Every finding on record at The Peaks Health & Rehabilitation

Based on observations, staff interviews and policy review, the facility failed to ensure expired food items in the kitchen were discarded, food items were dated and stored correctly. The deficient practice could result in possible food-borne illnesses and unwanted pests. Findings include: An initial kitchen observation was conducted on February 10, 2026 at 11:11 a.m. with the Dining Services Director (Staff #15). At this time an observation of the main kitchen refrigerator was conducted with Staff #15, the following was observed;Twenty small bowls with corn salad on a baking sheet uncovered with no dates or labelsLarge clear container with cantaloupe and honeydew open and exposed to airClear containers with peeled mandarins in liquid (x2) open and exposed to airRoughly, half of a chocolate sheet cake with chocolate frosting with no observed dates or coverDiced ham and corned beef wrapped in plastic wrap with no labels and a use-by date of January 27, 2026 written in black marker Clear plastic bag with 2-3 heads of romaine open and exposed to air and no dates found Half of a 10-pound box of Smithsville sausage patties open with no open date or expiration date visible. An interview was conducted on February 10, 2026 at 11:11 a.m. during the refrigerator observation with Staff #15. Staff #15 stated that foods in the fridge should be covered and labeled with their preparation dates. Staff #15 stated that the kitchen staff do not put the expiration date on the foods as the staff know when they should be thrown out. Staff #15 further stated that the risk associated with uncovered food could lead to the spread of food-borne illnesses. An observation was conducted on February 10, 2026 at 11:28 a.m. of the main freezer unit with Staff #15. The following was observed; Seven frozen burgers, with greyish patches and large ice crystals on the patties, showing freezer-burned appearance and loose sliced carrots in an open clear plastic bag Roughly, two pounds of frozen fish sticks in a clear plastic bag open and exposed to airSeven frozen chicken patties in a clear plastic bag open and exposed to airClear plastic bag of onion rings open and exposed to airAn observation was conducted on February 10, 2026 at 11:33 a.m, of the dry food storage with Staff #15, the following was observed; [NAME] container with clear lid storing rice open and exposed to air. Three pieces of paper and dried rice littered the ground surrounding the container [NAME] and tan small crumb-like granules, on top of canned vegetables A clear container with lemons and oranges some of the fruit was observed to have green/white fuzzy material on them. An interview was conducted on February 10, 2026 at 11:33 am with Staff #15. Staff #15 stated the kitchen staff usually do a large clean-out on the day that the truck comes in which is weekly. Staff #15 stated that the risks associated with food not being stored properly could lead to insects and rodents. An observation was conducted on February 11, 2026 at 11:07 a.m. of the resident food storage refrigerator with an agency registered nurse (RN/Staff #99). The Resident food refrigerator is located in one of the supply storage rooms. The refrigerator has a sign on the front indicating no left-overs are allowed in this refrigerator and everything must be labeled accordingly. The freezer was observed to have an unopened box of store-bought frozen fried rice with no room number, date, or label visible and two ice packs. The refrigerator contained two black lunch boxes inside on the bottom shelf which included no name, date, or room number. The refrigerator also contained a white plastic bag with two unopened yogurt containers inside dated February 16, 2026 with a resident room number. An interview was conducted on February 11, 2026 at 11:07 a.m. with Staff #99. Staff #99 stated one of those lunch boxes was hers and management instructed her to store her food here. Staff #99 stated she cleaned the refrigerator and freezer herself yesterday as it was dirty and she did not want to store her food there. Staff #99 stated she does not know who is responsible for the cleaning or what the process is. Staff #99 stated she does not know where the break room is. An interview was conducted on February 11, 2026 at 11:51 a.m. with Staff #15 and a registered dietician (Staff #31). Staff #31 reiterated that the reason the staff do not write the use by date on the opened food is because the staff know when to dispose of it. Staff #31 pointed to a piece of paper posted on a corkboard between the refrigerator and freezer, which indicated how long groups of foods are good for after opening. Staff #31 stated staff know where to find this paper. An interview was conducted on February 12, 2026 at 10:36 a.m. of kitchen cook (Staff #117) who stated the meals, including puree's, were being prepared for Skilled Nursing Facility (SNF) residents in this kitchen. An interview was conducted on February 12, 2026 at 10:36 a.m. with Staff #15. Staff #15 stated all food for the SNF gets made and prepped in the same kitchen as the assisted living, indicating there is no separation between the kitchens. Staff #15 stated once the food is made it gets transferred to the metal pans and transported via hotbox to the assigned halls and is plated and served by the SNF servers as residents come in. Staff #15 stated this process helps keep the food to proper temperatures. Staff #15 stated during the puree preparation, the order gets hung up by the blender on the other side of the cooking line and the therapeutic diet is prepped here. Review of the Date Marking for Food safety policy last reviewed on August 26, 2025 revealed food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded (use-by-date). The policy further revealed, the cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall be discarded accordingly.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to properly monitor and supervise the whereabouts of one resident (#28). The sample size was 12 and the universe was 43. The deficient practice could result in physical, mental, and/or psychosocial harm. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that include crushing injury of left foot, subsequent encounter, other fracture of left foot, subsequent encounter for fracture with routine healing, difficulty in walking, not elsewhere classified, and dependence on renal dialysis. Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #28 had a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the MDS revealed Resident #28 used a wheelchair and walker, required supervision for personal care activities, and required moderate assistance with transfers. Further review of the MDS revealed Resident #28 received hemodialysis and had central intravenous (IV) access. Review of the MDS revealed Resident #28 had dressings applied to his left foot. Review of the comprehensive care plan initiated on December 29, 2025 revealed a focus for potential for falls related to crushing injury on left foot with multiple fractures with non-weight bearing on lower left extremity and presence of a wound vacuum. Interventions included educating and providing cues, prompts, and reminders regarding safety precautions as needed and Fall Risk Assessment on admission and Quarterly. Update interventions as appropriate as the resident's condition changes. Further review of the care plan revealed a focus for requiring assistance with activities of daily living (ADLs) due to weakness and pain. Interventions included, using a manual wheelchair, stand-by assist to partial assist for transfers, and assist with ADLs as needed. Review of a Nursing - admission Evaluation dated December 27, 2025 revealed that Resident #28 was a high fall risk and was noted to have a weak gait. Further review of the admission evaluation revealed fall prevention measures in place which included frequent checks by staff. Review of a discontinued physician order revealed an order for, may go out on pass today (2/3/26), with an order start date of February 3, 2026. There was no evidence of documentation in Resident #28's medical records regarding the resident leaving the facility per the physician order.Review of a progress note dated February 3, 2026, at 3:16 p.m., revealed that staff made several attempts to contact Resident #28 regarding his return to the facility after being cleared to go out on pass to fix his phone, per day shift report. The note further indicated that the staff member had not been made aware that Resident #28 had not returned to the facility. The Director of Nursing, Administrator, and Nurse Manager were notified, and day shift will follow up in the morning.Review of a progress note dated February 4, 2026 at 7:16 a.m. revealed staff had made contact with Resident #28's sister and told the facility she would call her siblings to try to locate Resident #28 and follow-up with the facility. Review of a progress note dated February 4, 2026 at 7:46 a.m. revealed that staff made contact with Resident #28's sister and the sister was unaware of Resident #28's whereabouts or why he had not returned. The progress note further revealed that staff had asked Resident #28's sister to try to locate him as he had appointments to attend. Review of a progress note dated February 4, 2026 at 9:10 a.m. revealed Resident #28 had returned to the facility at 8:45 a.m. with no issues or problems noted during his leave of absence.An interview was conducted on February 10, 2026 at 2:06 p.m. with Resident #28. Resident #28 stated he never learned the rules of the facility regarding visitation, leaving the facility, or going home. Resident #28 stated he had asked the admission staff and they had directed him to social services, with no luck. Resident #28 stated he had gone out for lunch at the casino with a friend the weekend prior and had decided to stay the night while he was out. Resident #28 stated he called the front desk multiple times with no response and eventually left voicemails indicating he would not be returning until the next morning. Resident #28 stated upon his return the staff told him he was not supposed to do that and they had no idea where he was. Resident #28 stated he wished he would have known about the process. An interview was conducted on February 12, 2026 at 12:37 p.m. with an agency licensed practical nurse (LPN/Staff #80). Staff #80 stated since he is a newer employeehe will always refer to the provider if a resident may go out on pass. Staff #80 stated temporary leave requests can be made by the resident or the resident's family member, but require a physician's order. Staff #80 further stated that the order should explain the date and the estimated time of leave and return. Staff #80 stated if a resident has not returned within the expected timeframe he would talk with staff, search the facility, notify the provider and appropriate managers. Staff #80 stated he would not want to leave the facility knowing the resident had not returned and would most likely notify the police department. Staff #80 stated the potential harm could include missed medications, missed rounding, and the potential for serious harm. An interview was conducted on February 12, 2026 at 1:13 p.m. with a certified nursing assistant (CNA/Staff #6). Staff #6 stated she receives a piece of paper from the receptionist that explains which residents are going out on leave and the paper includes why they are leaving Staff #6 stated these papers are passed out the day before and are shredded at the end of the day. Staff #6 stated if a resident has not returned within the expected timeframe, she would report to the nurse and the nurse would take it from there. Staff #6 further stated she would include information on the missing resident to the oncoming CNA. Staff #6 stated that she checks on residents every two hours, keeping an eye on residents, and notifying the nurse of changes, which is included in their training to minimize the risk of missing residents. An interview was conducted on February 12, 2026 at 1:35 p.m. with the SNF receptionist (Staff #103). Staff #103 stated she is responsible for scheduling medical and non-medical appointments as well as the necessary transportation which includes coordinating with family members. Staff #103 stated that residents and family members are required to complete an entry in the logbook before going out on leave. Staff #103 stated the book includes the resident name, the person signing them out, a phone number, and leave/return time. Staff #103 stated the sign-out book is kept at the front desk, however, clinical staff have access to it when she is unavailable. Staff #103 stated that nurses will also take the logbook to have residents sign out which means she cannot always verify the information given before a resident leaves. Staff #103 stated that the facility doors lock at 5:00 p.m. Staff #103 stated the nurses carry cell phones, and the phone numbers are provided to family members and residents so they can contact the facility if needed. Staff #103 further stated she was not informed that Resident #28 had not returned and did not see the voicemail from Resident #28 until the following morning, at which time Resident #28 had already returned.Review of the resident off unit sign-in and sign out book for the dates of December 27, 2025 through February 10, 2026 revealed Resident #28 had signed out on February 3, 2026 at 11:00 a.m. and no evidence of a return time, responsible party name, or contact information.An interview was conducted on February 12, 2026 at 3:19 p.m. with the Director of Nursing (DON/Staff #120). Staff #120 stated the clinical staff must be notified in advance when a resident wants to go out on leave because the staff must notify the provider and obtain an order if the resident is deemed safe to leave. Staff #120 stated the provider order should be specific and include the date of the approved leave. Staff #120 stated she expects staff to get clarification from the provider if the order is unclear. Staff #120 stated that staff should obtain the contact information of the person who signed the resident out and the resident or family should notify staff of their expected return. Staff #120 stated if a resident has not returned within the expected timeframe, staff should attempt to contact the responsible party and the resident to get information of their expected return and provide education, if needed. Staff #120 further stated if staff cannot reach the responsible party or resident, the police and executive director should be notified; however, regarding Resident #28, there was no evidence in the electronic health record documentation that the police were notified.On February 12, 2026 at 3:25 p.m. a review of the medical record for Resident #28's was conducted in conjunction with Staff #120. Staff #120 stated the provider's order does not indicate the expected time frame of leave. Staff #120 stated there is no documentation in the medical record of Resident #28's departure time and expected return and further stated staff are expected to document that information. Staff #120 stated she received a text message at 12:00 a.m. but did not see the message until next morning, and stated staff should have called her when she did not answer. Staff #120 stated that since Resident #28 had not been accounted for, the nursing staff should have contacted the police. Staff #120 stated that families are given the nurses phone numbers and indicated it is her expectation to provide the nurses phone numbers to a cognitively intact resident. Staff #120 stated that she should have notified the state agency of the incident. Staff #120 stated there is a danger to the resident and something unknown could happen to the resident if staff are not aware of their whereabouts. Review of the Therapeutic Leave policy, last reviewed on January 1, 2026 revealed therapeutic leave to be defined as a resident absence for purposes other than hospitalization. Review of the therapeutic leave policy revealed the facility will coordinate with the resident and/or representative the length of time the resident will be gone to ensure that adequate amounts and appropriate medication is ready for administration while on the leave, education is given about the administration of medications, treatments and any other pertinent information, and any equipment is ready prior to the therapeutic leave. Further review of the policy revealed the facility will document in the medical record the resident's leave of absence, any medications sent with the resident, and any education given to the resident and/or representative prior to the leave. Review of the Elopement Risk Evaluation policy last revised October 10, 2025 revealed elopement is defined as a resident leaving the premises or a safe area without authorization and/or any necessary supervision to do so. Further review of the policy revealed the procedure for locating a missing resident which includes the following steps; alert facility personnel, conduct a search for the resident, administrator or designee will notify the police department and serves as the liaison between police and facility, notify the corporate office, notify the physician and family/legal representative, provide description of resident to the police, notify all parties of the outcome once the resident is located, and complete appropriate reporting requirements to the state survey agency. Review of the elopement policy revealed staff document the elopement incident and interventions in the resident's medical record.

Based on observation, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one medication cart was locked when unattended. The deficient practice could result in residents, visitors, or other staff members having unrestricted access to medications.Findings include:An observation was conducted on February 11, 2026, at 8:55 AM which revealed a medication cart was left unlocked with no nurse in the area to attend to the cart. An interview was conducted on February 11, 2026, at 8:59 AM with a registered nurse (staff #99), when staff #99 returned to the cart. Staff #99 stated that the cart was left unlocked. She further stated that this was not normal and medication carts should not be left unlocked and that risks would include that anyone can have access to the medications in the cart. An interview was conducted on February 12, 2026, at 1:29 PM with a registered nurse (staff #325). Staff #325 stated that the process regarding medication carts included that the cart is locked when unattended. She further stated that risks included that someone could have access to someone else's medications, including narcotics, and a result would be possible allergic reactions. An interview was conducted on February 12, 2026, at 2:03 PM with the Director of Nursing (staff #120). Staff #120 stated that the expectation is medication carts are locked and that this would be included in safety measures taken during medication administration. Staff #120 further stated that risks include residents could ingest medications that are contraindicated to their medical condition, or that residents could poke themselves or other with needles. Review of the policy titled, Accident Prevention and Supervision, revealed that facility policy includes, The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. The policy further states that a. All staff are to be involved in observing and identifying potential hazards in the environment. and, c. Various sources provide information about hazards and risks in the resident environment.

Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#5). The deficient practice could lead to an allegation of abuse not being investigated by all mandated entities timely, resulting in possible ongoing abuse to a resident.-Findings include:Resident #5 was admitted to the facility February 29, 2024, with diagnoses that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following unspecified cerebrovascular disease, bipolar disorder, dysarthria, and acquired absence of right leg above knee.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had a brief interview for mental status (BIMS) score of 10, indicating moderate cognitive impairment. Section E revealed no potential indicators of psychosis and no behavioral symptoms were present.A care plan dated March 13, 2024, revealed Resident #5 is at risk for impaired cognitive function or impaired thought processes due to expressive aphasia following cerebrovascular accident.An additional care plan dated March 13, 2024, revealed the resident is at risk for communication problem due to expressive aphasia and dysarthria following cerebrovascular accident.There was no evidence of a care plan or interventions to address a potential behavior of the resident making abuse allegations.A facility self-report submitted to the State Agency on December 12, 2024, revealed that on December 12, 2024, Resident #5 alleged that a male (possibly plural males) have hit him on the back while he is using the toilet or in the shower. The resident is unspecific as to person, place, or time.A Clinical Note dated July 1, 2025, revealed Resident #5 had difficulty breathing and thick white sputum. The provider was contacted, and an order was given to send the resident to the emergency room.A Provider Note dated July 7, 2025, revealed Resident #5 was readmitted to the facility July 6, 2025. The resident was treated in the hospital for aspiration pneumonia. While in the hospital, the resident reported that he was being sexually abused. Per the documentation, the resident has reported a different history to different staff members. Sexually transmitted infection screening was negative. Social services was consulted for assistance with next steps, and additionally, the resident has not made this allegation to anyone at the facility.There was no evidence that the facility reported Resident #5's abuse allegation to mandated reporting sources including the police, the ombudsman, adult protective services, or the State Agency.A written statement by a Speech Language Pathologist (Staff #29) dated July 8, 2025, revealed regarding Resident #5's complaint of possible sexual abuse at the facility, recent documentation from the hospital reports the resident made it sound like it was staff versus two other providers, and he has said that a different resident attempted to sexually abuse him. Additionally, the statement revealed I have worked with the above patient in speech therapy for over a year and the resident has a history of a previous cerebrovascular accident (stroke) with resulting dysarthric speech characteristics, decreased speech intelligibility, expressive aphasia, and memory impairments. The resident has mentioned above issues various times during therapy sessions with significant inconsistencies in information. He has been observed to give differing information to different people/staff members regarding this topic.An additional written statement by the Social Services Director (Staff #30) dated July 8, 2025, revealed regarding the discussion with Resident #5 regarding rape allegation at the hospital, that Resident #5 stated he was raped at this facility by a white man in he hall maybe 5 months ago, he could not recall the exact conversation he had with hospital staff on July 2, 2025. He stated it has happened in the past unsure as to the date, time, or place. The resident was unable to describe anyone who may have participated other than a white male, and unsure if the white male was a resident or staff member. The resident denies physical injury.A formal request was submitted to the facility on July 10, 2025, at 12:03 PM, for a full facility investigation regarding Resident #5's allegation of abuse in July 2025, and to include any evidence of submission of mandated reporting to the State Agency.The facility administrator signed a statement dated July 10, 2025, that revealed Resident #5 made no complaint or allegation to the facility regarding any physical or sexual abuse. On July 2, 2025, the hospital called the facility Social Services Director and stated that Resident #5 complained that he was sexually abused at the facility, and that the hospital was reporting the incident to adult protective services. Upon the resident's return to the facility, the Social Services Director asked Resident #5 about the statement made to the staff at the hospital. Resident #5 stated that it was about 5 months ago. On December 12, 2024, Resident #5 reported physical abuse and then recanted his statement when the police arrived to question him.An interview was conducted with a Certified Nursing Assistant (CNA / Staff #11) on July 10, 2025, at 11:04 AM. Staff #11 stated that she works with Resident #5, and that she has never heard the resident make any allegations or accusations, and if she did, that she would report it to management.An interview was conducted with a CNA (Staff #41) on July 10, 2025, at 11:13 AM. The CNA stated that he has not heard Resident #5 make any accusations or allegations since he has worked with him.An interview was conducted with a CNA (Staff #50) on July 10, 2025, at 11:16 AM, who stated that she normally works the unit with Resident #5, and that she has never heard the resident make any accusations or allegations.An interview was conducted with the Director of Nursing (DON / Staff #80) on July 10, 2025, at 11:18 AM. The DON stated that if there is an allegation of abuse, then the facility reports the allegation to the administrator immediately, and to mandated entities within 2 hours. Regarding Resident #5, the DON stated that she was made aware that the hospital called the facility and informed that Resident #5 made an allegation of rape from a staff or a resident while at the facility. The DON stated that she was not aware that the allegation was reported to mandated entities by the facility but that she believed it was reported, and that the DON was not involved in any part of an investigation conducted by the facility.An interview was conducted with the Social Services Director (Staff #30), on July 10, 2025, at 11:25 AM. Staff #30 stated Resident #5 made a report of a physical abuse allegation around December of last year (2024), and that the police were called, and that the resident kept changing his story. Staff #30 stated that she was notified of a call from the hospital regarding Resident #5, and returned the call to the hospital case manager on July 2, 2025. The hospital case manager stated that the resident told the hospital staff multiple stories alleging rape while at the facility. Staff #30 stated that the hospital staff said that they were going to report it (the allegation) to a mandated entity. Staff #30 stated that the resident re-admitted to the facility over the weekend, and on Tuesday (July 8, 2025), Staff # 30 went to the resident's room to talk to him about the allegation. Staff #30 stated that Resident #5 said that yes he talked to the hospital about the rape allegation, and that he said he was pushed outside and raped, and that it occurred at 8:00 AM today (July 8, 2025), and that he was pointing to indicate it happened in the hallway, and it was a white man. Additionally, Staff #30 stated that Resident #5 stated it happened in his room and outside.An interview was conducted with the Administrator (Staff #3) on July 10, 2025, at 12:51 PM. The Administrator stated that the Social Services Director (Staff #30) stated that Resident #5 reported while he was at the hospital, that he was abused at the facility, and that the hospital staff said they were reporting it. The Administrator stated that when the resident returned to the facility, the facility's investigation started. The Administrator stated that the facility did not report the allegation of abuse to mandated entities because the hospital staff said they were reporting it.Review of the facility policy titled Abuse, Neglect, and Exploitation, revised June 21, 2019, revealed each resident has the right to be free from abuse, including verbal, sexual, physical and mental abuse, neglect, corporal punishment, involuntary seclusion, misappropriation of property, exploitation, and any physical or chemical restraint not required to treat the resident's medical symptoms. Anytime that the nursing facility receives an allegation of abuse, the facility must comply with the reporting and investigation procedures set forth in this policy and with any state-specific policy and take steps to prevent further potential abuse. Sexual Abuse is non-consensual sexual contact of any type with a resident. Anyone with knowledge or concerns about the care of a resident in the facility must report suspected abuse to the Facility administrator, abuse agency hotline or file a complaint with the state survey agency and adult protective services (if applicable under state law) immediately (but not later than 2 hours after an allegation is made if the events that lead to the allegation involve abuse or result in serious bodily injury) or not later than 24 hours if the events that lead to the allegation do not involve abuse and do not result in serious bodily injury. Reporting and investigation should be in accordance with state law/regulation.

Based on staff interview, review of facility documentation, and policy, the facility failed to ensure that facility documents regarding grievances, reportables and resident council meeting minutes were available. The deficient practice could result in documentation regarding residents' issues and concerns pertaining to life and safety not being readily available. Findings include: The copy of the December 2023 self-reports and investigations, December 2023 grievance logs, and December 2023 Resident Council Meeting Minutes was requested from the facility on January 29, 2025 at 8:24 a.m. An email from the Executive Director (ED/staff #96) was received on January 29, 2025 at 10:13 a.m. The email stated that they are unable to locate the December 2023 reportables, grievance logs, and resident council meeting minutes. During an interview with the Interim Director of Nursing (Interim DON/staff #100) conducted on January 29, 2025 at 4:55 p.m., staff #100 stated that they did not know how long they have to keep documentation such as grievances or resident council meeting minutes. The Interim DON noted that the importance of maintaining documents is to be able to track them for investigators and to document the care that the facility provided. Staff #100 stated it is important documentation for residents. According to staff #100 the impact of not maintaining documentation is that the facility would not have support for their claims, they would not be able to track the care or interventions provided during the resident's stay. An interview with the Executive Director (ED/staff #96) was conducted on January 29, 2025 at 4:56 p.m. The ED stated that his expectation is that documentation is accurate, time and inclusive of all pertinent information. Staff #96 said that he expects for documentations/records to be retained on file within the required timeframe. The ED noted that the importance of maintaining documentation/records is to ensure that it is easily accessible. The impact of not maintaining documentation/records is that when it is requested by an agency it is not available and would not be able to provide accurate systems in place. The facility policy titled All Department Record Retention Policy and Schedule with a review date of January 11, 2024 indicated that the facility will maintain records for the appropriate time period as required by federal and state law and regulations. The policy included a record retention schedule. The retention schedule indicated that for resident complaint report (grievance) the retention period is permanent/electronic. The retention period for Committee Minutes is [AGE] years. While the retention period for all correspondence with Department of Health is permanent.

Based on observations, staff interviews, and review of facility policy, the facility failed to ensure that care and services met professional standards of practice regarding medication administration for one of six sampled residents (#3). The deficient practice could result in residents not receiving the appropriate medication and for additional errors in medication administration. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease. Review of physician order summary revealed the following active orders: -Ascorbic Acid (supplement) tablet 500 milligrams (mg) give two tablets by mouth one time a day for supplement; -Bupropion hydrochloride (antidepressant) ER (extended release) give 150 mg orally in the morning for mood disorder; -Levothyroxine (thyroid hormone) 50 mcg (microgram), take one tablet by mouth once daily in the morning and to take one hour before a meal on an empty stomach for hypothyroid; -Atorvastatin Calcium (anticholesterol) oral tablet 40 mg give one tablet orally in the morning for hyperlipidemia; -Oxybutynin chloride ER (anticholinergic) tablet 10 mg, give one tablet by mouth in the morning for overactive bladder (OAB); and, -Metoprolol Succinate ER (beta blockers) oral tablet 25 mg, give 0.5 tablet by mouth one time a day for congestive heart failure (CHF). During a medication administration observation conducted with a Registered Nurse (RN/staff #8) on November 6, 2024 at 7:23 a.m., the RN dispensed one ascorbic acid 500 mg tablet into a medication cup; however, the physician's order indicated two tablets. While dispensing the medication the RN was interrupted by a NP to look up another resident's orders and put in orders in for that resident. After dispensing all medications, the RN did not dispense the atorvastatin calcium 40 mg tablet into the medication cup. While preparing to place medication into the medication cup the RN was interrupted by a CNA who provided vital sign information about a different resident. The RN then placed the medication card back into the medication cart without dispensing the the atorvastatin medication. The RN stated that he was ready to administer the medications to resident #3; and that, the RN counted the medications that were dispensed into the medication cup and stated that he had only one ascorbic acid tablet in the medication cup. The RN then reviewed the physician's order for ascorbic acid and stated that there should have been two tablets dispensed. He then dispensed another ascorbic acid tablet into the medication cup. The RN then stated he had prepared all the medications for the resident. He pulled the atorvastatin medication card from the medication cart and verified that atorvastatin tablet was not in the medication cup. The RN then dispensed the tablet into the medication cup. During the same observation, the RN administered one levothyroxine sodium 50 micrograms (mcg) to the resident #3 after the resident had eaten breakfast. The RN did not ask resident #3 whether or not the resident had eaten breakfast. Resident #3 stated that she ate some oatmeal and milk prior to the medication administration observation. However, the physician orders was for levothyroxine to be administered one hour before a meal on an empty stomach. During the same observation, the RN crushed and administered one Bupropion (ER) 150 mg tablet, one Metoprolol Succinate ER tablet, and one Oxybutynin Chloride ER tablet to the resident and mixed it in the chocolate pudding. However, review of the drug specification documentation provided by the facility revealed the following: -Bupropion hydrochloride ER tablets were not to be chewed, cut, or crushed; and, the tablets must be swallowed whole; -Oxybutynin ER tablets must be swallowed whole with the aid of liquids, and must not be chewed, divided, or crushed; and, -Metoprolol succinate ER tablets are scored and can be divided. However, the whole or half tablet should be swallowed whole and not chewed or crushed. In an interview with RN (staff #8) on November 6, 2024 at 9:43 a.m., the RN stated that he double checks everything during medication administration including counting the pills to make sure he has the accurate amount; and, that, he should not have missed the second ascorbic acid and atorvastatin tablet. He stated that it was normal for other staff members to interrupt while he is in the middle of medication administration. The RN also said that medications could be crushed if there was an order to crush them; and that, there were medications that cannot be crushed and it usually states not to crush them in the order. The RN stated that ER means extended release but was not sure if extended release medications could be crushed or not. The RN also stated that Levothyroxine should be given after breakfast, and stated that the resident (#3) told him she did not eat. An interview was conducted on November 7, 2024 at 9:48 a.m. with the Director of Nursing (DON/Staff #123) who stated that the process for medication administration included making sure it was the right resident, right route, right medication, right dose, following physician orders as it was written, and following manufacturers recommendations about medication administration. The DON also stated that extended release medications should not be crushed, and that the risk to the resident would result in resident receiving the whole dose of the medication immediately rather than it being absorbed over a period of time. She further stated that for metoprolol succinate ER specifically the risks could be cardiac issues and arrythmias. The DON stated that levothyroxine should be administered before the resident eats breakfast; and the risk of administering after the resident eats would be that it interferes with the absorption of the medication. The DON stated that it does not meet the facility's expectation is staff does not administer medications/treatment as ordered by the physician. During a telephone interview with the Nurse Practioner (NP/Staff #60) on November 6, 2024 at 3:05 p.m., she stated that extended release medications should not be crushed; and that, the outcome of the resident receiving crushed extended release medications would be that the dose would be stronger and be released faster, and the resident could overdose on the medication. She also stated that she expected staff to follow orders as written and to contact her to discuss an order if they had questions. She further stated that levothyroxine would be given thirty minutes to an hour before the resident eats in the morning. Review of the facility's policy, Medication Administration, dated October 14, 2024, revealed that medications are administered in accordance with the written orders of the attending physician. It also revealed that crushing may be done using standards of practice; and crushing of long acting or enteric-coated medications is allowable only when there is a specific physicians order to do so. Review of the facility's policy, Medication Error Monitoring, revision #4, revealed that the facility shall ensure medications will be administered as follows: according to physician orders, per manufacture's specifications regarding the preparation and administration of the drug or biological, and in accordance with accepted standards and principles which apply to professionals providing services.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for one resident (#3). The medication error rate was 21.43%. Six medication administration errors were identified out of 28 opportunities during medication administration observation. The deficient practice could result in further medication errors. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, essential hypertension, hyperlipidemia, and Alzheimer's disease. Review of the physician order dated March 6, 2024 revealed an order for Ascorbic Acid tablet 500 mg give two tablets by mouth one time a day for supplement Review of the physician order summary revealed an order for the following: -Atorvastatin Calcium oral tablet 40 mg give one tablet orally in the morning for hyperlipidemia. -Bupropion hydrochloride (antidepressant) ER (extended release) give 150 mg orally in the morning for mood disorder; -Oxybutynin chloride ER (anticholinergic) tablet 10 mg, give one tablet by mouth in the morning for overactive bladder (OAB); and, -Metoprolol Succinate ER (beta blockers) oral tablet 25 mg, give 0.5 tablet by mouth one time a day for congestive heart failure (CHF). Review of the drug specification documentation provided by the facility revealed the following: -Bupropion hydrochloride ER tablets were not to be chewed, cut, or crushed; and, the tablets must be swallowed whole; -Oxybutynin ER tablets must be swallowed whole with the aid of liquids, and must not be chewed, divided, or crushed; and, -Metoprolol succinate ER tablets are scored and can be divided. However, the whole or half tablet should be swallowed whole and not chewed or crushed. During a medication administration observation on November 6, 2024 at 7:23 AM with a Registered Nurse (RN/Staff #8), the RN was observed to administer the following: -One Ascorbic Acid 500 milligram (mg) tablet; -One Bupropion Extended Release (ER) 150mg tablet, one Metoprolol Succinate ER tablet, and one Oxybutynin Chloride ER tablet were crushed and administered to the resident in chocolate pudding; and, -One Levothyroxine sodium oral tablet 50 micrograms (mcg) was administered after resident ate breakfast. The RN (staff #8) also pulled the Atorvastatin medication card from the medication cart, was interrupted by a CNA, and then was observed to place the medication card back into the medication cart without dispensing the medication into the medication cup. The RN verified that the Atorvastatin tablet was not in the medication cup and then dispensed the tablet into the medication cup. The RN (staff #8) counted the medications that were dispensed into the medication cup and verified that he had only one ascorbic acid tablet. The RN reviewed the physician's order and stated that there should have been two tablets dispensed. The RN did not ask resident #3 whether or not the resident had eaten breakfast. Resident #3 stated that she ate some oatmeal and milk prior to the medication administration observation. During an interview conducted on November 6, 2024 at 9:43 a.m., the RN (staff #8) stated that medications could be crushed if there is an order to crush them, and stated that there are medications that cannot be crushed and it usually states not to crush them in the order. The RN further stated that ER means extended release but was not sure if extended release medications could be crushed or not. He also stated that he should not have missed the second ascorbic acid and atorvastatin tablet. The RN further stated that Levothyroxine should be given after breakfast, and stated that the resident (#3) told him she did not eat. An interview was conducted on November 7, 2024 at 9:48 a.m. with the Director of Nursing (DON/Staff #123) who stated that the process for medication administration included making sure it was the right resident, right route, right medication, right dose, following physician orders as it was written, and following manufacturers recommendations about medication administration. The DON also stated that extended release medications should not be crushed, and that the risk to the resident would result in resident receiving the whole dose of the medication immediately rather than it being absorbed over a period of time. She further stated that for metoprolol succinate ER specifically the risks could be cardiac issues and arrythmias. The DON stated that levothyroxine should be administered before the resident eats breakfast; and the risk of administering after the resident eats would be that it interferes with the absorption of the medication. The DON stated that it does not meet the facility's expectation is staff does not administer medications/treatment as ordered by the physician. During a telephone interview with the Nurse Practioner (NP/Staff #60) on November 6, 2024 at 3:05 p.m., she stated that extended release medications should not be crushed; and that, the outcome of the resident receiving crushed extended release medications would be that the dose would be stronger and be released faster, and the resident could overdose on the medication. She also stated that she expected staff to follow orders as written and to contact her to discuss an order if they had questions. She further stated that levothyroxine would be given thirty minutes to an hour before the resident eats in the morning. Review of the facility's policy, Medication Administration, dated October 14, 2024, revealed that medications are administered in accordance with the written orders of the attending physician. It also revealed that crushing may be done using standards of practice; and crushing of long acting or enteric-coated medications is allowable only when there is a specific physicians order to do so. The policy indicated that medication time may be altered to meet resident and facility needs all while following medical doctors (MD) orders. Review of the facility's policy, Medication Error Monitoring, revision #4, revealed that the facility shall ensure medications will be administered as follows: according to physician orders, per manufacture's specifications regarding the preparation and administration of the drug or biological, and in accordance with accepted standards and principles which apply to professionals providing services. The policy also indicated that the facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events.

Based on observations, staff interviews, and policy review, the facility failed to ensure that medications the facility failed to ensure that medications were not left at bedside for one residents (#5); and failed to ensure that expired medications and supplies were discarded and readily available for resident use. The facility census was 41, and the sample was 13 residents. The deficient practice could result in adverse effects and residents, staff, and visitors having access to medications. Findings include: -Resident #5 was admitted to the facility on [DATE], with diagnoses that include chronic respiratory failure with hypoxia, acute and subacute allergic otitis media, unspecified ear, acute post hemorrhagic anemia A physician order dated March 22, 2023 revealed an order for Systane Solution eye drop in both eyes. A physician order dated July 17, 2024 included Fluticasone propionate suspension, one spray in each nostril. During an observation of the resident's room conducted on November 5, 2024, at 9:08 a.m., there was a bottle containing Fluticasone Propionate Suspension nasal spray and Systane complete eye drop at the resident's bedside table. In another observation conducted on November 6, 2024 at 9:39 a.m. Fluticasone and Systane eye drops were on the resident's bedside table. An observation was conducted November 7, 2024, at 8:38 a.m. and revealed that the Fluticasone and Systane eye drops were observed on the resident's bedside table. An interview was conducted on November 5, 2024, at 9:10 a.m. with with the Resident #5 who stated that she liked to keep the nasal spray and eye drops with her so she did not have to ask the nurses for them in case she needed them. An interview was conducted with a Registered Nurse (RN/Staff #33) on November 7, 2024, at 12:11 p.m. A review of the clinical record was conducted with the RN who stated that the orders for the Systane Solution eye drops and Fluticasone Propionate were active. The RN further stated that there was no evidence of an order for Resident #5 to self-administer medication. In an interview with the Director of Nursing (DON/staff #123) was conducted on November 8, 2024 at 10:24 a.m., the DON stated that she had not been in the resident's room, but eye drops and nasal spray should never be left at the bedside per facility policy. The DON stated that there was no reason for any medication to be kept at the bedside unless there was an order to do so. The DON further stated that there was no evidence that a medication self-administration was conducted for resident #5. The DON stated that the risk of leaving medication at the bedside could result in someone else taking the medication. The facility policy on Medication Storage (Medication Cart/Narcotics), included that it was their policy is to ensure that all medications housed on our premises are stored in the pharmacy and/or Medication rooms according to the manufacturer's recommendations and sufficient to ensure security. 50887 -During a medication room observation conducted with a Registered Nurse (RN/staff #6), on November 6, 2024 at 12:39 p.m., there were two Semglee insulin glargine pens in Ekit #1 in the fridge with an expiration date of June 2024; and, Moderna covid-19 vaccines in a black locked box in the fridge had a sticker on the box indicating the expiration date to be June 30, 2023. During the medication room observation with RN (staff #6) conducted on November 6, 2024 at 12:39 p.m., the following supplies were found having exceeded their expiration date: -Autoshield duo cap for insulin pen in Ekit #1 from fridge with an expiration date of February 2023; -Statlock intravenous kit with an expiration date of December 28, 2023; -Entraflo safety spike plus pump set with enfit with an expiration date of June 28, 2023; -Powerloc port access kit with an expiration date of October 31, 2024; and, -Even care blood glucose test strips with an expiration date of September 6, 2024 In an interview with RN (staff #6) conducted on November 6, 2024 at 12:39 p.m., the RN stated that the medications, vaccines and supplies found in the medication room exceeded their expiration date and would be disposed of immediately. The RN further stated they were trying to figure out where to send the expired vaccines instead of disposing of them. During an interview with the Director of Nursing (DON/staff #123) conducted on November 7, 2024 at 10:09 a.m., the DON stated that the risks of using expired medications or supplies on a resident would affect the efficay of the medications and supplies. The facility policy on Expired Drugs/Supplies, revealed that expired drugs and supplies should be disposed of with proper record keeping and prior to expiration date. The policy also indicated that the medication room supplies should be randomly checked and discarded prior to expiration date, and stock medications are to be discarded prior to expiration date.

Based on observation, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one sampled resident (#5) was assessed for medication self-administration. The deficient practice could result in resident not taking or able to take the medication needed for treatment. Findings include: Resident #5 was admitted to the facility on [DATE], with diagnoses of chronic respiratory failure with hypoxia, acute and subacute allergic otitis media, unspecified ear, and acute post hemorrhagic anemia The admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. Reviewed of the care plan revealed no evidence of a focus for medication self-administration. Physician orders revealed the following active medications: - Systane Solution eye drop (ocular lubricant) applied in both eyes with an order date of March 22, 2023; and. - Fluticasone Propionate Suspension (nasal corticosteroid) applied one spray in each nostril with an order date of July 17, 2024. Review of the clinical record revealed no evidence that the resident was assessed for medication self-administration; and that, self-administration was determined to be clinically appropriate for resident #5. During an observation conducted in the resident's room on November 5, 2024 at 9:08 a.m. a bottles of Fluticasone Propionate Suspension nasal spray, and Systane complete eye drop were observed on the resident's bedside table. The resident stated that she liked to keep her nasal spray and eye drops with her so she does not have to ask the nurses in case she needed them. An interview was conducted on November 07, 2024, at 12:11 p.m. with a Registered Nurse (RN/Staff #33) who reviewed the clinical record and stated that Systane eye drops and fluticasone orders were active orders for resident #5. She stated that there was no evidence of an order for the resident to self-administer medication. An interview was conducted with the Director of Nursing (DON/staff #123) on November 7, 2024 at 10:24 a.m. The DON said that she had not been in the resident's room, but eye drops, and nasal spray should never be left at the bedside of a resident. The DON stated that there was absolutely no reason for any medication to be kept at the bedside unless there was an order to do so; and, when medication self-administration assessment was not conducted. The DON stated that this practice was against facility policy; and,the risk could result in someone else taking the medication. The DON further stated that there was no self-administration evaluation found in the clinical record for Resident #5. Review of the facility's policy titled, Self-administration of Medication, revealed that the facility policy is to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely.

Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure policies were implemented regarding investigating and timely reporting of allegations of abuse for 3 sampled residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents. Findings include: -Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment. Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident. A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the resident about an incident that happened on October 29, 2024. Per the documentation, Resident #13 reported that another resident (#29) grabbed her left wrist and twisted it; and that, her left wrist hurt. The communication note dated November 1, 2024 revealed that staff called and left a voicemail to the resident's power of attorney (POA) to inform about the alleged abuse. Another communication note dated November 1, 2024 revealed the nurse practitioner was informed of an alleged abuse that a resident (#29) grabbed and twisted the wrist of Resident #13 when they were in the dining area eating lunch. Despite documentation of an allegation of abuse, there was no evidence found that the allegation of abuse was reported to the State Agency (SA). The care plan revised on November 03, 2024, revealed that Resident #13 had an alteration in comfort related to left wrist pain and swelling. Interventions included to administer scheduled pain medications per physician orders and for certified nursing assistants (CNAs) to report pain concerns to nurse. On November 06, 2024 at 7:57 a.m., an interview was conducted with Resident #13 who stated that the incident happened last week; and that, a resident (#29) grabbed her left wrist intentionally. The resident stated that resident #29 was like that and was mad. Resident #13 stated she went back to her room; and, staff asked if she was ok. Resident #13 further stated that her left wrist hurt. -Resident #29 was admitted on [DATE] with diagnoses that included unspecified fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed the BIMS assessment could not be completed because the resident was rarely understood. The care plan dated July 29, 2024 revealed the resident had the following episodes of physical aggression: -On July 26, 2024, the resident was yelling unintelligible words while swaying her arms to nurse and CNA and tried to grab anything. Per the documentation, resident grabbed her disposable gown and punched her in her abdomen; -On September 20, 2024, while being offered medications, resident smacked the nurse and was screaming at the nurse; and, -On October 26, 2024, resident grabbed another resident's arm trying to stop the other resident from touching her iPad. The care plan revealed interventions to intervene as necessary to protect the rights and safety of others, and to monitor, document, and report any signs and symptoms of resident posing danger to self and others. A nursing note dated September 05, 2024 written by a licensed practical nurse (LPN/Staff #111) revealed that the resident tried to hit other residents that were sitting and eating at her table. Per the documentation, resident hit another resident (#19) and tried to scratch him with her nails but the other resident (#19) was able to move. It also included that redirection was continued. Despite documentation of the incident, the clinical record and facility-provided documentation revealed no evidence that the incident report for the allegation of abuse on September 05, 2024 was reported to any manager and SA; and that, the facility had completed an investigation of the incident. A Behavior Note dated October 16, 2024, revealed that Resident #29 was aggressive towards CNA during brief change. The documentation included that the resident nodded 'Yes' when asked for permission to her change brief; but, then grabbed one of the CNAs by the throat. A Provider Note dated October 25, 2024, revealed that documentation of multiple episodes of aggressive behaviors from June through October 2024 such as hitting, attacking staff, clawing staff with her fingernails, increased agitation and combativeness, and violent at times. Continued review of the clinical record revealed no documentation of any regarding a resident-to-resident incident on October 29, 2024. However, a nursing manager investigation note dated November 1, 2024 included that an incident occurred on October 29, 2024, where Resident #29 grabbed another resident's wrist because the other resident tried to lower the volume of her tablet while they were at the dining room. Per the documentation, an intervention put into place was to not put the involved residents in the same table during meal time or together during activities. A Reportable Event Report dated November 4, 2024 revealed that on October 29, 2024 at 12:15 p.m., Resident #29 was using her tablet at the dining room table when another Resident (#13) reached over to turn the volume down on the resident's tablet. According to the documentation, the resident then grabbed and twisted the other resident's hand and twisted; and that, there were no injury occurred and both residents were immediately separated. The report further revealed that the resident had acted aggressively toward staff in the past, but not toward any other resident until this incident. A Communication note dated November 04, 2024 included that staff had told the resident's family regarding the resident grabbing and twisting another resident's (#13) wrist. -Resident #19 was admitted on [DATE] with diagnoses of Parkinson's disease and dementia. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 indicating the resident had moderate cognitive impairment. Review of the care plan revealed no evidence of any adjustments related to an incident of alleged abuse on September 05, 2024. Review of the progress notes revealed no evidence of any notes regarding an incident of alleged abuse on September 05, 2024. However, review of the clinical record for resident #29 revealed a nursing note dated September 05, 2024 that the resident #29 tried to hit other residents that were sitting and eating at her table. Per the documentation, resident #29 hit resident #19 and tried to scratch him with her nails but the resident #19 was able to move. It also included that redirection was continued. There was no evidence that this incident was reported to any manager and SA on September 5, 2024; and that, an investigation of this was completed by the facility. A telephone interview with Resident #29's family was conducted on November 4, 2024 at 1:21 p.m. The family stated that resident #29 and another new resident was sitting in the dining area; and that, resident #29 had her electronic tablet with her and the volume was on high. The family stated that the new resident reached over and tried to grab the tablet, and resident #29 grabbed the other resident's arm to try to defend her property. She stated there was a CNA nearby who reacted and diffused the situation; and that, the other resident was complaining of a sore wrist. The family further stated that the facility told her that resident #29 and the new resident would not be placed together again. On November 6, 2024 at 2:07 p.m. an interview was conducted with the LPN (Staff #111) who stated that she heard that there was an incident between residents #29 and #13. A review of the clinical record was conducted with the LPN who said that she recalled an incident that occurred on September 05, 2024. The LPN stated she was the nurse on the unit that day, and she witnessed Resident #29 hit and attempt to scratch another resident (#19) who was extremely friendly and wanted to be involved in peoples' spaces. The LPN said that she saw Resident #29 make contact with the other resident but that there was not any sort of force behind the contact. Further, the LPN stated that a risk management report was not completed for this incident. An interview was conducted on November 6, 2024 at 3:10 p.m. with the Director of Nursing (DON/ Staff #123) who stated that her expectation was that staff would report any allegation of abuse immediately; and that, mandatory reporting occurs within 2 hours of the incident. The DON stated that she became aware of the incident of regarding Resident #29 twisting the arm of Resident #13 on October 31, 2024 when the receptionist brought it up to management staff. The DON stated that staff have received an in-service since then on abuse reporting. Regarding the resident-to-resident altercation between resident #29 and resident #19 on September 05, 2024, the DON stated that she was not aware of the incident; and that, no staff reported the incident to her. She stated that if she had learned of this incident, she would have separated both residents and reported the incident to the abuse coordinator. The DON further stated that moving forward, to prevent further resident-to-resident incidents, residents #29 and #13 would not sit together; and, staff would monitor for behaviors. An interview was conducted on November 6, 2024 at 3:40 p.m. with the former administrator (Staff #149) who was the administrator at the time of the incident between residents #29 and #19 on September 5, 2024. The former administrator stated that any allegation of abuse should be reported immediately, should be investigated immediately, and should be reported to mandated sources within 2 hours. Regarding the allegation of abuse on September 5, 2024, staff #149 stated that he just found out about it; and that, no staff came to him at the time of the incident to report it. He further stated that there was no investigation done/completed for this incident. An interview was conducted on November 6, 2024 at 4:09 p.m. with the unit manager (Staff #6) who stated that no staff had reported to her the incident of between resident #29 hitting and attempting to scratch resident #19 on September 5, 2024. She stated that an incident report should have been done; however, there were no risk management (incident) report was done/completed for this incident. The unit manager said that if an incident report had been done, it would trigger an alert for an investigation to be completed. Regarding the incident between residents #29 and #13, the unit manager said that the incident was not reported by any staff when the incident occurred. The Unit manager stated that a staff member heard about the incident from another resident; and, it was not reported to management and investigated until October 31, 2024. Further, the unit manager stated that any allegation of abuse should be reported immediately and the investigation should start right away; and that, the importance of timely reporting was so staff could assess for any injuries and protect the resident's safety and wellbeing. The Unit manager further stated that if an incident was not reported timely, the incident could happen again. An interview was conducted on November 7, 2024 at 8:52 a.m. with a CNA (staff #122) who was in the dining room when the incident between resident #13 and #29 occurred. The CNA stated she was in the dining room approximately 2-3 feet away from the two residents; and, she saw Resident #13 turn down the volume on the tablet of Resident #29 who then grabbed the wrist of Resident #13. She stated the contact lasted approximately 1 second and the wrist of resident #13 was not twisted. She stated after the incident, the two residents are to remain separated and supervised in the dining room. An interview with the Administrator (Staff #58) was conducted on November 7, 2024 at 11:25 a.m. The administrator stated that staff were to report allegations of abuse immediately and mandatory reporting should be done within 2 hours. He stated that the importance of timely reporting was that it allows the facility to start the investigation and to protect the residents involved. He stated that if the facility's abuse policy was not followed, it allows for continued potential abuse to occur. The Administrator stated that that he was not the Administrator at the time of the incident between residents #29 and #19 occurred on September 5, 2024. He said that he became Administrator on October 01, 2024; and, he just became aware of the incident yesterday when staff was made aware by the state survey agency. He stated that it does not meet his expectation that staff failed to report both incidents (September 5 and October 29, 2024) within the timeframes specified by the abuse policy. Review of the facility's policy titled The Behavioral Management, reviewed October 07, 2024, revealed that inappropriate behaviors that may put the resident, other residents, staff, or guests at risk for injury are identified in an attempt to redirect or modify the behavior so proper treatment can be provided to the resident. The procedures revealed to notify the nurse in charge immediately when a resident is having any inappropriate behaviors, separate affected residents, document the behavior in the resident's medical record, follow through appropriate steps to modify the behavior, and modify the care plan to reflect the current interventions. Review of the facility's policy titled Incidents and Accidents, reviewed October 14, 2024, revealed that licensed staff will utilize the on-line risk management system to report all incidents and accidents and assist with completion of any investigative information to identify root causes. Combative behavior, resident-to-resident altercations, observed accidents, and alleged abuse are listed as incidents / accidents that require a report to be completed. Any injuries will be assessed by the LPN, and the supervisor and/or designee will be notified of the incident / accident. The nurse will enter the documentation of the incident / accident within 24 hours of the occurrence. Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed January 11, 2024, revealed each resident has the right to be free from abuse. Abuse is defined as the willful infliction of injury, with 'willful' further defined as deliberate action by an individual. The facility will make reasonable efforts to protect residents after alleged abuse. Allegations of abuse must be reported by staff to the administrator immediately, and allegations involving abuse must be reported to the state survey agency within 2 hours. An investigation should be initiated immediately. Further, the actions taken should be documented in the resident's medical record.

Based on observation, interviews, review of clinical record, facility documentation, and facility policy, the facility failed to ensure alleged violations of abuse were reported to proper authorities within prescribed timeframes for 3 residents (#13, #19, and #29). The deficient practice could lead to allegations of abuse not being investigated timely, and could lead to continued harm to residents. Findings include: -Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment. Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident. A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the resident about an incident that happened on October 29, 2024. Per the documentation, Resident #13 reported that another resident (#29) grabbed her left wrist and twisted it; and that, her left wrist hurt. The communication note dated November 1, 2024 revealed that staff called and left a voicemail to the resident's power of attorney (POA) to inform about the alleged abuse. Another communication note dated November 1, 2024 revealed the nurse practitioner was informed of an alleged abuse that a resident (#29) grabbed and twisted the wrist of Resident #13 when they were in the dining area eating lunch. Despite documentation of an allegation of abuse, there was no evidence found that the allegation of abuse was reported to the State Agency (SA). On November 06, 2024 at 7:57 a.m., an interview was conducted with Resident #13 who stated that the incident happened last week; and that, a resident (#29) grabbed her left wrist intentionally. The resident stated that resident #29 was like that and was mad. Resident #13 stated she went back to her room; and, staff asked if she was ok. Resident #13 further stated that her left wrist hurt. -Resident #29 was admitted on [DATE] with diagnoses that included unspecified fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed the BIMS assessment could not be completed because the resident was rarely understood. A nursing note dated September 05, 2024 written by a licensed practical nurse (LPN/Staff #111) revealed that the resident tried to hit other residents that were sitting and eating at her table. Per the documentation, resident hit another resident (#19) and tried to scratch him with her nails but the other resident (#19) was able to move. Despite documentation of the incident, the clinical record and facility-provided documentation revealed no evidence that the incident report for the allegation of abuse on September 05, 2024 was reported to any manager and SA. A Provider Note dated October 25, 2024, revealed that documentation of multiple episodes of aggressive behaviors from June through October 2024 such as hitting, attacking staff, clawing staff with her fingernails, increased agitation and combativeness, and violent at times. Continued review of the clinical record revealed no documentation of any regarding a resident-to-resident incident on October 29, 2024. However, a nursing manager investigation note dated November 1, 2024 included that an incident occurred on October 29, 2024, where Resident #29 grabbed another resident's wrist because the other resident tried to lower the volume of her tablet while they were at the dining room. A Reportable Event Report dated November 4, 2024 revealed that on October 29, 2024 at 12:15 p.m., Resident #29 was using her tablet at the dining room table when another Resident (#13) reached over to turn the volume down on the resident's tablet. According to the documentation, the resident then grabbed and twisted the other resident's hand and twisted; and that, there were no injury occurred and both residents were immediately separated. The report further revealed that the resident had acted aggressively toward staff in the past, but not toward any other resident until this incident. A Communication note dated November 04, 2024 included that staff had told the resident's family regarding the resident grabbing and twisting another resident's (#13) wrist. -Resident #19 was admitted on [DATE] with diagnoses of Parkinson's disease and dementia. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 indicating the resident had moderate cognitive impairment. Review of the care plan revealed no evidence of any adjustments related to an incident of alleged abuse on September 05, 2024. Review of the progress notes revealed no evidence of any notes regarding an incident of alleged abuse on September 05, 2024. However, review of the clinical record for resident #29 revealed a nursing note dated September 05, 2024 that the resident #29 tried to hit other residents that were sitting and eating at her table. Per the documentation, resident #29 hit resident #19 and tried to scratch him with her nails but the resident #19 was able to move. There was no evidence that this incident was reported to any manager and SA on September 5, 2024. On November 6, 2024 at 2:07 p.m. an interview was conducted with the LPN (Staff #111) who stated that she heard that there was an incident between residents #29 and #13. A review of the clinical record was conducted with the LPN who said that she recalled an incident that occurred on September 05, 2024. The LPN stated she was the nurse on the unit that day, and she witnessed Resident #29 hit and attempt to scratch another resident (#19) who was extremely friendly and wanted to be involved in peoples' spaces. The LPN said that she saw Resident #29 make contact with the other resident but that there was not any sort of force behind the contact. Further, the LPN stated that a risk management report was not completed for this incident. An interview was conducted on November 6, 2024 at 3:10 p.m. with the Director of Nursing (DON/ Staff #123) who stated that her expectation was that staff would report any allegation of abuse immediately; and that, mandatory reporting occurs within 2 hours of the incident. The DON stated that she became aware of the incident of regarding Resident #29 twisting the arm of Resident #13 on October 31, 2024 when the receptionist brought it up to management staff. The DON stated that staff have received an in-service since then on abuse reporting. Regarding the resident-to-resident altercation between resident #29 and resident #19 on September 05, 2024, the DON stated that she was not aware of the incident; and that, no staff reported the incident to her. She stated that if she had learned of this incident, she would have separated both residents and reported the incident to the abuse coordinator. The DON further stated that moving forward, to prevent further resident-to-resident incidents, residents An interview was conducted on November 6, 2024 at 3:40 p.m. with the former administrator (Staff #149) who was the administrator at the time of the incident between residents #29 and #19 on September 5, 2024. The former administrator stated that any allegation of abuse should be reported immediately, should be investigated immediately, and should be reported to mandated sources within 2 hours. Regarding the allegation of abuse on September 5, 2024, staff #149 stated that he just found out about it; and that, no staff came to him at the time of the incident to report it. He further stated that there was no investigation done/completed for this incident. An interview was conducted on November 6, 2024 at 4:09 p.m. with the unit manager (Staff #6) who stated that no staff had reported to her the incident of between resident #29 hitting and attempting to scratch resident #19 on September 5, 2024. She stated that an incident report should have been done; however, there were no risk management (incident) report was done/completed for this incident. The unit manager said that if an incident report had been done, it would trigger an alert for an investigation to be completed. Regarding the incident between residents #29 and #13, the unit manager said that the incident was not reported by any staff when the incident occurred. The unit manager stated that a staff member heard about the incident from another resident; and, it was not reported to management and investigated until October 31, 2024. Further, the unit manager stated that any allegation of abuse should be reported immediately and the investigation should start right away; and that, the importance of timely reporting was so staff could assess for any injuries and protect the resident's safety and wellbeing. The unit manager further stated that if an incident was not reported timely, the incident could happen again. An interview with the Administrator (Staff #58) was conducted on November 7, 2024 at 11:25 a.m. The administrator stated that staff were to report allegations of abuse immediately and mandatory reporting should be done within 2 hours. He stated that the importance of timely reporting was that it allows the facility to start the investigation and to protect the residents involved. He stated that if the facility's abuse policy was not followed, it allows for continued potential abuse to occur. The Administrator stated that that he was not the Administrator at the time of the incident between residents #29 and #19 occurred on September 5, 2024. He said that he became Administrator on October 01, 2024; and, he just became aware of the incident yesterday when staff was made aware by the state survey agency. He stated that it does not meet his expectation that staff failed to report both incidents (September 5 and October 29, 2024) within the timeframes specified by the abuse policy. Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed January 11, 2024, revealed each resident has the right to be free from abuse. Abuse is defined as the willful infliction of injury, with 'willful' further defined as deliberate action by an individual. The facility will make reasonable efforts to protect residents after alleged abuse. Allegations of abuse must be reported by staff to the administrator immediately, and allegations involving abuse must be reported to the state survey agency within 2 hours. An investigation should be initiated immediately. Further, the actions taken should be documented in the resident's medical record.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure an allegation of abuse was thoroughly investigated, and to prevent further abuse from occurring during the investigation for two residents (#19 and #29). The deficient practice could lead to allegations of abuse not being investigated thoroughly, and residents not being protected from further abuse and retaliation. Findings include: -Resident #13 admitted to the facility on [DATE], with diagnoses that included rheumatoid arthritis, collapsed vertebra, depression, and myasthenia gravis. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 11, indicating moderate cognitive impairment. Review of the clinical record revealed no evidence of any documentation on October 29, 2024, regarding a resident-to-resident incident. A communication note dated October 31, 2024 revealed that an RN and an MDS coordinator spoke with the resident about an incident that happened on October 29, 2024. Per the documentation, Resident #13 reported that another resident (#29) grabbed her left wrist and twisted it; and that, her left wrist hurt. The communication note dated November 1, 2024 revealed that staff called and left a voicemail to the resident's power of attorney (POA) to inform about the alleged abuse. Another communication note dated November 1, 2024 revealed the nurse practitioner was informed of an alleged abuse that a resident (#29) grabbed and twisted the wrist of Resident #13 when they were in the dining area eating lunch. Despite documentation of an allegation of abuse, there was no evidence found that the facility conducted an investigation of this incident. On November 06, 2024 at 7:57 a.m., an interview was conducted with Resident #13 who stated that the incident happened last week; and that, a resident (#29) grabbed her left wrist intentionally. The resident stated that resident #29 was like that and was mad. Resident #13 stated she went back to her room; and, staff asked if she was ok. Resident #13 further stated that her left wrist hurt. -Resident #29 was admitted on [DATE] with diagnoses that included unspecified fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease. Review of the quarterly MDS assessment dated [DATE] revealed the BIMS assessment could not be completed because the resident was rarely understood. A nursing note dated September 05, 2024 written by a licensed practical nurse (LPN/Staff #111) revealed that the resident tried to hit other residents that were sitting and eating at her table. Per the documentation, resident hit another resident (#19) and tried to scratch him with her nails but the other resident (#19) was able to move. Despite documentation of the incident, the clinical record and facility-provided documentation revealed no evidence that the incident was thoroughly investigated by the facility. A Provider Note dated October 25, 2024, revealed that documentation of multiple episodes of aggressive behaviors from June through October 2024 such as hitting, attacking staff, clawing staff with her fingernails, increased agitation and combativeness, and violent at times. Continued review of the clinical record revealed no documentation of any regarding a resident-to-resident incident on October 29, 2024. However, a nursing manager investigation note dated November 1, 2024 included that an incident occurred on October 29, 2024, where Resident #29 grabbed another resident's wrist because the other resident tried to lower the volume of her tablet while they were at the dining room. A Reportable Event Report dated November 4, 2024 revealed that on October 29, 2024 at 12:15 p.m., Resident #29 was using her tablet at the dining room table when another Resident (#13) reached over to turn the volume down on the resident's tablet. According to the documentation, the resident then grabbed and twisted the other resident's hand and twisted; and that, the resident had acted aggressively toward staff in the past, but not toward any other resident until this incident. A Communication note dated November 04, 2024 included that staff had told the resident's family regarding the resident grabbing and twisting another resident's (#13) wrist. -Resident #19 was admitted on [DATE] with diagnoses of Parkinson's disease and dementia. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 indicating the resident had moderate cognitive impairment. Review of the care plan revealed no evidence of any adjustments related to an incident of alleged abuse on September 05, 2024. Review of the progress notes revealed no evidence of any notes regarding an incident of alleged abuse on September 05, 2024. However, review of the clinical record for resident #29 revealed a nursing note dated September 05, 2024 that the resident #29 tried to hit other residents that were sitting and eating at her table. Per the documentation, resident #29 hit resident #19 and tried to scratch him with her nails but the resident #19 was able to move. It also included that redirection was continued. There was no evidence that the facility investigated this incident on September 5, 2024. On November 6, 2024 at 2:07 p.m. an interview was conducted with the LPN (Staff #111) who stated that she heard that there was an incident between residents #29 and #13. A review of the clinical record was conducted with the LPN who said that she recalled an incident that occurred on September 05, 2024. The LPN stated she was the nurse on the unit that day, and she witnessed Resident #29 hit and attempt to scratch another resident (#19) who was extremely friendly and wanted to be involved in peoples' spaces. The LPN said that she saw Resident #29 make contact with the other resident but that there was not any sort of force behind the contact. Further, the LPN stated that a risk management report was not completed for this incident. An interview was conducted on November 6, 2024 at 3:10 p.m. with the Director of Nursing (DON/ Staff #123) who stated that her expectation was that staff would report any allegation of abuse immediately; and that, mandatory reporting occurs within 2 hours of the incident. The DON stated that she became aware of the incident of regarding Resident #29 twisting the arm of Resident #13 on October 31, 2024 when the receptionist brought it up to management staff. The DON stated that staff have received an in-service since then on abuse reporting. Regarding the resident-to-resident altercation between resident #29 and resident #19 on September 05, 2024, the DON stated that she was not aware of the incident; and that, no staff reported the incident to her. She stated that if she had learned of this incident, she would have separated both residents and reported the incident to the abuse coordinator. The DON further stated that moving forward, to prevent further resident-to-resident incidents, residents An interview was conducted on November 6, 2024 at 3:40 p.m. with the former administrator (Staff #149) who was the administrator at the time of the incident between residents #29 and #19 on September 5, 2024. The former administrator stated that any allegation of abuse should be reported immediately, should be investigated immediately, and should be reported to mandated sources within 2 hours. Regarding the allegation of abuse on September 5, 2024, staff #149 stated that he just found out about it; and that, no staff came to him at the time of the incident to report it. He further stated that there was no investigation done/completed for this incident. An interview was conducted on November 6, 2024 at 4:09 p.m. with the unit manager (Staff #6) who stated that no staff had reported to her the incident of between resident #29 hitting and attempting to scratch resident #19 on September 5, 2024. She stated that an incident report should have been done; however, there were no risk management (incident) report was done/completed for this incident. The unit manager said that if an incident report had been done, it would trigger an alert for an investigation to be completed. Regarding the incident between residents #29 and #13, the unit manager said that the incident was not reported by any staff when the incident occurred. The unit manager stated that a staff member heard about the incident from another resident; and, it was not reported to management and investigated until October 31, 2024. Further, the unit manager stated that any allegation of abuse should be reported immediately and the investigation should start right away; and that, the importance of timely reporting was so staff could assess for any injuries and protect the resident's safety and wellbeing. The unit manager further stated that if an incident was not reported timely, the incident could happen again. An interview with the Administrator (Staff #58) was conducted on November 7, 2024 at 11:25 a.m. The administrator stated that staff were to report allegations of abuse immediately and mandatory reporting should be done within 2 hours. He stated that the importance of timely reporting was that it allows the facility to start the investigation and to protect the residents involved. He stated that if the facility's abuse policy was not followed, it allows for continued potential abuse to occur. The Administrator stated that that he was not the Administrator at the time of the incident between residents #29 and #19 occurred on September 5, 2024. He said that he became Administrator on October 01, 2024; and, he just became aware of the incident yesterday when staff was made aware by the state survey agency. He stated that it does not meet his expectation that staff failed to report both incidents (September 5 and October 29, 2024) within the timeframes specified by the abuse policy. Review of the facility's policy titled Abuse, Neglect, and Exploitation, reviewed January 11, 2024, revealed each resident has the right to be free from abuse. Abuse is defined as the willful infliction of injury, with 'willful' further defined as deliberate action by an individual. The facility will make reasonable efforts to protect residents after alleged abuse. Allegations of abuse must be reported by staff to the administrator immediately, and allegations involving abuse must be reported to the state survey agency within 2 hours. An investigation should be initiated immediately. Further, the actions taken should be documented in the resident's medical record.

Based on observation, clinical record review, staff interview, and policies and procedures, the facility failed to ensure a comprehensive person-centered care plan with interventions was developed and implemented related to dialysis care and assessment for one resident (#22); and, oxygen use for one resident (#29). The deficient practice could result in staff not being aware of changes in interventions and asessments. Findings include: Resident #22 was readmitted to facility September 9, 2024 with diagnoses of urinary tract infection, type 2 diabetes mellitus, end stage renal disease (ESRD) and kidney disease. A review of physician orders dated September 9, 2024 revealed the following: - Dialysis appointment: Patient on hemodialysis (Tuesday, Thursday, Saturday) at (US Renal) Dialysis Center. Please complete pre-dialysis form and fax to dialysis center then place the form in MD box. - POST DIALYSIS: Assess dialysis site Q 30 mins x 4 hours post dialysis treatment. Assess for bruit/thrill and for sign/symptom bleeding, infections, or any issues. Document in nurses note if any issues are present and Notify MD. The care plan dated September 10, 2024 revealed that the resident had a potential for alteration in skin integrity related to ESRD on Dialysis. The care plan revealed no evidence of interventions related to pre and post dialysis care as ordered. Review of the Treatment Administration Records (TAR) from September through November, 2024, revealed that the resident was receiving dialysis every Tuesday, Thursday and Saturday as ordered, and upon return, vital signs and the assess site were monitor per order. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Active diagnoses included ESRD, dependence on renal dialysis and that the resident was receiving dialysis on admission and while a resident. Review of the clinical record September through November 2024 revealed no evidence of post dialysis access site monitoring. An interview was conducted on November 6, 2024 at 7:31 a.m. with the resident who stated that he goes to dialysis three times a week and that staff checks his vitals when he returns from dialysis. An interview was conducted with the Quality Infection Control (QIC/ staff #6) on November 6, 2024 at 3:08 p.m. The QIC stated that the care plan must be triggered within 24 hr. by the admission nurse and reviewed by a unit manager and MDS coordinator. The QIC reviewed the clinical record and stated that there was no evidence in the care plan related to dialysis or interventions for dialysis that included vital signs and assessment of assess site; and, there should be. An interview was conducted with the Director of Nursing (DON/ staff #123) on November 7, 2024 at 8:51 p.m. The DON said that the care plan was specific to each individual resident. A review of the clinical record was conducted with the DON who stated that there was no evidence in the care plan that related specifically to dialysis interventions of post dialysis vital sign monitoring and assessment of the dialysis assess site. She said that the facility did not follow our policy; and, risk of not having the care plan could result in staff not having full information regarding residents. The DON further stated that the care plan for resident #22 was corrected yesterday. Review of the facility policy titled, Dialysis Communication and Site Monitoring, reviewed on October 14, 2023, revealed that when a resident is admitted and requires dialysis as a part of their care, dialysis care plan interventions will be implemented to list the specific cares needed. 51124 -Resident #29 admitted on [DATE], with diagnoses of fracture of right wrist and hand, hemiplegia affecting the right side, and Alzheimer's disease. A physician order dated June 14, 2024 included for oxygen therapy, titrated between 1-5 L (liters) via nasal cannula to maintain oxygen saturation at or above 90%; and, may wean to room air as appropriate. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had received oxygen therapy. A nurse practitioner (NP) note dated October 28, 2024 revealed the resident remained on 2 liters of oxygen via nasal cannula. Despite documentation that the resident was on oxygen, there was no evidence found that care plan with interventions for the use of oxygen was developed and implemented. An observation was conducted on November 5, 2024 at 10:34 a.m. Resident #29 was self-propelling in her wheelchair to the doorway of her room with a portable oxygen tank hanging on the back of her wheelchair. The oxygen cannula tubing was not on the resident's face, but was wrapped around the left armrest of her wheelchair. Another observation was conducted on November 6, 2024 at 12:22 a.m. and revealed Resident #29 lying in bed, wearing an oxygen nasal cannula connected to an oxygen concentrator at bedside. A telephone interview was conducted on November 4, 2024 at 1:21 p.m. with the resident's family who stated that three separate occasions, she had noticed resident #29 wearing the oxygen cannula tubing, but the portable oxygen tank was not on. She stated that she requested staff to address this, and on each time, staff took the tank, and would refill it. An interview was conducted on November 5, 2024 with a certified nursing assistant (CNA /Staff #122) who stated that Resident #29 was always on oxygen. On November 7, 2024 at 10:52 a.m., an interview was conducted with an MDS coordinator (staff #61) who stated that she assists in editing and adjusting resident's care plans and uses the care area triggers from the MDS assessment as a guide to know what the resident needs on their care plan. She stated if a resident was on oxygen, the staff will usually add this to the resident's care plan. In an interview with the unit manager (staff #6) conducted on November 7, 2024 at 10:58 a.m., the unit manager stated that care items that need to be addressed on a resident's care plan would be a resident's code status, narcotic use, anticoagulant use, fall risk interventions, and oxygen therapy. A review of the clinical record was conducted with the unit manager who stated that she could not find the care plan for oxygen use for resident #29; and that, it should have been in the resident's care plan. The unit manager stated that a potential outcome of not having necessary care items on a care plan may affect the continuity of care between staff members. An interview was conducted on November 7, 2024 at 11:06 a.m. with the Director of Nursing (DON / Staff #123) who stated that oxygen use should be on a resident's care plan. A review of the clinical record was conducted with the DON stated that resident #29 had a care plan for oxygen use added on November 7, 2024. The DON stated that the resident did not have a care plan for oxygen use prior to November 7, 2024. Further, the DON stated that a resident having a physician order for oxygen but no care plan for oxygen use, did not meet her expectation. The DON stated that the importance of having patient-centered care plans was that it lets the caregivers know how to care for the residents appropriately. Review of the facility's policy on Care Plan Revisions Upon Status Change, reviewed October 14, 2024, revealed that the care plan will be modified with the new or modified intervention, that care plans will be modified as needed by the MDS Coordinator or other designated staff member, and the Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in a resident's care.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan was revised after each fall for two sampled residents (#18 and #22). The deficient practice could result in resident not getting the appropriate care they need. Findings include: -Resident #22 was readmitted to facility September 9, 2024 with diagnoses of urinary tract infection, type 2 diabetes mellitus, end stage renal disease (ESRD) and kidney disease. An admission evaluation dated September 9, 2024 revealed that the resident was a fall risk related to poor vision. Interventions included the following: -4P's rounding (pain concerns, positioning needs, personal items are within reach and personal needs are being met) -Mat next to bed -Hi/low bed A care plan initiated on September 10, 2024 revealed the resident had the potential for falls related to ESRD, T2 DM and PVD. Interventions included 4P's rounding (pain concerns, positioning needs, personal items are within reach and personal needs are being met); to anticipate needs as able; call light within reach when in room; to educate and/or provide cues, prompts, and reminders regarding safety precautions as needed; Fall Risk Assessment on Admission and Quarterly; to observe for sign and symptom of drug related side effects and report to physician; to orient resident to new surrounding as applicable; and, therapy screen/evaluation as ordered or as needed. Further review of the actual care plan revealed that the resident had fall incidents on October 9 and November 4, 2024; and that, the resident with pain on right side of the body. However, the care plan revealed no evidence that interventions were revised. A post fall progress note dated October 14, 2024 revealed that current preventive measures were in place: 4P rounding, Hi/low bed, PT/OT/ST Keep wheelchair close to bed; and that, there were no new interventions required at this time. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated resident had moderate cognitive impairment. The assessment also included impaired vision, need partial/moderate assistance with chair/bed to chair transfer A post fall progress note dated November 5, 2024 revealed that current preventive measures were in place: Call light education, 4P's, high/low bed, mat next to bed, frequent checks. No new interventions required at this time. An interview was conducted with the resident on November 4, 2024, at 12:44 p.m., who stated that he fell this morning and his back to the head was hurting. He stated that two staffs were present when he fell and no pain medication was given so far. An interview was conducted with the resident on November 6, 2024, at 7:31 a.m. who stated that he was getting up on November 4 and that a provider and a male staff were present in the room. He said that the provider was assisting his roommate when while he was dressing up he fell and hit on wall between the bed and table. The resident said that few minutes later, the male staff came and pulled his shirt out and stated that there was no bruise and put me back on bed. The resident also said that his lower back started hurting and they rushed him to the hospital; and that, he was given a shot at the hospital and he came back at the facility on the same day around noon. He further stated that he was not on any medication for fall. An interview with a certified nurse assistance (CNA/staff # 137) was conducted on November 6, 2024, at 7:31 a.m. The CNA stated that resident #22 was a stand by assist and does not need any help getting up; but, staff want to ensure the resident was safely getting up without any obstruction in his path and also no loose cloth to prevent tripping. The CNA said that staff usually assist resident #22 in the morning to get him up in wheelchair; and that, the resident was mostly independent rest of the evening. Regarding resident #22, the CNA said that the resident was not a fall risk, did not have injury due to a fall, does not have any pain and does not refuse any fall intervention. The CNA stated that if the resident refuses intervention then the CNA was not sure what to do and whom to ask. The CNA said that resident #22 had fall on November 4 and the CNA was not sure who was present with the resident in the room at the time of the incident. The CNA said that the facility then took measures such as frequent monitoring every 4 hr. In an interview conducted with Registered Nurse (RN/staff 8) on November 6, 2024 at 12:32 p.m., the RN stated that staff would always tell resident #22 to wait for a CNA; but, the resident always wanted to do things by himself. The RN said that on November 4, 2024, the resident tried to stand up and hit his right side of trunk of body; however, there was no bruise, cut or open wound were found. The RN stated that interventions put in place after a fall included for CNAs to be on high alert, answering call lights and lowering the resident's bed. The RN further stated that he thinks the interventions were working; and that, the resident does not have any pain. An interview was conducted with Quality Infection Control (QIC/ staff #6) on November 6, 2024 at 03:08 p.m. The QIC stated that the care plan must be triggered within 24 hr. by the admission nurse and reviewed by a unit manager and MDS coordinator. Regarding resident #22, the QIC said that the resident had two falls since admission and the resident did not report the incidents immediately. The QIC said that during admission, the resident was assessed for fall risk due to poor vision; and, interventions put in place included high or low bed and mat next to bed. The QIC also said that after the resident's fall on October 14, interventions included call light educations, high or low bed and activities/exercises. The QIC also said that the resident had a second fall on November 4 and had a head strike. She said that 911 was called, vital signs were monitored and resident was given some pain pills, family/provider were notified, and lab result was negative. The QIC further stated that there were no new interventions required at this time which means intervention in place were basically the same. She further stated that the facility/staff had used and exhausted all its resources and was using the same intervention. The QIC further stated that if a care plan was not updated then will not able to provide continuity of care. During an interview with the Director of Nursing (DON/ staff #123) conducted on November 7, 2024 at 8:51 p.m., the DON stated that the care plan was specific to each individual resident. A review of the clinical record was conducted with the DON who stated that there was no intervention was changed or added in the resident's care plan after the fall on October 14 and November 4, 2024. She said that the facility did not follow our policy; and, risk of not having the care plan could result in staff not having full information regarding residents. The DON further stated that the care plan for resident #22 was corrected yesterday. Review of the facility's policy titled Care Plan Revisions Upon Status Change, reviewed October 14, 2024, revealed that the care plan will be modified with the new or modified intervention, that care plans will be modified as needed by the MDS Coordinator or other designated staff member, and the Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in a resident's care. 51239 -Resident #18 was admitted on [DATE] with diagnoses of sacral fracture, Type 2 Diabetes Mellitus, history of fall, transient ischemic attack (TIA), and cerebral infarction. The progress note dated June 16, 2024 revealed the resident was found on the floor with an increased pain; and that, 911 was called for further evaluation and transfer to the hospital. Review of a care plan initiated on June 19, 2024 included the resident had potential for falls. The goal was that the resident will be free from fall related injury through the next review. Interventions included educate/ reminders regarding safety precautions, fall risk assessment admission and quarterly, therapy screen/evaluation as ordered. On June 23, 2024, the resident was found on the floor next to his bed which was in the lowest position. Immediate actions included pain and skin assessments. The report also revealed that there was a skin abrasion on left elbow and the resident was reeducated on call light use. The Care Plan initiated on June 25, 2024 revealed that the resident had an actual fall on June 16, 2024 with major injury that resulted in nondisplaced anterior S2 fracture. Interventions included to continue interventions on the at-risk plan. However, there was no evidence that the care plans were evaluated for the effectiveness of its interventions; and, there was no evidence that it was revised with each fall to include new interventions to prevent recurrent falls. The documentation on June 30, 2024 included that the resident was found on the floor, and trying to reach his milk. The clinical record revealed that the resident was non-compliant with fall prevention, confused at times, ordered fall mattress, process e-examined and corrected. The progress note dated July 1, 2024 included that the current preventive measures in place were call light education, 4Ps, Hi/lo bed, Therapy evaluation, frequent checks and scoop mattress. Per the documentation, there were no new interventions required at this time. A progress note dated July 12, 2024 revealed the resident was found on the floor and did not have skid socks on. On August 21, 2024, the resident was found on the floor; and, the resident reported that he was trying to get out of bed to go to the bathroom. Per the documentation, there were no injury reported. The documentation on September 4, 2024 revealed that the resident was found on the floor beside his bed; and that, the resident reported that he was trying to get off of his blanket. It also included that the resident did not have any injury. A progress note dated September 6, 2024 included that the resident was found on the floor beside his bed; and that, the resident wanted to crawl down from bed because wanted sleep on floor. Per the documentation, there were no injuries noted. The clinical record documentation dated September 9, 2024 revealed the resident had two falls with no injury. On September 11, 2024, the resident was found lying on the floor on stomach on fall mat and had no injury. The quarterly Admission Minimum Data Set (MDS) assessments dated September 24, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had mild cognitive impairment. The MDS also included that the resident displays behaviors of rejection evaluation of care for 1 to 3 days, and the resident had two or more falls since admission or prior to assessment. Despite documentation that the resident had multiple falls, there was no evidence found that fall care plan interventions were revised to include new interventions and revised with each fall to include new interventions to prevent recurrent falls after June 25, 2024. There was no evidence that the care plans were evaluated for the effectiveness of its interventions. An interview was conducted on November 6, 2023 at 11:10 a.m. with a Licensed Practical Nurse (LPN/Staff #111) who stated that the intervention for the June, 16, 2024 fall sending the resident to the hospital; and, it should have been documented in the care plan. She also stated that new interventions should been placed in to the care plan after the falls on June 30, July 12, September 4, and September 9, 2024. The LPN stated that the risks for not having no new interventions would be that the resident will be in higher risk for recurrent falls and cause injuries. An interview was conducted on November 6, 2024 at 12:24 p.m. with the Director of Nursing (DON/Staff #123) who stated that the facility process for care planning was to complete initial and baseline care plan upon admission, and add interventions as necessary. In another interview with the DON conducted on November 6, 2024 at 12:42 p.m., the DON stated that she oversees the residents' care plan; however, she was not able read the care plan for resident #22. She also stated that floor nurse was expected to put interventions on to the care plan and update the care plan as necessary. A policy titled, Care plan revision upon change, reviewed on October 14, 2024, revealed that the purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. The comprehensive care plan will be reviewed, and revised as necessary.

Based on observation, staff interviews, and review of facility policy, the facility failed to ensure that one medication was disposed of in accordance with professional standards of practice, the deficient practice could result in medications not being disposed of properly. The sample was 28 medication administrations observed. Findings include: During a medication administration observation with a Registered Nurse (RN/Staff #8) conducted on November 6, 2024 at 7:23 AM, the RN dispensed a multiple vitamins capsule into a medication cup with other medications and then verified on the order that it was the incorrect medication. The RN then used gloved hands to retrieve the capsule and put it back into the multiple vitamins container. An interview was conducted with a RN (Staff #8) on November 6, 2024 at 9:43 AM who stated that he usually does not put the medication back into the container after it being dispensed and that he would dispose of it in the drug buster. He further stated that he should not have put the capsule back into the container because of aseptic technique and that it could be contaminated by touching the other medications that were already dispensed into the medication cup. During an interview with the Director of Nursing (DON/Staff #123) on November 7, 2024 at 9:48 AM, the DON stated that the process for disposing non-controlled medications would be to discard the medication and not put it back into the container. She also stated the risks of placing the medication back into the container after it was dispensed would be that it could contaminate the other vitamins that are in the container. She further stated that this did not meet facility expectations. The facility provided documentation that there was not a policy for disposition of non-controlled medications and that medications are placed in the Drug Buster per standards of practice.

Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one sampled resident (#342) did not receive a pneumococcal vaccine. The deficient practice could result in residents not receiving vaccines. Findings included: Resident #342 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, fracture of unspecified part of neck of right femur, and muscle weakness. A progress note dated September 20, 2024, revealed that the resident would like to receive a pneumococcal vaccination during skilled nursing facility stay. The admission Minimal Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of an Immunization Informed Consent-V7 form dated October 29, 2024, revealed a signed consent by the resident's sister to receive the pneumonia vaccine Prevnar 20. Despite documentation that the family agreed to the vaccination, there was no evidence that the medical record of a physician order for the pneumonia vaccine Prevnar 20. Progress note dated October 29, 2024 to November 7, 2024 revealed no evidence that the vaccine had been administered or ordered. An interview was conducted with Quality Infection Control (QIC/ staff #6) on November 7, 2024 at 12:13 p.m., who stated that the resident consented for pneumonia on October 29, 2024. She further stated that immunizations are offered upon admission and during the flu season. The QIC reviewed the clinical record and stated that the resident did not receive the pneumonia vaccine. She further stated that she did not place the order for pneumonia into the resident's record. She then stated that the risk could result resident's getting pneumonia. An interview was conducted with the Director of Nursing (DON/ staff #123) on November 7, 2024 at 12:47 p.m., who stated that the facility conducts a yearly flu/pneumonia clinic in September. She also stated that the resident's pneumonia vaccination was missed, and that she will order it. She further stated that the risk could resulted in residents becoming sick with pneumonia and flu. Review of facility policy titled, Pneumococcal vaccine (series), reviewed on October 16, 2023, revealed that each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications the immunization may be administered in accordance with physician-approved standing orders.

Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#4 and #101) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in incompetent care of residents. The facility census was 32 and the sample was 12. Findings include: The personnel file of a certified nurse assistant (CNA/staff # 4) revealed a hire date of August 06,2007. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training since April 25, 2021. The personnel file of a certified nurse assistant (CNA/staff # 101) revealed a hire date of May 31,2023. The file revealed no evidence of Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training. An interview was conducted on September 20, 2023 around 3:25 p.m. with the Business Office Manager (staff # 26), he stated that staff # 4's, last in-service training was done on April 25,2021 and staff #101 hasn't completed her new hire orientation in last 3 months. An interview was conducted on September 21, 2023 at 10:15 a.m. with the Director of Nursing (DON/ staff # 51), he stated that new hire staffs are required to complete Abuse/neglect/exploitation, Resident rights, Dementia care, Infection control and Communication training within 30 days of being hired. He further stated that Inservice training for staff are done annually or as needed. A review of the facility Training Requirements policy revealed that Training requirements should be met prior to staff and volunteers independently providing services to residents, annually, and as necessary based on the facility assessment.

Based on facility documents and closed clinical record review, staff interviews, and review of policies, the facility failed to ensure one resident (#81) was free from a significant medication error. The deficient practice could result in adverse medication side effects for a resident. Findings include: Resident #81 was admitted to the facility on [DATE] and discharged from the facility on December 3, 2021. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan revealed an undated problem: Black Box Warnings for Antipsychotics: [MEDICATION(S)]; Adverse cardiovascular effects, risk for infections, falls, blood glucose and lipid elevations, abnormal involuntary movement, [CONDITION(S)] adverse events like stroke, sedation. The goal included: Side effects and adverse reactions for antipsychotics will be minimized, recognized early, or prevented daily. Interventions stated to observe for dizziness, sedation, unsteady gait, especially during initiation of therapy or with dosage changes. Report to the physician immediately. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate impaired cognition. The assessment included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #98). Review of a nurse progress note dated December 27, 2020 revealed: Resident Alert and Oriented (A&O) times two, recently started on [MEDICATION(S)] before sleep (HS). The resident had aggressive behaviors toward nursing staff today. The resident was grabbing at nursing staff, holding their arms very tightly, and resistant to letting go. The resident appeared agitated and was attempting to get up several times during the early morning. The RN contacted the on-call provider and informed her of the resident's behaviors at approximately 7:00 a.m. The on-call provider ordered [MEDICATION(S)] (antianxiety) as needed (PRN) and a one-time dose of [MEDICATION(S)] (antipsychotic), administered [MEDICATION(S)] at 7:45 a.m. The resident fell asleep after about a half hour, and remained asleep throughout lunch and did not want to eat despite being roused by staff. At around 3:00 p.m. the resident became increasingly sedated, pupillary response brisk, resident responded physically to verbal stimuli by squeezing fingers. The resident was not responding verbally. The RN notified the provider of the resident's condition and the resident was sent to the Emergency Department (ER) via ambulance at 4:15 p.m. Review of facility documentation revealed a medication error report for resident #81 dated December 27, 2020 that included the resident was sent to the hospital, was non-responsive, and referred to a nurse's note on December 27, 2020 under notes. Review of facility documentation revealed a Facility Self Report regarding an incident that occurred on December 27, 2020 and included that resident (#81) was given an incorrect dose of medication with possible adverse reaction, the resident was sent to the Emergency Department as a precaution. Review of a nurse progress note dated December 28, 2020 at 6:33 a.m. revealed the nurse received a report from the hospital nurse that the resident was admitted to the Intensive Care Unit (ICU) at 9:00 p.m. Review of a nurse progress note dated December 28, 2020 revealed the resident re-entered the facility from an overnight stay at the hospital. Review of the facility investigation revealed that on December 27, 2020 resident #81 was exhibiting behaviors including aggression. The RN (staff #98) called the physician and was given orders including an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN (staff #98) unknowingly gave 200 mg of [MEDICATION(S)] instead of 25 mg. At 3:00 p.m., the nurse noted that the resident was having increased lethargy and only responding to voice. The RN (staff #98) then checked the bubble pack card and realized that she had given the wrong dosage. The provider's direction was to send the resident to the hospital for further evaluation and the resident was transferred via ambulance. The resident returned to the facility on [DATE] and was observed to be at baseline but still exhibiting aggressive behaviors. The conclusion stated the facility determined that the RN (staff #98) failed to confirm the proper dose prior to administering [MEDICATION(S)] which precipitated an unintended reaction from the resident causing the resident to be sent to the Emergency Department as a precaution. Plan of Correction included the Director of Nursing (DON) and/or designee would re-educate nurses regarding The Five Rights of Medication Administration; Written Correction for staff #98 for failure to follow the Five Rights of Medication Administration; DON and/or designee would perform random audits including quizzing nurses on the Five Rights of Medication Administration; and the (QAPI) Quality Assurance and Performance Improvement Committee would review the audits of the DON and/or designee for a period of 90 days and/or until the committee had determined that substantial compliance had been achieved. -RN (staff #98) was interviewed by the facility on December 28, 2020: She checked the emergency kit for [MEDICATION(S)] and did not see it there. She remembered that the night nurse mentioned having someone on [MEDICATION(S)]. Resident #81's behaviors were pretty bad, she was trying to address the resident behaviors before they got worse. She went to the other hall to borrow some [MEDICATION(S)] from the medication cart. The other nurse (RN/staff #99) was there doing medication passes and the RN (staff #98) told her what she was doing. She (RN/staff #98) popped it out of the card. At around 3:00 p.m. resident #81 was still lethargic and after the resident refused lunch she started to worry that the resident was not responding. She called the Nurse Practitioner (NP) and received direction. She realized that she was in such a hurry that when she pulled the medication she had not looked at the card for the actual dosage. She went to look at the card and realized that she gave the resident 200 mg of [MEDICATION(S)]. She called the NP to tell her what happened. -The timeline included: [MEDICATION(S)] administered at 7:45 a.m. on December 27, 2020; by 8:15 a.m. the resident had fallen asleep; by 3:00 p.m. the resident became increasingly despondent and would only squeeze the nurse's hand but would not verbally engage and the NP was notified of the resident's condition; At 3:45 p.m. the nurse discovered the error and called the provider, at that time was advised to send the resident to the hospital for further evaluation; At 4:00 p.m. the resident was transferred to the hospital; On December 28, 2020 the resident returned to the facility and appeared to be at baseline. -Included in the documentation was a page that started with: Medication Error with associated adverse event December 27, 2020 that included that on December 27, 2020 at 7:15 p.m. the resident had been intubated and sent to the ICU for further monitoring. Review of hospital records for an admitted [DATE] revealed resident #81 was admitted to the hospital for an unintentional iatrogenic [MEDICATION(S)] overdose with severely diminished Level of Consciousness (LOC). The final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital course included: The resident was accidentally given 200 mg of [MEDICATION(S)] on December 27, 2020 instead of the normal dose of 25 mg. Upon arrival at the emergency department, the patient was intubated for airway protection. Question of [CONDITION(S)] activity noted with brief eyelid fluttering post intubation. The patient was admitted to ICU and was extubated overnight without issue. The patient was discharged back to the facility as the resident was at baseline. The resident discharge date was December 28, 2020. A NP progress note dated December 29, 2020 revealed nursing reports that the resident is declining and has been unable to feed self in the last few weeks. Patient was recently hospitalized after receiving an increased dose of [MEDICATION(S)]. Today, nursing reports the resident cognition is at baseline. Assessment and plan included: [MEDICATION(S)] overdose, patient was sent to the hospital and returned December 28, 2020. Patient is at baseline this morning. Review of the personnel record for RN (staff #98) revealed a Corrective Action Notice signed December 31, 2020 for a concern of inefficient, negligent or substandard performance. The description included that on 12/27/2020 she failed to obtain medication via standard operating procedures and to follow the Five Rights of medication administration, specifically the right dose. These actions resulted in resident #81 receiving the wrong dose of [MEDICATION(S)]. In turn, it required a transfer to the hospital for further evaluation. Required corrective action included: When performing medication administration, she was expected to practice the 5 Rights of Medication Administration which included; right patient, right drug, right dose, right route, and the right time. Review of the personnel record for RN (staff #99) revealed a Corrective Action Notice signed January 1, 2021 for a concern of inefficient, negligent or substandard performance. The description included that on December 27, 2020 she failed to keep both of her medication carts locked at all times. This resulted in the availability of her medications to others that resulted in a medication error. Review of a nurse in-service revealed re-education related to preventing medication errors, accessing and troubleshooting the RxNow machine (emergency medication supply), 5 rights, and securing medication carts dated January 1, 2021 and revealed a sign in sheet with 15 signatures, including staff #98 and staff #99. Review of the facility documentation revealed 13 nurses completed a quiz on Avoiding Medication Errors on January 1, 2021 which included the 5 Rights of Medication Administration, borrowing medication, and medication storage. Review of facility QAPI documentation revealed: -January 18, 2021: A quality metric for Medication Errors which included a goal of zero, a current rate of zero, and the area was trending in the right direction and no action was needed. -February 15, 2021: A quality metric for Medication Errors which included a goal of zero, a current rate of zero, and the area was trending in the right direction and no action was needed. -March 22, 2021: A quality metric for Medication Errors which included a goal of zero, a current rate of zero, and 2/15-no action needed, 1/18 the area was trending in the right direction and no action was needed. An interview was conducted on August 10, 2022 at 8:47 a.m., with a RN (staff #3). She stated the nurses are expected to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the nurse was expected to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the risk of not following the 5 rights of medication administration were that the resident could get the wrong medication, including the wrong dose, and it could cause a health issue for the resident. An interview was conducted on August 10, 2022 at 8:57 a.m. with the Director of Nursing (DON/staff #97). She stated that she expected the nurses to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated if a nurse did not follow the rights of medication administration, it would be a medication error and could cause adverse effects to the patient. Regarding resident #81, she stated from what she had seen the resident was having behavioral issues and was ordered a one-time medication order for [MEDICATION(S)]. She stated the nurse borrowed the medication from another resident, did not note the dosage, and gave 200 mg of [MEDICATION(S)] instead of 25 mg which was a significant medication error. The resident became very lethargic and was sent to the hospital. The DON stated the error caused the resident to receive emergency medical attention related to effects from the medication (severe LOC and a hospital visit). The DON stated the nurse gave way too much, which would be considered harm. An interview was conducted on August 10, 2022 at 2:48 p.m. with a RN (staff #98). She stated that she remembered the incident that occurred with resident #81. She stated that she had received an order to administer [MEDICATION(S)] 25 mg to resident #81. The RN stated that when she was unable to find the medication in the emergency medication kit she borrowed [MEDICATION(S)] from another resident's medication supply. She stated that she administered the medication to the resident and throughout the day the resident became more somnolent. She stated that she called the provider and told her that she did not know if the resident was tolerating the medication. She stated that she was looking in the resident's chart and at the medication and that she saw that the other resident was on a different dose of the medication, both 25 mg and 200 mg. She stated that she realized there were two dose amounts that could have been administered and went and looked at the medication cards. She stated that she notified the provider immediately after realizing that she gave a dose of 200 mg, and the provider had her send the resident to the E.R. She stated that she had to do a report of the incident and receive counseling. The RN stated that she should have confirmed the medication dosage before administering the medication and should not have borrowed from another resident. She stated that she did not follow the rights of medication administration because she gave the medication to the wrong resident, and gave the wrong dose. She stated that the resident suffered harm as a result of the medication error and that it was a significant medication error of an antipsychotic medication. Review of a facility policy for Medication Administration dated October 21, 2021 included: Medications will be administered to residents as prescribed by the physician or only by persons lawfully authorized to do so in a safe and prudent manner. Medications are administered in accordance with the written orders of the attending physician. Each resident is to be identified before administering medications. Medications provided for one resident are not to be used for another resident. Review of a facility policy for Medication Incident dated October 21, 2021 included: Medication incidents are to be reported to the Director of Nursing so that an investigation can be initiated. The following will be considered medication incidents: Omission of ordered medication, Medication given to the wrong resident; The wrong dosage, form, route or time in administration of medication; Unordered medication given to the resident.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure a written notice of transfer/discharge was provided to one resident (#182) and that a copy was sent to the Office of the State Long Term Care Ombudsman for two residents (#12 and #133). The deficient practice could result in residents/representatives not being provided written notice of transfers/discharges and the ombudsman not receiving a copy of the notices. Findings include: -Resident #12 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing note dated May 28, 2022 at 11:30 a.m. stated that the resident was sent to the emergency room for difficulty breathing, with oxygen saturation decreasing to 87% even with O2 at 3.5 LPM (liters per minute). At the time of discharge the resident was oriented to person, place and time. The resident was informed of the reason for transfer to the hospital in a language and manner they could understand. Further review of the clinical record did not reveal evidence that the ombudsman received written notification of the transfer/discharge. -Resident #133 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing note dated July 15, 2021 at 8:50 a.m. stated the resident was discharged on [DATE] at 2:00 p.m. Reviewed Discharge Plan of Care with resident. Discharge medications/treatments reviewed with resident/POA (power of attorney). All questions regarding discharge medications/treatments were answered prior to discharge. Discharge medications obtained from the pharmacy and sent with the resident/family. Documents sent home on discharge included: Copy of this Discharge Plan of Care (Summary); Schedule II handwritten scripts. Further review of the clinical record did not reveal evidence that the ombudsman received written notification of the transfer/discharge. On August 11, 2022 at 8:34 a.m., an interview was conducted with the Director of Social Services (staff #21), who stated that she has never notified the ombudsman when a resident is transferred/discharged . Staff #21 stated the prior Director of Social Services told her that she never contacted the ombudsman when there was a discharge. An interview was conducted on August 11, 2022 at 8:38 a.m. with the Director of Nursing (DON/staff #97), who stated that the ombudsman needs to be notified regarding discharges. The DON stated she spoke to the ombudsman and told him that the facility will begin emailing him the discharge notifications monthly. During an interview conducted on August 11, 2022 at 2:28 p.m. with the DON (staff #97), she stated that the facility does not have a policy regarding ombudsman notifications because the facility was not aware that the ombudsman had to be notified. -Resident #182 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record indicated that the resident was his own responsible party. Review of the Admission Evaluation dated October 26, 2021 revealed the resident was alert and oriented x 4 (person, place, time, and situation). Review of corresponding nursing notes revealed the resident had been transferred to the hospital on October 27, 2021. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had been discharged from the facility on October 27, 2021 to an acute hospital. Further review of the clinical record revealed no evidence that the resident was notified in writing of the transfer/discharge. In an interview with a Registered Nurse (RN/staff #1) conducted on August 11, 2022 at 10:30 AM, she stated that when a resident is transferred to the hospital they complete a transfer form that is faxed with other paperwork to the hospital. She also stated that the resident and family are not provided a written copy of the transfer notice. The RN reviewed the medical record and stated that the documentation showed that the resident had a fall and was transferred to the hospital on October 27, 2022. An interview was conducted on August 11, 2022 at 11:17 AM with the Director of Nursing (DON/staff #97), who stated that when a resident is transferred to the hospital, there is an acute care transfer form that is to be completed and sent to the hospital. The DON stated that it is not a practice of this facility to provide written notification of transfer/discharge to the resident or resident's representative. Review of the facility policy titled, Transfer and Discharge, revealed emergency transfers should include a physician's order, the nurse should complete and send with the resident a transfer form, a copy of the advanced directive, and a copy of the transfer form should be kept in the medical record. Record the reasons for, the effective date of transfer or discharge, and the location to which the resident is being transferred or discharged , in the medical record and on a discharge for or letter. Give a copy of the discharge notice to the resident and/or the family/legal representative. The review also revealed that the Notice of Discharge should be sent to the Ombudsman. A copy of the notice must be sent at the same time notice is provided to the resident/resident representative at least 30 days prior to the discharge or as soon as practicable. When an emergency transfer/discharge occurs a copy of the transfer notice may be sent when practicable, such as a list of residents on a monthly basis.

Based on clinical record review, staff interview, and review of policy, the facility failed to ensure one resident (#85) was provided with the required information concerning the formulation of advance directives. The sample size was 3. The deficient practice could result in residents not being informed of the right to formulate advance directives. Findings include: Resident #85 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The active care plan was reviewed, it did not include the resident's advance directives/code status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. However, a clinical record review was conducted on August 8, 2022 at 1:11 p.m. and did not reveal evidence that the facility informed and provided written information to the resident concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. An interview was conducted on August 9, 2022 at 3:35 p.m. with the Director of Nursing (DON/staff #97). She stated, in the facility, staff did a verbal confirmation with the resident to determine if the resident wished to be full code or Do Not Resuscitate (DNR) and then an order would be written. The DON stated if a resident was a DNR they would have an orange form in the record. She stated if the resident was a full code, there would be no documentation that the resident chose to be full code, except an order written [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated when she started working at the facility, she asked the question about advanced directives and was informed that the facility did not do the advance summary form anymore and only used the orange do not resuscitate form. She stated that she was aware of the requirement to offer the resident the opportunity to form advance directives and that she was aware that the requirement was not being met in the facility. She stated this presented a risk factor that the staff would not know what treatments the resident wanted when the resident was not able to speak for themselves and had no one else to speak for them. The DON stated that advance directives included more than the code status. The facility policy for Advance Directive and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . We will inquire of all new residents upon admission whether he or she has an advance directive or POLST in place or would like to create an advance directive. At the time of admission, the facility shall document in a prominent part of the resident's medical record whether or not the individual has executed an advance directive or POLST and place the document in the medical record. Provide written information to residents regarding rights to formulated, at the resident's option, advance directives.

Based on observations, staff and resident interviews, review of facility policies and procedures, and documentation from the Centers for Disease Control (CDC), the facility failed to maintain an effective infection control program, which provided a safe and sanitary environment, in order to help prevent the development and transmission of disease and infection. As a result, the Condition of Immediate Jeopardy (IJ) was identified. The facility also failed to ensure that one staff member washed her hands between glove changes, during a wound care observation. Findings include: On April 22, 2014 at 11:00 a.m., the Condition of Immediate Jeopardy was identified. The Administrator was informed of the facility's failure to consistently implement infection control precautions for one resident (#192), who was on contact precautions for[DIAGNOSES REDACTED]. Multiple observations were conducted of resident #192, wandering around the facility, without any precautions in place. Facility staff were aware of the resident being out of her room and did not ensure the resident was following proper precautions to protect the other residents. Staff were also observed going in and out of resident #192's room, without wearing gowns and/or gloves. In addition, resident #192's roommate (resident #23), had loose stools and was being tested for[DIAGNOSES REDACTED] and was on contact precautions. Resident #23 was observed on April 22, in the dining room and in the hallways in her wheelchair, without gloves and a gown. The Administrator presented a plan of correction on April 22, 2014 at 4:45 p.m. The Administrator was informed of the need for additional corrective action to be included in the plan of correction. A revised plan of correction was presented on April 24, 2014 at 10 a.m., and was accepted at 10:12 a.m. The plan included infection control measures the facility was implementing, such as cleaning contact surfaces throughout the building with the appropriate disinfectant, and staff in-services regarding infection control, including contact precautions for[DIAGNOSES REDACTED]. Multiple observations were conducted of the facility implementing their plan of correction, which included the cleaning of contact surfaces throughout the building, in-services regarding infection control and contact precautions for[DIAGNOSES REDACTED], and observations of staff implementing contact precautions. The Condition of IJ was abated on April 24, 2014 at 10:18 a.m., due to the corrective measures taken by the facility. -Resident #192 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact and was always continent of bowel. Review of a progress note written by the Nurse Practitioner (NP) dated April 21, 2014, revealed that last week, the resident had a fever of 101.8 and her stool was tested two times for[DIAGNOSES REDACTED], which were negative. Per the note, the lab refused to run a third test, as the stools had been formed since the test was run. However, review of the clinical record revealed a lab report dated April 20, 2014, that documented the resident was positive for[DIAGNOSES REDACTED] Toxin B. Further review of the NP progress notes revealed an addendum dated April 21, 2014, that included a stool for[DIAGNOSES REDACTED] came back positive and the resident was started on [MEDICATION NAME]. physician's orders [REDACTED]. Review of the CNA report sheets dated April 21, 2014, revealed the resident had two stools, one was medium soft and the second was medium formed. A current care plan for Presence of Infective Process, as evidenced by Cellulitis and[DIAGNOSES REDACTED] included the following interventions: the resident will be treated with appropriate medications and receive the treatment required to resolve the infection over the next 14 days, monitor for fever, signs and symptoms of sepsis, report abnormal findings to Medical Doctor, assess the need for increased fluid intake due to fever, and initiate infection control/isolation-contact precautions, as necessary. On April 21, 2014, a sign was observed outside of resident #192's room. The sign stated to see the nurse before entering and that a gown and gloves were required. Also, outside of the room was an isolation cart containing gloves and gowns. In an interview with a Registered Nurse (RN) on April 21, 2014 at 3:45 p.m., the nurse stated that the resident was not feeling well, but had no diarrhea that she knew of. The nurse stated that resident #192 was on contact precautions for[DIAGNOSES REDACTED]. An observation was conducted on April 21, 2014 at 6 p.m., of resident #192 in the dining room, without a gown and gloves on. An observation was conducted on April 22, 2014 at 10:15 a.m., of resident #192 walking in the hallway and in the Great Room with a physical therapy aide. Neither the physical therapy aide, nor the resident had gowns or gloves on. In an interview with the physical therapy aide on April 22, 2014, she stated that she forgot the resident was on contact precautions, when she took her out of her room. An interview was conducted with the NP on April 22, 2014 at 10:30 a.m. The NP stated that the resident was diagnosed with [REDACTED]. She stated the resident told her that she had some cramping and some diarrhea, so she ordered stools times three. The NP further stated resident #192 should be having her physical therapy and other therapies in her room. An interview was conducted on April 22, 2014 at 10:45 a.m., with the RN caring for resident #192. She stated that she was unaware that the resident had any diarrhea, and that the Certified Nursing Assistance (CNA) would be more aware. Reviewed of the CNA report sheet dated April 22, 2014, revealed resident #192 had one medium soft stool. In an interview on April 22, 2014 at 10:50 a.m., resident #192 stated she had one stool today around 6:00 a.m., and had two stools yesterday, which were formed. She stated that she uses the commode in her room and cleans her hands with gel, and then goes to the restroom and washes her hands. During an interview conducted on April 22, 2014, the DON (Director of Nursing) stated that if a resident has diarrhea, they are put on contact precautions until three stool specimens come back negative or diarrhea ceases. The DON stated that resident #192 was on contact precautions and staff should be applying gloves and gowns before entering the room. The DON further stated that resident #192 should not be out of the room, without gloves and a gown on. In an interview on April 22, the NP also stated that she was testing the roommate (resident #23) of resident #192 for[DIAGNOSES REDACTED], due to resident #23 complaining of foul smelling gas and loose stools. Cultures were pending for these tests. Observations conducted on April 22, revealed that resident #23 was on contact precautions. However, on this same day, resident #23 was observed in the dining room and in the hallways in her wheelchair, without gloves and a gown on. An observation was conducted on April 23, 2014 at 10:30 a.m. A nurse went into the room of resident #192 and donned gloves, but no gown. The nurse proceeded to assist the resident with a thermometer and then rested her gloved hands on her uniform. An observation was conducted on April 23, 2014 at 2:50 p.m., of a CNA entering resident room [ROOM NUMBER], without donning gloves and a gown, prior to entering. The CNA then came out of the room and used hand sanitizer. A CNA was interviewed on April 23, 2014 at 2:50 p.m. The CNA was asked if she had been in-serviced within the last 24 hours related to contact precautions/infection control and she stated that she had not been in-serviced. Review of a facility policy on Contact Precautions, reflected that contact precautions will be used during care and treatment of [REDACTED]. The policy included the following: Contact transmission; most important and frequent mode of transmission of nosocomial infections. Personal protective equipment (PPE) such as gowns and gloves should be worn during procedures and resident care activities and discarded in appropriate trash, with good hand washing before leaving the resident room. Also, the policy stated to limit the transport of the resident from the room for essential purposes only and when the resident is transported out of the room, instruct health care workers on necessary precautions. Review of the 2007 Centers for Disease Control and Prevention (CDC) guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands who have touched a contaminated surface or item. For the prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, it stated to use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines also stated to use gloves and gowns when entering patients room and during care and for all interactions that may involve contact with the patient or potentially contaminated areas in the patients environment. It further documented that before exiting the patient room, discard PPE (personal protective equipment) to contain pathogens. In addition, the CDC guidelines included that[DIAGNOSES REDACTED] infected patients continue to shed organisms for a number of days following the cessation of diarrhea. The guidelines also stated to implement an environmental and disinfection strategy to ensure the adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently -During a pressure ulcer dressing change conducted on April 23, 2014, a staff member was observed changing her gloves, after removing a soiled dressing. The staff member then donned clean gloves, without washing her hands or using hand sanitizer. An interview was conducted with the staff member immediately following the observation on April 23, 2014. The staff member stated that she did not know what the facility's policy was regarding hand-washing between glove changes. Review of the facility's policy on Hand Hygiene revealed that hand hygiene is the single most important measure for preventing the spread of infection. The policy included to wash hands immediately after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn and to wash hands immediately after gloves are removed. The policy also stated that "...The health care community will take every precaution to prevent the spread of infections by using proper hand hygiene techniques at all times...Hand hygiene requirements: before performing a resident care activity of daily living (ADL) procedure and after removal of gloves if worn..."