/05/24 and Immediate Jeopardy on 01/03/25. Monitoring of the facility's Plan of Removal included the following: Record review of Resident #3's clinical records revealed the resident had been assessed by nursing after the incident on 11/04/24 and was transferred to the hospital for treatment. Interviews were conducted on 01/05/25 from 1:10 PM to 4:57 PM with staff from various shifts. The staff included CNA A, LVN G, CNA H, CNA I, RN J, LVN K, LVN L, LVN M, CNA N, LVN O, and LVN P. All staff were able to identify: What neglect was and different types of neglect. The staff understood that a resident could not be left unattended in a shower chair ever. Staff knew how to identify if a resident was at risk for falls. Staff said if they needed assistance to transfer a resident from a shower chair they would wait for help and not leave the resident alone. Observations and interviews with residents on 01/05/25 from 1:10 PM to 4:57 PM revealed they were not left alone in the shower chair. An interview on 01/05/25 at 4:34 PM with the DON revealed her roles in the facility plan of removal included: Review fall risk evaluations for new admissions and readmissions in clinical morning meeting Monday - Friday, to validate accuracy and thoroughness and validate care plans and resident profiles have been updated as appropriate. Continue to complete rounds 3 times a week to verify appropriate fall interventions are in place and residents are not being left unattended during bathing. An interview on 01/05/25 at 4:57 PM with the Administrator revealed he knew the definition of neglect. He said his role in the Plan of Removal was to ensure all steps were completed and that the monitoring was on-going. An interview was attempted on 01/05/25 at 4:26 PM with the Medical Director. The Medical Director did not return the call of the Surveyor prior to exit. The Administrator and DON were informed the Immediate Jeopardy was removed on 01/05/25 at 5:30 PM. On 01/03/25 at 5:00 PM, an IJ was identified. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #2) of 3 residents reviewed for quality of care. RN C failed to assess and notify the physician when Resident #2 fell in the bathroom on 10/05/24. The resident required hospitalization and suffered a clavicle fracture. On 01/03/25 at 1:40 PM, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents who require assistance and supervision at risk for injuries, hospitalization , and death. The findings were: Record review of Resident #2's admission MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included arthritis, osteoporosis, and seizure disorder. Resident #2 had a BIMS score of 14 meaning her cognition was intact. The MDS further reflected Resident #2 required moderate assistance (Helper does less than half the effort) for toileting and ambulating. The resident used a walker. Record review of Resident #2's Progress notes reflected: 10/06/24 2:48 PM Late Entry Note 10/5/24 at 9:35 PM Floor CNA notified this nurse that resident stated, she fell but right now resident is on the toilet. Upon entering resident's bathroom, resident was noted sitting up on the toilet. This nurse asked resident what happened. Resident stated she slid and fell , but she got herself up. When I asked how she got herself up from the floor, Resident was not able to account for how she got herself up from the floor. Resident denied pain. Pain meds was given 5 minutes before the incident happened. Resident awake, alert, oriented, ambulatory, and able to make needs known. Education provided to the resident on the importance of call light usage and waiting for help before ambulation. Resident was on the toilet she was told to call when she was finished. Call light within reach. Written by RN C 10/06/24 1:09 AM Resident called the husband that she was in excruciating pain. The husband called the facility and said he was coming to take the wife to the hospital. Resident was encouraged to take pain medication which she declined. Vital signs were obtained, Blood Pressure 122/78, Pulse 72, Temperature 97.8, Oxygen Saturation 97% Room Air, Respirations 18. Husband arrived to the facility and requested that the wife be sent to the ER. Patient was sent to the hospital. DON and physician was notified. Written by LVN D Record review of Resident #2's Care Plans, dated 10/01/24, reflected: Resident is at risk for falling related to impaired mobility, muscle weakness, and incontinence. Facility interventions included: Encourage resident to use environmental devices such as hand grips, hand rails, etc. Keep call light in reach at all times. Provide an environment free of clutter. Review of Resident #2's Hospital Records, dated 10/06/24 reflected: Resident was a [AGE] year-old female who presented to the emergency department with a fall. Patient was in an inpatient rehabilitation facility. She was ambulating to the bathroom with her walker when she lost balance and fell to the floor. She did not remember specific(s) of the fall but was assisted back to bed by staff. She began experiencing progressive pain and was subsequently transported to our facility. CT scan revealed the resident had a right clavicle fracture. Record review of the facility Provider Investigation Report for Resident #2, dated 10/07/24 reflected: 10/05/24 9:35 PM Family member reported that Resident #2 was left on the toilet for hours in pain after she fell self-transferring to toilet. MD and family notified, assessed for pain and injury, sent to hospital for treatment, staff interviews. Allegation: Unconfirmed Investigation Summary for Resident for 10/05/24: CNA reports that resident called around 9:45 PM, and she was in the bathroom on the commode. Resident reported that she had had a fall when she ambulated to the bathroom with her walker. Resident reported that she was able to get herself up and to the bathroom. CNA reported the fall to the RN who went in to see the resident. Resident had taken a pain pill shortly before she reported the fall. She denied pain to the RN. Resident was not finished using the restroom, so the RN instructed her to call for assistance when she was done. CNA reported that the emergency light came on shortly after 10:00 PM, and she answered the light. She assisted the resident to the wheelchair and back to bed. CNA reported that resident did not complain of pain during the transfer to the wheelchair or to the bed. CNA stated she was making rounds a little before midnight and resident asked her to hand her the cell phone. Resident used her cell phone to call her husband. CNA heard resident tell her husband about the fall. Resident told the CNA that her husband was coming to the facility. Family arrived around 15-20 minutes later. Family visited with his wife and then asked the charge nurse to send her to the ER to be evaluated. Family told the charge nurse that the resident was complaining of pain to her shoulder. LVN went in see the resident. The resident refused pain medication. The LVN called the physician and prepared the paperwork and to send the resident to the ER. Resident was transferred to the ER via EMS around 1:00 AM. Written by the DON Interview conducted with RN C: RN reported that around 9:45 PM the CNA reported that resident was in the bathroom and reported that she had fallen while taking herself to the bathroom. RN went into the room to find resident on the commode. Resident told her she fell earlier while ambulating to the bathroom. Resident told her she was able to get herself up and continue to the bathroom. RN states she had medicated the resident with Tylenol #3 around 9:30 PM. Resident denies pain at that time. RN states she instructed the resident to use the call light when she was finished in the bathroom, and a staff member would assist her back to bed. Interview conducted with CNA R who worked the 2:00 - 10:00 PM shift on 10/05/24. CNA R reported that around 9:45 PM, she responded to the emergency light for the resident, and she was sitting on the commode. Resident reported to the CNA that she had fallen while she was ambulating to the bathroom. CNA R asked her who got you up?, resident stated I got up by myself and came into the bathroom. CNA R stated she immediately went to get the RN, who came right into the room. Interview conducted with CNA E: CNA E was the aide assigned to the resident on the 10:00 PM - 6:00 AM shift on 10/05/24. CNA E stated she answered the light shortly after 10:00 PM and the resident was in the bathroom. She assisted the resident to the wheelchair and back to bed. The resident did not complain of any pain and had no changes in her transfer. She checked on her around 2 hours later and the resident asked for her cell phone to call her husband. CNA E stated she overheard the resident tell her husband that she had had a fall. CNA E stated the resident told her that her husband was on his way up to the building. CNA E stated in about 15 minutes the family was here and rang the bell. CNA E let him in. The family spoke to his wife and reported to the charge nurse that she was in pain. CNA E stated the charge nurse went into the room. The husband was upset and wanting her sent to the ER. Interview conducted with LVN D: LVN D was working 10:00 PM - 6:00 AM with the resident. LVN D reported that around 12:30 PM, the family was in the facility to see his wife. He reported to the nurse that she was in excruciating pain to her shoulder. LVN D went in to see the resident, who refused pain medication. Family stated he just wanted her to go to the hospital to be evaluated. LVN D notified the Physician and prepared the paperwork. EMS arrived around 1:00 AM and resident was transferred to the ER. Facility staff was in-serviced on abuse and neglect. Review of a facility in-service for RN C, dated 10/06/24, revealed RN C was in-serviced on ensuring a resident who had a fall was assessed and the physician was notified. An interview on 01/02/25 at 9:55 AM with the family of Resident #2 revealed the resident never returned back to the facility after being sent to the hospital. He said the facility did not call him when she fell . He said the resident did not call for help to go to the restroom. She used her wheelchair to take herself to the bathroom. She said she went to the restroom and fell . She pressed the emergency light and it took a while for them to answer. The family member said when he got to the facility the resident was in pain. The family member said the nurse did not ask the resident if she wanted to go to the hospital. An interview on 01/02/25 at 2:30 PM with RN C revealed on 10/05/24 Resident #2 would always call for help to transfer. RN C said the resident could barely walk. RN C said she gave the resident pain medicine 30 minutes before the fall. When she interviewed the resident, RN C said the resident told her she fell but was able to get back on the toilet. RN C said the resident did not tell her she was hurting. RN C also said the resident could not tell her how she fell . RN C said she could not establish for sure that the resident actually fell so she just gave the resident education about using her call light. RN C said she did not assess the resident. RN C said she only did a head-to-toe assessment if the resident was on the floor. RN C said it was necessary to assess a resident after a fall in case there was a fracture. A follow-up interview on 01/03/25 at 11:00 am with RN C revealed she did not call the physician after the reported fall because the physician would have asked her about the fall, and she did not have those answers. An interview on 01/03/25 at 3:00 PM with CNA E revealed she worked with Resident #2 on the 10:00 PM-6:00 AM shift on 10/05/24. CNA E said she did her rounds with the resident between 10:00 PM - 10:15 PM and assisted the resident to bed. CNA E said Resident #2 complained of pain in her shoulder and she told LVN F. An interview on 01/03/25 at 3:05 PM with LVN D revealed when she came on shift at 10:00 PM, she saw Resident #2 in bed. Her family member called LVN D at 11:00 PM and said she was in pain. LVN D said she went to the resident's room and assessed her. Resident #2 complained of pain so she went to get pain medicine for her. She said she did not see the resident fall. LVN D said the resident refused pain medicine and that she only wanted to go to the hospital. LVN D said the resident did not have swelling or bruising on her shoulder and she sent her to the hospital. An interview was attempted with CNA R for 2:00 PM-10:00 PM shift, but she did not return the call of the Surveyor. An interview on 01/02/25 at 4:10 PM with the DON revealed if a resident fell , the nurse was to do a full assessment. The assessment would include full range of motion, pain assessment, and to assess for bruises and fractures. The nurse was also supposed to check to see if the resident hit their head. The DON said she did not know RN C did not assess Resident #2 after she fell . The DON said the resident could not be assessed for injuries if an assessment was not be completed. The DON said she thought maybe RN C was not aware that the resident fell . The DON said if an incident was not thoroughly investigated then staff would not be educated, and it could happen again. A follow-up interview on 01/03/25 at 9:55 AM with the DON revealed she thought RN C notified the physician after the fall. The DON also said staff were in-serviced on completing and assessment and notifying the physician after a fall. Review of the facility policy, Fall Management, dated 05/05/23, reflected: Definitions: Fall refers to the unintentionally coming to rest on the ground, floor, or other lower level, but not because of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred . 5. Qualified staff evaluates patient/resident for injury from a fall, identify and treat for pain related to fall, and determine contributing causes, including ascertaining what the resident was trying to do before he or she fell , addresses the risk factors for the fall such as the resident's medical conditions(s), facility environment issues, or staffing issue; and determines interventions to prevent future falls and completes a Fall Investigation Worksheet . 7. Neurological evaluations will be performed for a resident who sustains an unwitnessed fall, regardless of the resident's cognitive status at the time of the incident. 8. The physician and family are promptly notified, and an incident report is completed . This was determined to be an IJ on 01/03/25 at 1:40 PM. The Administrator and the DON were notified. The Administrator was provided with the IJ template on 01/03/25 at 2:45 PM. The following Plan of Removal was submitted by the facility and was accepted on 01/05/25 at 08:27 AM and reflected the following: Identified resident was no longer at the facility. Residents who had a fall in the last 14 days would have a medical record review by the Director of Nursing/Designee by 01/03/25 to validate assessments were completed and physician was notified. Residents identified without an assessment would have one completed by the Director of Nursing/ Designee by 01/03/25. Residents identified without physician notification would have notification completed by 01/03/25. All staff would be re-educated by the Director of Nursing/Designee by 01/04/25 on the fall management policy, which included: Qualified staff evaluated patient/resident for injury from a witnessed or unwitnessed fall and identify and treat for pain related to fall by conducting and documenting a head-to-toe assessment. Neurological evaluations would be performed for a resident who sustained an unwitnessed fall, regardless of the resident's cognitive status at the time of the incident. The physician and family would be promptly notified, and an incident report would be completed. Any staff not present would be in-serviced prior to their next scheduled shift. The Director of Nursing/Designee would review the 24-hour report and the Facility Activity Report beginning 01/04/25 to identify any documentation regarding a fall and validate that the resident had been assessed, physician notified, responsible party notified, and orders implemented. This would be completed in the Clinical Meeting Monday thru Friday. Ad Hoc QAPI was held on 01/03/25. The Medical Director was notified of the Immediate Jeopardy on 01/03/25. Monitoring of the facility's Plan of Removal included the following: Record review of Resident #2's clinical records revealed the resident did not return to the facility after her fall. Interviews were conducted on 01/05/25 from 1:10 PM to 4:57 PM with staff from various shifts. The staff included CNA A, LVN G, CNA H, CNA I, RN J, LVN K, LVN L, LVN M, CNA N, LVN O, and LVN P. RN C was not available for interview. RN C was in-serviced per in-service review. All staff were able to identify: The nurse was responsible for assessing a resident after a fall. The nurse was to complete a head-to-toe assessment and range of motion assessment. Neurological assessments were to be completed for falls where a resident hit their head or for an unwitnessed fall. Nurses knew to assess residents even if they did not know for sure if a resident had a fall. The nurse knew to notify the doctor, DON, ADON and family member for all resident falls. An interview on 01/05/25 at 4:34 PM with the DON revealed her roles in the facility plan of removal included: She reviewed residents who had had a fall in the last 14 days to ensure assessments were completed and the physician was notified. She said there were no issues identified with her review. She said she all would review the 24-hour report and the Facility Activity Report to identify any documentation regarding a fall and validate that the resident had been assessed, physician notified, responsible party notified and orders implemented. This would be completed in the Clinical Meeting Monday through Friday. The DON said she did a 1:1 in-service with RN C regarding doing full assessments. An interview on 01/05/25 at 4:57 PM with the Administrator revealed he knew the definition of neglect. He said his role in the Plan of Removal was to ensure all steps were completed and that the monitoring was on-going. An interview was attempted on 01/05/25 at 4:26 PM with the Medical Director. The Medical Director did not return the call of the Surveyor. The Administrator and DON were informed the Immediate Jeopardy was removed on 01/05/25 at 5:30 PM. On 01/03/25 at 1:40 PM, an IJ was identified. While the IJ was removed on 01/05/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of six residents reviewed for advanced directives, in that: The facility failed to honor the rights of Resident #1's wishes to die a dignified death by failing to honor a signed OOH DNR order on [DATE] at 07:42 pm when LVN A failed to inform EMS of Resident #1's DNR status and a full code was initiated to include CPR for approximately 43 minutes when Resident #1 became unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 03:25 PM. The IJ template was provided to the facility on [DATE] at 03:41 PM and signed by the Administrator. While the IJ was removed on [DATE] at 1:25 PM, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This facility failure placed residents at risk of not having their rights honored, to include pain, fractures, psychological and physical harm. The findings included: Record review of Resident #1's undated electronic face sheet reflected she was a [AGE] year-old female that admitted to the facility on [DATE]. Her diagnoses included: anxiety disorder (intense, excessive, and persistent worry and fear), cognitive communication deficit (difficulty with thinking and how someone uses language), dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), cerebral infarction (disrupted blood flow to the brain), chronic obstructive pulmonary disease (damage to the lungs that block airflow that makes it difficult to breathe), gastro-esophageal reflux disease (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). Resident #1's electronic face sheet also reflected she had a directive for Do Not Resuscitate (DNR) status. Further review revealed Resident #1 expired on [DATE]. Record review of Resident #1's MDS assessment dated [DATE] reflected she scored a ,d+[DATE] on her BIMS (brief Interview for mental status) which signified she was mildly impaired related to her diagnosis of dementia. She had a reduced ability to understand others and to be understood. She required one-person physical assistance with her ADL's. Record review of Resident #1's comprehensive care plan revised on [DATE] reflected Problem: Resident request code status of DNR, Goal: Status will be maintained over the next 90 days, Approach: Inform staff of code status. Monitor for decrease in change of condition, report to MD and responsible party. Record review of Resident #1's Physician Order Details dated [DATE] reflected Code Status: DNR. Record review of Resident #1's OOHDNR revealed it was signed on [DATE] by Resident #1, FAM A, the SW and the MD. Record review of Resident #1's progress notes written by the SW dated [DATE] at 03:50 PM, reflected SW, ADON, Activities Director, and Dietary met with [FAM A] to complete a care plan meeting. Code status is a DNR. Record review of Resident #1's progress notes written by LVN A dated [DATE] at 09:03 PM, reflected Summoned to [Resident #1] room, [Resident #1]'s eyes were bulging, and she was wheezing and yelling help me help me. [CNA A] reported that [Resident #1] had food stuck in her throat and was choking. [LVN A] told [Resident #1] to cough so as to let the food out, but [Resident #1] couldn't. [LVN A] gave [Resident #1] back blow and suctioning but no respite. [Resident #1] stop responding and was turning blue, [Resident #1] was placed on O2 running @3LNC then [LVN A] started the Heimlich maneuver and called Code Blue. The paramedics was called, and [Resident #1] was sent to the ER. Vitals taken: 98.0 F (temperature), 20 (respiratory rate), 92% (pulse oximetry), ,d+[DATE] (blood pressure), 89 (pulse). MD, RP, DON notified. Record review of Resident #1's progress notes written by LVN A dated [DATE] at 09:03 PM, reflected [LVN A] received a call from the [Company] police department and wanted to know what happened to [Resident #1]. [LVN A] explained what transpired and was informed that [Resident #1] had passed away. The MD was notified, and a voice message was left for the DON. Record review of [Company's] Patient Care Record Summary dated [DATE], revealed, Medic three arrived on the scene to find a [AGE] year-old female sitting upright on the side of the bed with nursing home staff attempting the Heimlich maneuver. [Resident #1] was apneic (a temporary cease of breathing) and pulseless, and staff deny [Resident #1] having a DNR, so [Resident #1] was moved to the EMS stretcher and chest compressions began. [Resident #1]'s airway presents with food and vomit present. The food was removed, and the vomit was suctioned prior to beginning ventilation via BVM. An IO (process of injecting medication, fluids, or blood products directly into the bone marrow) was established in [Resident #1]'s right leg with total of three epinephrine being administered. [Resident #1] was intubated with a 7.0 ET tube (provides oxygen and inhaled gases to the lungs and protects them from contamination) placed at 21 centimeters at the teeth. Initial rhythm was asystole (heart stopped pumping) with no change. [Resident #1] was transported to [Company] Hospital for further evaluation. Upon arrival hospital, staff resumed compressions from EMS and effort were terminated via physician prior to EMS departure. Record review of Resident #1's hospital paperwork dated [DATE] and an arrival time of 08:04 PM under Chief Complaint revealed, Chief Complaint: Cardiac Arrest.72 yo female presents to the ED via EMS in cardiac arrest. EMS reports [Resident #1] is coming from a living facility and staff reports [Resident #1] was eating and began choking and went unresponsive. Arrest was witnessed by staff, and they attempted the Heimlich maneuver but were unsuccessful. On arrival EMS states [Resident #1] was unresponsive with an initial rhythm of asystole. CPR was initiated and an obstruction was noted in [Resident #1]'s airway, which was removed, and [Resident #1] was intubated. EMS gave 3 rounds of epi but only got a PEA rhythm prior to arrival. EMS states [Resident #1] had been down for ,d+[DATE] minutes. Record review of Resident #1's hospital paperwork dated [DATE] revealed the ED Course/Rechecks as: Progress: 8:06 PM: CPR paused for pulse check. No pulse palpated. Asystole on bedside monitor. CPR resumed. 8:06 PM: 1 of epi given 8:07 PM 1 of bicarb given 8:08 PM: CPR paused for pulse check. No pulse palpated. Asystole on bedside monitor. CPR resumed. 8:09 PM: 1 of epi given 8:10 PM: CPR paused for pulse check. No pulse palpated. Asystole on bedside monitor. CPR resumed. 8:12 PM: 1 of epi given 8:12 PM: CPR paused for pulse check. No pulse palpated. Asystole on bedside monitor. CPR resumed. 8:14 PM: CPR paused for pulse check. No pulse palpated. Asystole on bedside monitor. CPR resumed. 8:15 PM: 1 of bicarb given. 8:15 PM: 1 of epi given. 8:16 PM: CPR paused for pulse check. No pulse palpated (method of feeling with the fingers or hands during a physical examination). Asystole on bedside monitor. CPR resumed. 8:19 PM: 1 of epi given 8:20 PM: CPR paused for pulse check. No pulse palpated. Asystole on bedside monitor. 8:20 PM: Time of death called. Interview on [DATE] at 02:44 PM with FAM A, she stated it was Resident #1's decision to be a DNR and they had discussed it at every care plan meeting. FAM A stated protocol was not followed as Resident #1's decision had not been respected. Interview on [DATE] at 03:32 PM with LVN A, she stated, EMS intubated Resident #1 and started CPR on her. LVN A stated, she left Resident #1's room and grabbed the paperwork from LVN B and when she returned to Resident #1's room, EMS had already started CPR. LVN A stated everything was chaotic. LVN A paused and then stated she did not tell EMS Resident #1 was a DNR because it was hectic; she just gave them the face sheet after she returned back to Resident #1's room. LVN A stated the policy was that if a resident was a DNR, they must not resuscitate them. LVN A stated normally nursing staff informed EMS if the resident was a DNR or not. LVN A stated not respecting Resident #1's code status could have made her feel not respected as her decision had no value. Interview on [DATE] at 04:20 PM with CNA B, he stated if a resident had a DNR, they were not supposed to receive CPR. CNA B stated they could administer other life-saving measures, just not resuscitate them. CNA B stated when EMS arrived, staff must tell EMS the status of the resident to avoid them providing CPR. CNA B stated staff could find a resident's code status in their electronic file, and they also had copies of the code statuses already printed out and placed in a binder at the nurse's station and on the crash cart. Interview on [DATE] at 11:52 PM with the ADM, he stated, EMS would be provided a copy of the resident's face sheet and be informed of the resident's code status. The ADM stated information regarding DNR's could be found in the discharge policy. The ADM stated staff should have paperwork printed to hand over with that information available when EMS arrived at the facility. Interview on [DATE] at 12:08 PM with CNA A, she stated she was not aware Resident #1 was a DNR. CNA A stated she had not left the room as LVN A was walking by and she told LVN A she needed her because something was wrong with Resident #1. CNA A stated LVN A asked Resident #1 what was wrong, and Resident #1 just kept repeating, Help Me. CNA A stated then LVN B entered the room and asked if Resident #1 had swallowed something and then called a Code Blue. CNA A stated she left the room when the Heimlich maneuver was started and escorted the EMTs to Resident #1's room. CNA A stated she never re-entered Resident #1's room and proceeded to assist with getting other residents ready for bed. CNA A stated as she walked past Resident #1's room, she observed the EMTs putting the CPR machine on Resident #1's chest. Interview on [DATE] at 02:34 PM with LVN B, she stated she stepped out of Resident #1's room to call 911. LVN B stated she called a code blue for more assistance. LVN B stated EMS arrived and she and CNA A escorted EMS to Resident #1's room. LVN B stated she and CNA B did not re-enter the room. LVN B stated she printed the paperwork but did not get the paperwork off the printer. LVN B stated she did not see Resident #1 when she was transported out of the facility. LVN B stated the chain of events happened so fast, she did not remember anything. Record review of the facility policy and procedure titled, Do Not Resuscitate (DNR) ([DATE]) reflected: Facility staff will follow the resident's Advance Directives in accordance with applicable law and regulation as well as the applicable Facility Policies and Procedures. It further reflected: 2. At the time of admission and/or readmission to the Facility, Social Services or a Nursing Designee will meet with the resident and/or his/her legal representative (in the order and manner prescribed by State-specific regulations) to thoroughly review the State and the Facility protocols for advanced directives, including the resident's right to determine whether or not he/she wishes to be resuscitated in the event he/she suffers cardiac or respiratory arrest. Record review of the facility policy and procedure titled, Discharge/Transfer (Email Revision: [DATE]) reflected: B. Emergency: 2) Send the patient's/resident's face sheet, Advance Directives, bed-hold policy, physician orders, MAR and TAR, and any state specific records in accordance with state regulations with the patient/resident. If unable to complete the information, verbally communicate the necessary information and fax when complete. Record review of the facility policy and procedure titled Cardiopulmonary Resuscitation, Emergency Code Blue (Revised: [DATE]) reflected: The Facility implements policies and procedures for the provision of cardiopulmonary resuscitation (CPR) by staff, safely and according to current Basic Life Support guidance. 1. Code Blue will be announced to notify the appropriate team members to participate in a systematic, organized procedure during a potential life-threatening situation. 2. This policy only applies to residents who are full code. 3. This policy does not apply to residents who have elected DNR status. The policy further reflected under Definitions: 5. Do Not Resuscitate (DNR) Order: Medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer CPR in the event of cardiac or respiratory arrest. Existence of an advance directive does not imply that a resident has a DNR order. The medical record should show evidence of documented discussions leading to a DNR. The Administrator was notified of an Immediate Jeopardy (IJ) on [DATE] at 03:41 pm and given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's Plan of Removal was accepted on [DATE] at 1:25 pm and reflected: Resident #1 no longer resides at the facility. Residents in the facility have the potential to be affected by this alleged deficient practice. The Director of Nursing and Administrator were reeducated by the Clinical Consultants on [DATE] on Resident Rights including When a resident is going to be transferred out of the facility via Emergency Medical Services a verbal communication to the technicians regarding the resident's code status will occur upon Emergency Services entrance along with a copy of the Out of Hospital Do Not Resuscitate paperwork A notebook can be found with the crash cart with Advance Directives including code status Licensed Nurses will be re-educated by the Director of Nursing/designee beginning [DATE] on Resident Rights including: When a resident is going to be transferred out of the facility via Emergency Medical Services a verbal communication to the technicians regarding the resident's code status will occur upon Emergency Services entrance along with a copy of the Out of Hospital Do Not Resuscitate paperwork A notebook can be found with the crash cart with Advance Directives including code status This re-education will be completed by [DATE], by Director of Nursing/designee Any Licensed Nurse not receiving this education by this date will be educated prior to next scheduled shift. This information will be presented in new hire orientation. Licensed nurses will be interviewed daily for 5 days on each shift then weekly for 2 weeks by members of nursing management to validate that the transfer of learning regarding the expectation that verbal communication to Emergency Services on a resident's requested code status will happen upon Emergency Services entrance. Interviews will begin on [DATE] An Ad Hoc QAPI was held [DATE]. The Medical Director was notified of the Immediate Jeopardy on [DATE] and will be updated with any changes. Verification of the POR: -Review of the facility's Ad Hoc QAPI meeting notes, dated [DATE], reflected there was discussion of the system for resident code status and the importance of following resident's wishes at end of. -Review of the facility's in-services revealed, the CSD conducted an in-service on [DATE] with the ADM and the DON (with signatures) regarding Resident Rights, Verbal Communication to EMS regarding Code Status and locations of the binder for Code Statuses. The details of the in-service revealed: 1) When a resident is going to be transferred out of the facility via Emergency Medical Services a verbal communication to the technicians regarding the resident's code status will occur upon Emergency Services entrance along with a copy of the Out of Hospital Do Not Resuscitate paperwork. 2) A notebook can be found with the Crash Cart and at both nursing stations with Advance Directives including code status. -Review of an in-service conducted on [DATE] by the DON titled, Advanced Directives DNR/Full Code Status and Giving Report to EMS, reflected staff (with signatures) had been educated on the facility's Resident Code Status Order Policy and the following: 1) Check for resident code status 2) When resident transferred out give verbal report to EMS of being full code or DNR 3) Have OOHDNR ready once EMS is called to transfer the resident 4) If the resident is DNR ensure that the paperwork is sent out with the resident 5) There will be a notebook at the nurses' station with Advanced Directives including code status Observation on [DATE] at 01:35 PM revealed the Advanced Directives binders were at the two nurses' station and on the crash cart. On [DATE] interviews with multiple staff members across various departments and shifts revealed the staff members were recently in-serviced properly on DNR Election Form Policy and Procedure. Each staff member was aware of the steps of completion of the DNR Election Form. No concerns were noted from these interviews. Interview on [DATE] at 01:40 PM with the ASW, she stated the SW left the Advanced Directives in a folder and she filed them. The ASW stated she assisted with scanning the forms as needed. The ASW stated family and/or the resident chose the DNR status. The ASW stated after the decision was made, it stood. The ASW stated the SW advised nursing staff and management, and a copy was left at the nursing station and also uploaded into the residents' EMARs. Interview on [DATE] at 01:51 PM with the CM, she stated she met with new residents and completed the assessments checklist. The CM stated she confirmed the residents code status at this time. The CM stated if the resident was already a DNR, she verified it with the family and the doctor to make sure there was an order for a DNR. The CM stated she made copies and placed the copies in the binders (5 copies for easy retrieval if a resident was sent out) at the nursing station. The CM stated she uploaded a copy into the EMAR under the documentation tab and made sure the face sheet was updated with the DNR status. The CM stated as a nurse, she notified EMS when they entered the facility and gave them a quick assessment. The CM stated she or someone else had printed the transfer paperwork and given it to the EMTs. The CM stated she was in-serviced on Monday ([DATE]) by the Education Staff Development (ESD) on DNR's, where they were kept, and properly notifying the EMTs if the resident was DNR or full-code. The CM stated today, Tuesday ([DATE]) the DON completed an in-service with her on where the DNR binder was located. The CM stated the binders were located at the nursing stations and also on the crash cart. Interview on [DATE] at 02:05 PM with LVN C, she stated prior to EMS arriving, she would have already checked a resident's code status. LVN C stated when EMS arrived, she would inform the status immediately and hand them the paperwork. LVN C stated she would remain with her resident and had a different nurse print the paperwork so she could stay with EMS from the beginning to the end. LVN C stated that way she would be in the room if EMS attempted CPR and the resident was a DNR. LVN C stated she was in-serviced on remaining with the resident. LVN C stated nursing staff should know where the code status binder was located. LVN C stated the binder was located at the nursing station. LVN C stated they had two binders (one for the DNR status and the other binder had all residents with DNR and full code). LVN C stated the binder for all residents was on the crash cart and it was updated every night. LVN C stated she learned to prepare herself as a nurse in any type of situation. LVN C stated staff should act fast when things happened and complete the total assessment. LVN C stated paperwork should be ready prior to EMS' arrival. LVN C stated if staff needed help from a co-worker, call for assistance immediately so they could help with paperwork, etc. LVN C stated the code status should had been checked and provided to EMS upon their arrival. LVN C stated in addition to Resident #1 expiring, she could had received broken bones of her ribs, bruising, dislocations, and hematomas (pool of mostly clotted blood that forms in an organ, tissue, or body space). Interview on [DATE] at 02:20 PM with the ADON, she stated she arrived to work last night at 9:45 PM and educated the night nurses and interviewed them. The ADON stated she educated staff on what to do if a resident was going to the hospital or any emergency. The ADON stated she instructed the night nurses to check the code status first and upon entrance EMS was to be provided a verbal report as well as paperwork if they are transferring the resident out. The ADON stated they also discussed where to locate the Code Status/Advance Directive binders which were kept at each nursing station and on the crash cart. The ADON stated no one had any questions. The ADON stated management would discuss any changes to the binders during the morning meetings and the binders would be updated accordingly. The ADON stated she learned how important it was for EMS to have the printed directive in their hand and to receive a verbal confirmation. The ADON stated her expectations were for the nursing staff to follow directions and protocols. The ADON stated if staff had any questions to not hold off, especially if it needs to be addressed immediately. The ADON stated the nurses should had double-checked the status code and not panicked. Interview on [DATE] at 02:34 PM with LVN B, she stated she had been in-serviced several times on Monday ([DATE]) by the ADON on what to do when EMS was called. LVN B stated they were to verbally inform EMS of the code status, provide a printout of the code status, the face sheet, and the medication sheet. LVN B stated she was also in-serviced today ([DATE]) by the DON on the same material regarding the code status, verbal status, to print directives, the face sheet, and the medication list. LVN B stated the DON also quizzed her about where to locate the code status. LVN B stated if a resident was a DNR, staff must ensure the resident's paperwork was printed and sent out with the resident. LVN B stated also, she was quizzed on where to locate the advanced directives (electronic and paper form). LVN B stated the DON made sure she knew where to locate all the information. LVN B stated she did not learn anything new; it was more of a refresher. Interview on [DATE] at 02:47 PM with the CSD, she stated she re-educated the ADM, the DON, and all licensed nurses on when a resident was going to be transferred by EMS, they must provide a verbal report and a printed copy of the code status when EMTs entered the building and a printed copy of the OOH DNR. The CSD stated she interviewed the nursing staff and ensured the information was understood. The CSD stated the nursing staff would also be quizzed for 5 days on the in-service to ensure the information was retained. The CSD stated on [DATE], they had an Ad Hoc QAPI meeting via phone with one of their MDs. The CSD stated the Advanced Directive binders were located on the crash cart and at each nursing station. The CSD stated they had not made any changes to their policy. The CSD stated during morning meetings, they discussed any changes and updated the binders throughout the day. The CSD stated her expectation was for the staff to inform the EMTs of the resident's name, code status and give an assessment of the situation. Interview on [DATE] at 03:00 PM with the DON, she stated she started education yesterday ([DATE]) with the nursing staff on checking code status and giving verbal reports to EMS. The DON stated the ADON came to the facility last night ([DATE]) at 10:00 PM to continue in-servicing the night staff. The DON stated she arrived at the facility at 5:00 AM ([DATE]) to complete in-services with the morning crew. The DON stated they were in-servicing and conducting questionnaires for 5 days on EMS, code status, and proper paperwork. The DON stated she wanted the facility to start conducting code drills monthly, currently they do annual competencies and the next one is in [DATE]. The DON stated for now they would start conducting code drills monthly and monitor. The DON stated she just wanted everyone to not panic. The DON stated staff should never leave EMS alone in the room. The DON stated even though staff provided EMS paperwork, staff should verbally give EMS a report to include the reason staff called, the baseline, vital signs, labs, and have the fracture information ready in case the resident must go into surgery. The DON stated staff must be as accurate as possible. Interview on [DATE] at 03:16 PM with the ADM, he stated they completed in-services with the nursing staff on where to find the code status and how to present the information to EMS. The ADM stated the information should be given verbally and a printout should also be provided to EMS. The ADM stated the binder with the advanced directives were located on the crash cart and at each nursing station to remain readily available to provide a printed copy to EMS. The ADM stated the nursing staff would be quizzed daily for 5 days, then once a week for 2 weeks, etc. The ADM stated they would not allow any nurse to start their shift until they were in-serviced. The ADM stated whenever EMS entered the facility, they would be handed a printout and the information would be verbally communicated. The ADM stated an Ad Hoc QAPI meeting was held with the MD on [DATE]. The ADM stated the policy said to hand EMS the information, and they would be changing it to say do both (verbally and printed). The Administrator was notified the IJ was removed on [DATE] at 1:25 PM, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for five (Residents #1, #2, #3, #4, and #5) of five residents reviewed for pharmacy services related to new admissions. 1. The facility failed to follow physician orders and provide Resident #1 with Clozapine, an antipsychotic medication to treat her schizoaffective disorder for two weeks (03/04/24 through 03/17/24). 2. The facility failed to follow physician orders, acquire, and administer Resident #2 with Buspirone, Gabapentin, Oxybutynin Chloride, Trazadone, Venlafaxine, and Hydroxyzine on 05/03/24, the day after she admitted to the facility. 3. The facility failed to follow physician orders, acquire, and administer Resident #3 with Calcitriol, Calcium Acetate, Cholestyramine Light Power, Creon, Culturelle, Donepezil, Eliquis, Latanoprost, and Budesonide on 05/09/24, the day after she admitted to the facility. 4. The facility failed to follow physician orders, acquire, and administer Resident #4 with Docusate Sodium, Ezetimibe, Isosorbide Mononitrate, Losartan, Premarin, Symbicort, Baclofen, Quetiapine Fumarate/Seroquel, Carvedilol, Culturelle, and Rosuvastatin on 05/10/24, the day after she admitted to the facility. 5. The facility failed to follow physician orders and provide Resident #5 with daily Flonase allergy spray since her admission (approximately two months). The failures could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort. Findings included: 1. Record review of Resident #1's Face Sheet (not dated) reflected she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses that included depression (a depressed mood or loss of pleasure or interest in activities for long periods of time), schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations, or delusions, and symptoms of a mood disorder, such as mania and depression), extrapyramidal and movement disorder (drug induced movement disorder), and neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function). Resident #1 was noted to have discharged from the facility on 04/03/24. Record review of Resident #1's admission MDS assessment dated [DATE] reflected her BIMS score was 05, which indicated severe cognitive impairment. Resident #1 had an additional diagnosis of non-Alzheimer's dementia. Resident #1 had no signs or symptoms of delirium, no negative mood issues, and no behavioral symptoms. Resident #1 was dependent on assistance from staff for her ADLs, had no range of motion limitations, and used a walker to ambulate. Resident #1 had no previous falls for six months prior to admission to the facility or during the admission assessment period. Resident #1 received anti-psychotic and anti-depressant medication. The MDS indicated Resident #1's antipsychotic medication was not received since admission. Record review of Resident #1's care plan initiated on 02/16/24 and last revised on 03/28/24 did not address her need for antipsychotic medication, related behaviors, and interventions specific to her needs. Record review of Resident #1's March 2024 physician orders reflected she was prescribed the antipsychotic, Clozapine 200 mg two tablets once a day (Clozapine is an atypical antipsychotic indicated for the treatment of severely ill patients with schizophrenia who fail to respond adequately to standard antipsychotic treatment for schizoaffective disorder). The diagnosis listed for Resident #1's Clozapine was schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), start date 02/19/24-open ended. Record review of Resident #1's February 2024 MAR reflected she received Clozapine from 02/19/24 through 02/29/24. Resident #1's March 2024 MAR reflected she did not receive Clozapine from 03/04/24 through 03/17/24, for approximately two weeks. Under each entry it reflected, Not administered: Drug/Item not available, waiting on pharmacy. There was no order in Resident #1's clinical chart to discontinue the medication. The medication administration resumed on 03/18/24 through the end of her stay at the facility on 04/02/24. Record review of nursing progress notes related to Resident #1's Clozapine and lack of administration and availability reflected: -[Recorded as Late Entry on 03/07/2024] This nurse has interacted several times with [MD A] and [MD B] via text messages regarding the medication clozapine. The pharmacy will not dispensed until MD fills out a REM's form on line to update her status, lab with WBC's was sent as well to MD. [Physician A] responded that PSYCH should get involved in doing so. I addressed this matter with the ADON. The SW will contact PSYCH to eval and treat. -03/17/2024 -STAT labs results sent to MD and pharmacy to have Clozapine re-filled. This nurse called [Pharmacy name]'s pharmacist to ensure the medication delivery, however the pharmacist stated that the psychiatrist has to sign a consent on line in order for [Pharmacy name] to fill and deliver the medication. -03/18/2024-Resident remained on skilled services, AOX2 with mild confusion, refused food but will drink juice, still waiting for clozapine from pharmacy. -03/18/2024 -Patient medication Clozapine taken care of by Psych Dr Pharmacy stat medication out. Drug was given to patient will monitor for adverse behaviors. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] reflected she was being seen for psychosis, paranoia, hallucinations, resistance to ADL/medications, and paranoia. The assessment reflected, Staff reports recent delays in receiving patient's ordered clozapine. Following, increased negative symptoms of psychosis were reported to occur. Once this provider was contacted by the facility, a verbal order was given for collection of CBC with Differential. Following results, Clozapine REMS website was updated with results on 3/17, and clozapine was restarted. Prior to initiation of the exam, staff reports continued, but [sic] decreased symptoms of psychosis (patient has received Clozapine X 3 days at this time). Staff reports patient has been 'more talkative and appetite had overall improved .Psychosis: Staff reports RECENT increased symptoms of delusional thoughts, catatonia, and negative symptoms of psychosis. Patient exhibited disorganized thought progress and reported visual hallucinations during exam. Per staff, sx are ongoing, but have decreased once Clozapine restarted. (Note: Clozaril/Clozapine: Discontinuing Treatment-For abrupt treatment discontinuation .Monitor all patients carefully for the recurrence of psychotic symptoms and symptoms related to cholinergic rebound such as profuse sweating, headache, nausea, vomiting, and diarrhea. Re-Initiation of Treatment: When restarting clozapine in patients who have discontinued clozapine (i.e., 2 days or more since the last dose), re-initiate with 12.5-mg once daily or twice daily. This is necessary to minimize the risk of hypotension [low blood pressure], bradycardia [slower than normal heart rate], and syncope [fainting]. If that dose is well tolerated, the dose may be increased to the previously therapeutic dose more quickly than recommended for initial treatment; https://clozaril.com/important-safety-information/- retrieved 05/23/24) Record review of a facility grievance dated 03/17/24 from Resident #1's RP and communicated to the DON reflected a concern with the resident's medication Clozapine not being dispensed. The DON and ADON C were assigned responsibility for the investigation and the findings determined the medication required a REMS form to be completed on the medication database. MD A had been unable to complete it and requested psyche to complete it. Psyche services were notified and stated they had been working on it. The result was new stat labs were ordered due to the labs being out of date range for the medication and had to be less than a week old for the medication to be approved through the pharmacy. The medication was noted as being received on 03/18/24 and given as ordered. An interview with the DON on 05/17/24 at 3:15 PM revealed it was her first week of employment when Resident #1 admitted to the facility. The DON stated that one night (date unknown), someone in the therapy department contacted her because during one of the therapy sessions earlier that day, Resident #1's RP called and said she was out of her Clozapine. The DON did not know how the RP knew the resident was out of her Clozapine but was able to verify it was true. The DON stated that with Clozapine, she found out that there was a national database where the physician had to go into the database and update the patient's information and ensure labs were completed within seven days of the prescription being filled. The DON stated MD A tried to get the order filled but could not log into the database and he thought MHMR was working on it because that was who had seen her prior to admission. The DON stated, So by the time he [MD A] told me, we thought maybe psyche services could help up. I called the NP and got stat labs done. The labs prior had been too far gone. The DON said she was not aware of the situation for about four days after the issue had been brought up from the RP, but she did an investigation on the issue and communicated with the RP. The DON stated going forward, At new admission, it is going to be a flagged and have a plan in place before we admit [a resident with a restricted medication]. An interview with the ADM on 05/17/24 at 3:29 PM revealed he had worked the grievance related to Resident #1 and the unavailability of her antipsychotic medication Clozapine. The ADM stated that prior to her admission, Resident #1 was in a rehab hospital where they decreased her dose. The RP was upset and disagreed, and felt it was impeding her therapy progress as a result. However, the rehab hospital had concerns that the dose was too high and felt she was more stable on a lower dose and at less risk for falls. The ADM stated when Resident #1 admitted to the facility, the medication Clozapine was not on her transfer orders so the RP tried to bring the medication from home and that was what the facility used until it ran out. The ADM stated ADON C was the person who would know more because she was the one trying to get in touch with the rehab hospital to see if they every administered Clozapine during her stay and why it was not on the transfer orders. The ADM stated, I do know when she was on the medication, she seemed to have more falls but her [RP] was certain it was holding her back by not getting it. An interview with ADON C on 05/17/24 at 9:45 AM revealed when Resident #1 admitted to the facility, she had a bottle of Clozapine but there was no order for it on the transfer orders from the rehab hospital. ADON C stated the facility did not inventory medications that residents admitted with because most of them are on cards/sheets and not loose in bottles so she did not know how many pills of Clozapine Resident #1 admitted with. She stated the day after admission, Resident #1's RP came to her office and said the medication was not listed on Resident #1's MAR. She contacted the rehab hospital who verified Resident #1 was supposed to be on it. Then ADON C added it to the MAR and put the sheet of Clozapine the RP had for Resident #1 on the medication cart to be administered, which was done until she ran out. ADON C stated when Resident #1 got down to her last pill of Clozapine, the charge nurse called the pharmacy for a refill, but they denied it because the resident did not have a current CBC lab with diff nor did she have an REMS form completed (a federally required risk management strategy document that can include one or more elements to ensure that the benefits of a drug outweigh its risks). ADON C stated she did not know what the REMS form was, Just something they [a doctor] have to do online. Then ADON C stated the charge nurse reached back out to MD A to see what he could do but he was not able to access the REMS form online. When ADON C left for vacation during that time frame, she said she returned back to work and the medication for Resident #1 was available and present in the facility. She was not sure, but thought the psychiatrist completed the form to get it filled. ADON C stated, We had to do a stat CBC with diff and then send it in. She was out [of Clozapine] quite a few days, over a week I believe. With that med, there could be a danger to suddenly stopping it like a change in state of mind or something. ADON C stated that while at the facility, Resident #1 had a lot of falls but she did not know when they started and felt she had done better without the Clozapine when it was not available as she was able to participate in more therapy. She did not feel like going without the medication did any harm to Resident #1. However, if she could have done things differently, the facility would have liked to know that medication required the REMS form and the current labs before the pharmacy would fill it. 2. Record review of Resident #2's Face Sheet (not dated) reflected she was an [AGE] year old female who admitted to the facility on [DATE] at 9:49 PM. Resident #2's active diagnoses included sepsis (a serious condition in which the body responds improperly to an infection), hypertension (when the pressure in your blood vessels were too high, congestive heart failure (a complex clinical syndrome characterized by inefficient myocardial performance, resulting in compromised blood supply to the body), cellulitis of left lower limb (a deep bacterial infection of the skin), acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood), pain, enterocolitis (an inflammation that occurs throughout your intestines) due to clostridium difficile, and depression (a depressed mood or loss of pleasure or interest in activities for long periods of time). Record review of Resident #2's admission MDS dated [DATE] reflected her BIMS score was 12, which indicated mild cognitive impairment. Resident #2 received antibiotic, antidepressant, diuretic, and opioid medications. Record review of Resident #2's May 2024 Physician orders reflected all medications were ordered by MD G on the date of admission (05/02/24) and included Buspirone 10 mg two tablets three times a day for depression, Gabapentin 300 mg three times a day for pain, Oxybutynin Chloride 5 mg three times a day for pain, Trazadone 150 mg once a day for depression, Venlafaxine 37.5 mg once a day for depression, and Hydroxyzine 25 mg three times a day on 05/03/24. Review of Resident #2's May 2024 MAR reflected she did not receive the following medications on 05/03/24 because they were documented as unavailable, the day after admission by MA D: -Buspirone (PM and HS doses) -Gabapentin (evening dose) -Oxybutynin Chloride (PM and HS dose) -Trazadone (daily dose) -Venlafaxine (daily dose) -Hydroxyzine (PM and HS dose) Record review of Resident #2's nursing progress notes at the time of admission on 05/02/24 through 05/03/24 reflected no documentation in the clinical chart to indicate the medications were not available and what follow up was being done by the facility. 3. Record review of Resident #3's Face Sheet (not dated) reflected she was a [AGE] year old female who admitted to the facility on [DATE] at 5:12 PM. Resident #3's active diagnoses included pleural effusion (a buildup of fluid between the layers of tissue that line the lungs and chest cavity), pneumonia (an infection in the lungs caused by bacteria, viruses, or fungi), acute respiratory failure with hypoxia (a condition where there was not enough oxygen in the tissues of the body), chronic pancreatitis (prolonged abdominal pain with intermittent pain-free periods, weight loss, and relief of abdominal pain when leaning forward), end stage renal disease (kidneys cease functioning on a permanent basis), pain, depression (a depressed mood or loss of pleasure or interest in activities for long periods of time), anxiety (a feeling of fear, dread, and uneasiness), atrial fibrillation (a type of arrhythmia, or abnormal heartbeat), and hypertension (when the pressure in your blood vessels is too high). Record review of Resident #3's admission MDS dated [DATE] reflected a BIMS score of 10, which indicated moderate cognitive impairment. Resident #3's MDS reflected she did not take any high-risk medications. Record review of Resident #3's May 2024 Physician orders reflected all medications were ordered by MD G on the date of admission (05/09/24) and included Calcitriol, Calcium Acetate, Cholestyramine Light powder 4 gram three times a day for chronic pancreatitis, Creon (lipase-protease-amylase) capsule delayed release one capsule orally three times a day for chronic pancreatitis, Culturelle one capsule once a day for chronic pancreatitis, Donepezil 5mg once a day for anxiety, Eliquis 2.5 mg twice a day for atrial fibrillation, Latanoprost one drop once a day for lack of coordination, and Budesonide suspension for nebulization 0.5 mg/2 mL one tab inhalation once a day for pneumonia. Review of Resident #3's May 2024 MAR reflected she did not receive the following medications because they were documented as unavailable on 05/10/24, the day after admission: -Calcitriol (daily dose) -Calcium Acetate (AM, PM, and HS dose) -Cholestyramine Light powder (AM and PM dose) -Creon (AM, PM, and HS dose) -Culturelle (daily dose) -Donepezil (daily dose) -Eliquis (PM dose) -Latanoprost (daily dose) -Budesonide suspension for nebulization (daily dose) Record review of Resident #3's admitting nursing progress note dated 05/09/24 reflected the resident came from the hospital and admitted with a diagnosis of shortness of breath related to pneumonia and medications were verified. There was no documentation in the clinical chart to indicate the medications were not available and what follow up was being done by the facility. 4. Record review of Resident #4's Face Sheet (not dated) reflected she was a [AGE] year old female admitted to the facility on [DATE] at 7:31 PM. Resident #4's active diagnoses included metabolic encephalopathy (problems with the metabolism cause brain dysfunction), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), gastro-esophageal reflux disease (when stomach contents move up into the esophagus), constipation (difficult time passing stool), osteoarthritis (degenerative joint disease), acute kidney failure (when the kidneys become unable to filter waster from the blood), pain, hypertensive urgency (marked elevation in blood pressure), hypothyroidism (when the thyroid does not create and release enough thyroid hormone into your bloodstream), and hyperlipidemia (an elevated level of lipids/fats in the blood). Record review of Resident #4's admission MDS dated [DATE] reflected it was still in progress and being finalized. Review of Resident #4's May 2024 Physician orders reflected the following medications were ordered by MD B on the date of admission (05/09/24) and included Carvedilol 25 mg twice a day for hypertensive urgency, Culturelle one capsule once a day for GERD, docusate sodium [OTC] capsule 100 mg twice a day for constipation, Ezetimibe 10 mg once a day for hypertensive urgency, Isosorbide mononitrate extended release 30 mg once a day for hypertensive urgency; Losartan 100 mg once a day for hypertensive urgency, Montelukast 10 mg once a day for asthma, Quetiapine Fumarate/Seroquel 25mg once a day for metabolic encephalopathy, Rosuvastatin 20 mg once a day for hyperlipidemia, Premarin (conjugated estrogens) 0.5 gram once a day for kidney failure, Symbicort 2 puffs inhalation twice a day for morbid obesity. Review of Resident #4's May 2024 MAR reflected she did not receive the following medications because they were documented as unavailable on 05/10/24, the day after admission: -Carvedilol (PM dose) -Culturelle (daily dose) -Docusate sodium (PM dose) -Ezetimibe (daily dose) -Isosorbide mononitrate (daily dose) -Losartan (daily dose) -Montelukast (daily dose) -Quetiapine Fumarate/Seroquel (daily dose) -Rosuvastatin (daily dose) -Premarin (daily dose) -Symbicort (AM and PM dose) Record review of Resident #4's admitting nursing progress note dated 05/09/24 reflected the resident came from the hospital at 7:45 pm and had a marked increase in delirium and was very confused with ESBL so she was on contact isolation and aspiration precautions. There was no documentation in the clinical chart to indicate the medications were not available and what follow up was being done by the facility. 5. Record review of Resident #5's Face Sheet (undated) reflected was an [AGE] year old female admitted to the facility on [DATE] at 9:11 PM with active diagnoses that included pneumonia (an infection in your lungs caused by bacteria, viruses or fungi), respiratory failure with hypoxia (when there is not enough oxygen in the blood), bronchitis (inflammation of the lining of bronchial tubes, which carry air to and from the lung)and allergic rhinitis (stuffy nose). Record review of Resident #5's admission MDS assessment dated [DATE] reflected her BIMS score was 10 which reflected moderate cognitive impairment. Resident #5 did not have any special respiratory treatments or procedures prior to or during the assessment period. Record review of Resident #5's current physician's orders for May 2024 reflected a prescription for Flonase Allergy Relief OTC spray/suspension; 50 mcg/actuation one spray each nare once a day for allergic rhinitis (start date 03/25/24 open ended). Record review of Resident #5's March, April and May 2024 MARs reflected that since the day after admission on 03/26/24 through 05/17/24, her medication Flonase was not given per physician's orders. The statement documented on the MAR entries for those administrations were, Not Administered: Drug/Item unavailable-Comment: Waiting on Pharmacy C/N Notified. Record review of Resident #5's nursing notes from date from 03/26/24 through 05/17/24 reflected no documentation that Flonase was not available and what follow up was being done by the facility. 6. An interview with the DON on 05/17/24 at 3:15 PM revealed when a resident admitted to the facility, the medication transfer orders came from the hospital and the accepting charge nurse at the facility notified the facility physician that had been assigned to the resident. Then the charge nurse would notify the pharmacy to get the medications delivered. The pharmacy delivered medications to the facility on ce a day in the afternoon, but the DON was not sure. She stated the pharmacy would also do stat deliveries which was four hours 24/7. The DON stated she had never had any issues with the pharmacy delivering medications on time for the residents. The DON stated there was in E-kit as well if there was going to be delay in pharmacy delivery for certain medications such as pain medications. If that occurred, the charge nurse had to call the pharmacy, get a code and then could retrieve the medication from the E-kit. If a resident admitted to the facility and the pharmacy had already come out for the day and the medication was not available in the E-kit, the DON stated, We would just call and notify them [pharmacy] and arrange for them to deliver or we can call [local drug store pharmacy] to get them delivered. The DON stated the ADONs were supposed to check the residents' MARs in the mornings and they should be looking for medications that were not administered late and address it. She said the medication aides or nurses were supposed to contact the pharmacy for a refill when a resident was down to their last five or seven doses. The DON stated if a medication was not able to be filled, the charge nurse was supposed to contact the physician to either put a hold on the medication or find out what an alternative was. An interview with ADON C on 05/20/24 at 9:45 AM revealed many of the medications not available to be administer were for the residents who were new admissions. ADON C stated, They come in at 6:00PM and the nurses put orders in at 8:00 PM for bedtime, but don't always start it until the next day. She said the pharmacy came at midnight and medications for those new admissions were usually available the next morning. ADON C stated the pharmacy made routine deliveries twice a day, one around six in the evening and another after midnight. She stated whatever was ordered after 2 pm, came with the overnight delivery around midnight and were able to be given the following day. ADON C stated there were no morning or afternoon pharmacy deliveries to the pharmacy. With the medication aides, ADON C stated if the medication was not available during their med pass, they were supposed to tell the charge nurse and then document it was not available. Then the charge nurse was supposed to go to the E-kit to see if the medication was available. If that medication was not available in the E-kit, the nurse had to call the pharmacy and have them send out the prescription as soon as possible. ADON C stated the fasted time frame the pharmacy could deliver was for a stat request which was two to four hours turnaround time. ADON C stated for the new admissions, a lot of times the DON or the MDS Coordinator would look at the new admissions pending and send clinicals out to the nursing management team, but ADON C said she did not always look at them. She said the facility did not order medications until the residents actually admitted because the orders could change. ADON C stated the facility got the transfer orders when the resident arrived and the charge nurse contacted the assigned physician to get clarification and then entered the orders into the system on the MAR. An interview with the C-RN on 05/20/24 at 10:00 AM revealed once the charge nurse entered in an order in the system on the MAR, they system automatically sent it to the pharmacy. If it was after hours and had to be stat delivered, the charge nurse just had to call the pharmacy and tell them to deliver it stat. An interview with the ADM on 05/20/24 at 10:05 AM revealed after investigator intervention, the facility had in-serviced all the medication aides and nurses on medication administration and pharmacy procedures. He stated they went over the five rights of medications, E-kits and how to access it, and talked to the medication aides about what to do when a medication was not available and to notify the nurse, and for nurses to contact the pharmacy and how to get over the counter medications when they were not available. The ADM for OTC meds, there was a central supply staff who had a list of needed OTC meds (such as Resident #5's Flonase) and all the nurse or med aide had to do was write the medication on the list and he could go out and purchase it immediately. An interview with MA D on 05/17/24 at 12:13 PM revealed the medication aides were responsible for ensuring the residents medications did not run out. MA D stated, We want to pay attention to how many pills are left and how many sheets (blister packs) and there was a re-supply order button on the e-MAR and then you report it to the nurse. MA D stated when medications ran low, she tried to notify the charge nurse a day or two before it ran out and the med aide could reorder it via the e-MAR as long as there was a prescription rx number. If there was no rx number available, the charge nurse had to handle the refill or the ADON. MA D stated if a medication continued to not be available, the med aide was supposed to keep following up with the charge nurse and if necessary, get the ADON involved. MA D stated the potential harm of a resident not having medication available, Could be that what the medication is for is not going to be effective. MA D stated for new admission, what she had learned was the charge nurse was supposed to give the initial dose, not the medication aide. With over the counter medications not available, MA D stated the charge nurse was supposed to contact the physician and see if he could write/change the order to one they had as a house stock (already in house) because certain medications were usually expensive for one person when you can use the house stock and it is the same. For example, MA D stated for Resident #3's order for Culturelle which was a probiotic, the facility did not usually supply it because it was so expensive and the house stock medication that did the same thing was called Acidophilus and that was why did not have it initially available to give to her. MA D stated she thought they got that figure out and she was getting the medication now. With the new admission of Resident #2, MA D stated the charge nurse should have checked the E-kit if the medications were not available from the pharmacy in time, and then if they were not there, the charge nurse should notify the ADON. MA D stated, But the nurse really should have handled it. It is all on the nurse, if I was a nurse, I would have written a note and asked for help. An interview with MA E on 05/17/24 at 12:46 PM revealed the medication aides were responsible for re-ordering medications on already existing prescriptions if they were a scheduled dose, but there were some medications the system would not let them order. When that happened, the medication aide was supposed to notify the charge nurse who would re-order it. MA E stated the potential harm of a resident running out of or not having medications available could be that they may get agitated. MA E stated medications were supposed to be re-filled when a resident got down to their fourth pill. If a resident needed an OTC medication that was not available on admission, there were other options to use from the house stock from central supply, so the med aide just had to let the charge nurse know and they would get authorization from the physician. MA E stated the charge nurse was supposed to give the first dose of all medications for new admissions, so if the medication was not available, the charge nurse would know and would be responsible to handle it. An interview on 05/17/24 at 1:03 PM with LVN F revealed the charge nurse was supposed to handle all new admissions and the latest to put in a new order for pharmacy delivery same day was by 5 PM. After 5 PM the pharmacy would not send it out until the following day anywhere from 10 PM to one in the morning (over 24 hours wait time), It is a long wait. LVN F stated there were no morning pharmacy deliveries so if the medication did not come in during the night from 10pm-2am, then they would have to wait until the next overnight delivery. She stated stat meds, however, could be requested and delivered with two to four hours any time of the day and a stat med was determined by the ADONs and DON. For OTC meds not available, LVN F stated the nurse would have to get an order from the physician to change it to an in-house stock supply. LVN F stated the potential harm to a resident of not having prescription medications available were, Plenty in rehab section, so many surgeries so there are blood clots, also pain, seizures and heart attacks if we don't give it and unnecessary suffering because some patients are so aware of their medications and they suffer emotionally feeling like we are not taking care of them. When a medication was not available, LVN F stated the charge nurse was supposed to document it in the clinical chart under a nursing note. LVN F stated, Unfortunately it doesn't happen very[TRUN