Every finding on record at The Village at Gleannloch Farms

Number of residents sampled: Number of residents cited: Based on observations, interviews, and record reviews, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication carts (Cart B) and 1 of 1 medication storage rooms, reviewed for medication storage.- The facility failed to ensure 2 albuterol inhalers without an open date for Resident #24 and a Fluticasone-Salmeterol inhaler without an open date for Resident #24, were removed from Medication Cart B.- The facility failed to ensure a box of Juven packets with 19 packets in it, expired 9/1/25, and a glucose test trip bottle without an open date on it, were removed from Medication Cart B.- The facility failed to ensure a box of Align with 7 capsules in it, expired 8/31/25, was removed from the medication storage room. These failures could place residents at risk of not receiving therapeutic benefits of the medication, adverse reactions, inaccurate test results, and hospitalization.Findings included:Record review of Resident #24's undated face sheet revealed she was a [AGE] year-old female, readmitted [DATE], and originally with an original admitted admission date of 5/22/25. Her diagnoses included COPD (progressive lung disease causing airflow limitation and breathing problems), Afib (irregular heartbeat), dysphagia (trouble swallowing), dementia (progressive or persistent loss of intellectual functioning), major depression, HTN (high blood pressure), anemia (low iron), and polyneuropathy (nerve pain).Record review of Resident #24's admission MDS assessment, dated 8/7/25, revealed a BIMS score of 15 out of 15, which indicated normal cognition. The MDS revealed the resident had asthma (COPD) or chronic lung disease and had shortness of breath or trouble breathing when lying flat.Record review of Resident #24's Care Plan, dated 8/2/25, revealed a Focus: Resident has COPD, with a goal of optimal breathing pattern daily through the review date. The interventions were to give aerosols or bronchodilators (medications that open the lungs) as ordered, monitor for breathing difficulty, elevate the head of the bed, monitor for s/sx of acute respiratory insufficiency (not enough oxygen in the blood), and monitor/document/report to MD any s/sx of respiratory infection.Record review of Resident #24's H&P, dated 8/28/25, at 9:15am from CNS P, revealed the resident was taking Advair Diskus (fluticasone propion-salmeterol) 100-50 mcg/dose, 1 puff inhale orally BID for COPD/asthma.Record review of Resident #24's Physician Orders as of 9/10/25, revealed the following orders from MD N:- Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) mcg/act (Albuterol Sulfate), 2 puff inhale orally BID for asthma. Ordered on 8/1/25, discontinued 8/4/25.- Advair Diskus Aerosol Powder Breath Activated 100-50 mcg/dose (Fluticasone-Salmeterol), 1 puff inhale oral every 12hrs for COPD/asthma. Ordered on 8/4/25.In an observation on 9/10/25 at 11:45am, medication Cart B had 2 Albuterol Sulfate inhalers of Resident 24's that did not have an open date on them and 1 Fluticasone-Salmeterol inhaler of Resident #24's that had an open date of 8/3/25, which was past the 30 days of being opened. There was also a box of Juven Nutrition Powder in the cart with 19 packets in it that had expired 9/1/25, and a bottle of glucose test strips that did not have an open date on it and were only good for 30 days after opening. In an observation and interview on 9/10/25 at 11:55am, the medication storage room had a box of Align (probiotic) with 7 pills left in the box that had expired on 8/31/25. RN L said there was no one assigned to monitor the medications for those expired. She said all the nurses looked at the expiration dates as they were giving medications. She said all the nurses were responsible for checking the dates on the medications in the medication carts as well. RN L said if a resident took an expired medication, it would not be as effective.In an interview on 9/10/25 at 3:25pm, the DON said she expected the staff to be mindful before administering medications and to look at the expiration date before giving them. She said the facility had someone who looked in the medication storage closet for expired medications and she would get with them about being more thorough. The DON said the medication carts were checked by the staff who were using the cart, and they should be checking them as they gave the medications. She said inhalers should be dated as soon as they were first opened and then they were only good for 30 days because they could get bacteria in them and not be as effective. She said glucose strips were supposed to be dated as soon as they were opened as well and were only good for 30 days because they lost effectiveness. The DON said if a resident took an expired medication, a number of adverse effects could happen, but also the medication would not work as well.Record review of the facility's policy and procedure on Medication Labeling and Storage, (Revised February 2023), read in part: .If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.Record review of the facility's policy and procedure on Administering Medications, (Revised April 2019), read in part: .The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 10%, based on 3 errors out of 28 opportunities, which involved 1 of 4 residents (Resident #13) reviewed for medication administration.- RN A failed to administer Fluticasone Propionate nasal spray 50mcg/act, Biotin 5000mcg, and Magnesium Oxide 400mg to Resident #13 on 9/9/25, resulting in missed doses.This failure could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.Findings included:Record review of Resident #13's undated face sheet revealed she was a [AGE] year-old female admitted [DATE] and readmitted [DATE]. She had diagnoses of acute sinusitis (sinus infection), afib (irregular heartbeat), major depression, osteoarthritis (protective cartilage wears away, causing pain, stiffness, and swelling), GERD (reflux), HTN (high blood pressure), polyneuropathy (nerve pain), cardiac pacemaker (controls heart rate), and arthrodesis (surgical immobilization of a joint by fusion of the adjacent bones).Record review of Resident #13's admission MDS assessment, dated 8/7/25, revealed a BIMS score of 15 out of 15 which indicated normal cognition.Record review of Resident #13's Care Plan, dated 8/1/25, revealed a Focus: Medication Management with a goal that the resident would be informed of the medication regimen. The interventions included confirming all orders with the MD, the pharmacist's medication review with recommendations, and reviewing the medication list.Record review of Resident #13's H&P, dated 9/8/25, at 9:00am by MD N revealed she was taking Magnesium Oxide Oral Tablet 400mg, 1 tablet PO BID for supplement, Biotin Oral Tablet 5000mcg, 1 PO Qam for supplement and Fluticasone Propionate 50mcg/actuation spray, 1 spray in each nostril Qam for allergen control.Record review of Resident #13's Physician Orders as of 9/9/25, by MD N revealed the following orders:- Fluticasone Propionate Nasal Suspension 50mcg/act, 1 spray in each nostril Qam for allergen control. Ordered on 8/1/25.- Biotin Oral Tablet 5000mcg, Give 1 tablet PO Qam for supplement. Ordered on 8/4/25.- Magnesium Oxide Oral Tablet 400mg, Give 1 tablet PO BID for supplement. Ordered on 9/5/25.In an observation on 9/9/25 at 8:28am, RN A took Resident #13's blood pressure on her L wrist and it was 107/58 with a HR of 65. RN A held Resident #13's metoprolol (blood pressure) 25mg and her hydralazine (blood pressure) 50mg due to the DBP (bottom number in blood pressure) being less than 60. RN A also did not give the MiraLAX (laxative) 17gm or the Tums (heartburn) because the resident refused them. Therefore, 8 pills were confirmed to be in her medicine cup for the medication pass on Resident #13.In an interview on 9/9/25 at 9:45am, RN A said, Oh shoot, I did forget about the Fluticasone when asked about the 3 missed medications. She said she must have checked off the Biotin and the Magnesium but forgot to pull them. She said she did not check off the medication before pulling them, so she was not sure what happened.In an interview on 9/9/25 at 1:58pm, the DON said she expected the staff to check off the medications in the system while they were pulling them, but to not save the screen stating all the medications were given until after the resident took the medication, in case they did not take something. She said if a resident missed a medication, they would not receive what was ordered and were not getting the benefits of the prescribed treatment.Record review of the facility's policy and procedure on Administering Medication, (Revised April 2019), read in part: Medications are administered in a safe and timely manner, and as prescribed.The director of nursing services supervises and directs all personnel who administer medications and/or have related functions.Medications are administered in accordance with prescriber orders.Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication.

Based on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of (Resident #20, Resident #8 and Resident #2) of 8 residents whose records were reviewed for accurate assessments. -The facility failed to list Resident #20's fall on 1/8/24 and 6/14/24 on the MDS. -The facility failed to list Resident #8's oxygen continuously at 2 lpm via NC, on the MDS. -The facility failed to list Resident #2's oxygen PRN at 2 lpm via NC, on the MDS. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being. Findings include: Resident #20 Record review of Resident #20's undated face sheet revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of displaced fracture of second cervical vertebra (break in the vertebra of the neck), fracture with routine healing, displaced fracture of first cervical vertebra (break in the vertebra of the neck), and unspecified fall. Record review of Resident #20's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 6 out of 15 which indicated severely impaired cognition. She was dependent with toileting, hygiene, shower/baths, lower body dressing, and putting on/taking off footwear. She was max assist with upper body dressing and personal hygiene. The MDS said Resident #20 had not had any falls since admission/entry or reentry or the prior assessment. Record review of Resident #20's Annual MDS assessment dated [DATE], revealed a BIMS score of 6 out of 15 which indicated severely impaired cognition. The MDS indicated the resident had not had any falls since admission/entry or reentry or the prior assessment. Record review of Resident #20's Care Plan dated 3/21/23, revealed a Focus: Resident is at risk for falls. She had a CVA (stroke) and fell before admission (Initiated: 3/21/23 Revised: 3/30/23). Goal: Resident will not sustain serious injury through the review date (Initiated: 1/8/24 Revised: 1/8/24 Target: 10/20/24). Interventions: Resident had a fall from bed. She will be on a low bed and will have fall mats. She will be on a bolster mattress. Record review of Resident #20's chart revealed a Change in Condition note from 1/8/24 at 6:25 a.m., that said an aid notified the nurse that the resident had an unwitnessed fall. Upon entering the room, the resident was seen with her feet in the bed and her back on the floor. A fall assessment was performed with no injuries noted. The resident reported hitting her head, vitals were checked, and the resident was put back in bed. The resident's SBP (top number in the blood pressure) was elevated, hospice was notified, and the hospice nurse was going to come evaluate the resident. Record review of Resident #20's chart revealed a Nurse's Note from 6/14/24 at 5:10 p.m., that said the resident was yelling and when the nurse went into her room, she was found laying on the floor mat, on her left side. Resident was assisted back to bed and there were no injuries noted. Hospice was notified and they sent a nurse to evaluate resident. Record review of Resident #20's chart revealed a Post Fall Evaluation from 6/14/24 at 6:39 p.m., that said the resident fell on [DATE] and was found in the resident's room. Record review of Resident #20's chart revealed an IDT Meeting note from 6/17/24 at 9:42 a.m., that revealed it was for the resident's fall on 6/14/24. The note said MDS was in attendance and her care plan was updated. In an observation of Resident #20 on 8/18/24 at 10:02 a.m., she was asleep in bed with fall mats on both sides of the bed. Resident #8 Record review of Resident #8's undated face sheet revealed she was a [AGE] year-old female admitted [DATE], with an original admitted [DATE]. She had diagnoses of hypertensive heart and chronic kidney disease with heart failure and chronic kidney disease (heart and kidney disease due to high blood pressure with the heart not pumping effectively), stage 3 pressure ulcer (pressure sore through the skin and fat but not to the bone), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), seizures, and cellulitis (skin infection). Record review of Resident #8's Annual MDS assessment from 5/19/24 revealed a BIMS score of 15 out of 15, which indicated normal cognition. The MDS revealed under Special Treatments, Procedures, and Programs, oxygen therapy was not selected for the resident. Record review of Resident #8's Care Plan dated 5/11/21 revealed a Focus: Resident has oxygen therapy r/t heart failure and COPD (lung disease causing restricted airflow and breathing problems) (Initiated: 2/21/23 Revised: 2/21/23). Goal: Resident will have no s/sx of poor oxygen absorption through the review date (Initiated: 2/21/23 Revised: 7/5/24 Target: 8/29/24). Interventions: Monitor O2 sat and titrate O2 to keep O2 sat >90%. Resident has oxygen at 2 L via NC. Record review of Resident #8's Physician Orders revealed the following orders from MD D read in part . -O2: Oxygen at 2 liters per nasal cannula, every shift. Ordered 1/4/24. -O2: Change tubing every night shift, every Sunday, for infection control. Ordered 5/14/24 . Record review of Resident #8's August 2024 MAR-TAR revealed staff documented for each shift that the resident was on 2L O2 via NC, and the oxygen saturation at that time. In an observation of Resident #8 on 8/18/24 at 10:27 a.m., she was on oxygen 2L via NC. Resident #2 Record review of Resident #2's undated face sheet revealed she was a [AGE] year-old female admitted [DATE], with diagnoses of atrial fibrillation (heart skips a beat), hypertensive heart disease with heart failure (heart does not pump effectively due to chronic high blood pressure), and hypertension (high blood pressure). Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15, which indicated moderately impaired cognition. Under Special Treatments, Procedures, and Programs oxygen therapy was not marked. Record review of Resident #2's Care Plan dated 1/10/24 revealed a Focus: Resident has self-care deficit related to diagnosis of acute respiratory failure with hypoxia (not enough oxygen in the blood) (Initiated: 4/17/24). Record review of Resident #2's Physician Orders revealed the following orders from MD D read in part . -Oxygen via nasal cannula at 2L/min PRN for shortness of breath, every 1 hour as needed for shortness of breath or O2 sat <90%. Ordered on 5/17/24 Record review of Resident #2's August 2024 vital signs revealed the resident used oxygen on 8/6/24, 8/8/24, 8/12/24, and 8/19/24. Interview and observation of Resident #2 on 8/18/24 at 10:10 a.m., there was an oxygen concentrator next to the resident's bed that was not in use. The resident said she used the oxygen as needed when she felt short of breath. Interview with the MDS Coordinator on 8/21/24 at 9:25 a.m., she said she had been with the facility for [AGE] years. She said she updated the MDS by looking through the resident charts and observing the residents. She said she tried to make sure everything was correct on the MDS but sometimes she made a mistake and overlooked something. She did not think anything would happen to the resident if the MDS was wrong, she just wanted to make sure the MDS was correct. The MDS Coordinator said Resident #20's falls should have been on the MDS, and Resident #8's and Resident #2's oxygen should have been on their MDS. She was not sure how they were left off and said they must have been overlooked. The facility did not have a policy and procedure on completing the MDS and followed the RAI Manual.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 8 residents (Resident #15) reviewed for oxygen therapy. - Resident #15's oxygen setting was on 4 L instead of 2 L as ordered by the physician. This failure could place residents at risk of adverse side effects or inadequate therapeutic outcomes. The findings were: Record review of Resident #15's face sheet revealed an [AGE] year-old male who readmitted to the facility on [DATE]. His diagnoses included acute on chronic combined systolic and diastolic heart failure (in systolic heart failure, the heart cannot effectively contract with each heartbeat. In diastolic heart failure, your heart cannot relax between heartbeats), atrial fibrillation (irregular heart rhythm), and hypertension (high blood pressure). Record review of Resident #15's admission MDS assessment dated [DATE] revealed his BIMS score was 15 out of 15 which indicated intact cognition. The resident was on oxygen therapy. Record review of Resident #15's care plan dated 8/2/24 revealed he was on oxygen therapy related to congestive heart failure. Interventions were to give medications as ordered by physician. Record review of Resident #15's Physician orders for August 2024 revealed an order for O2: oxygen at 2 liters per nasal cannula, order date 7/31/24. In an observation and interview on 8/18/24 at 10:31 a.m., Resident #15's oxygen was on 4 L. He was sitting in his wheelchair with the nasal cannula in place. He said he did not have concerns with his oxygen. In an observation on 8/19/24 at 2:58 p.m. Resident #15's oxygen was on 4 L, he was in his room with the nasal cannula in place. In an observation on 8/20/24 at 10:36 a.m. Resident #15's oxygen was on 4 L, he was in his room with the nasal cannula in place. In an observation on 8/20/24 at 1:16 p.m. Resident #15's oxygen was on 4 L, he was in his room with the nasal cannula in place. Interview on 8/20/24 at 1:28 p.m., LVN W said Resident #15 was on 4L of O2 and had been since she started working with him (unknown date). She said she was made aware he was on 4L of oxygen through the hospital records and nurse report. LVN W said she did not see the physician's order for 4L in his medical record but instead saw the batch order that was put in by the admitting nurse for 2L of oxygen. She said no one updated his order from 2L to 4L. She said she did notice the discrepancy between what Resident #15 was receiving versus what was ordered but did not update the order because the MD had to verify it. She said there was no bad risk to the resident receiving a different amount than what was ordered. She said the DON and ADON were responsible for ensuring the order matched what the resident was receiving. She said she would update his oxygen order to 4L. Interview on 8/21/24 at 9:47 a.m., the DON said the MD prescribed a batch order for oxygen which included the level of 2L but the resident had been on 4L of oxygen. She said someone dropped the ball on that. She said nurses should monitor for the correct liter when they round on the resident. She said physician orders should match what the resident is receiving and if not, respiratory issues could happen. She said all nurses were responsible for ensuring the order matched what the resident received. She said nurses were trained to verify orders with the MD. Record review of the facility's Administering Medications policy dated December 2012 read in part, Medications shall be administered in a safe and timely manner, and as prescribed .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in accordance with professional standards for food safety in 1 of 1 facility kitchen . -The facility failed to ensure [NAME] A wore a hair restraint while preparing meals in the kitchen. This failure could place residents receiving food from the facility kitchen at risk for cross contamination. The findings included: During an observation on 8/18/24 at 9:11 a.m., in the cooking area of the kitchen revealed [NAME] A was standing over a pan of rice, sampling it. He did not have on a hair restraint. Interview on 8/18/24 at 9:20 a.m., [NAME] B said it was a mistake that [NAME] A did not have on a hair restraint. He said [NAME] A normally wore a hair net but was unsure what happened this time. He said the purpose of a hair restraint was to protect the food from having hair in it. He said he normally provided reminders to the staff to wear a hair restraint. Interview on 8/18/24 at 9:23 a.m., [NAME] A said he normally wore a hat but forgot it at home. He said he was supposed to wear a hair net because of cross contamination and to prevent hair from getting into the residents' food. Interview on 8/21/24 at 9:00 a.m., the Administrator said anyone in the service prep area of the kitchen should wear a hair covering to ensure food sanitation. He said if a hair net was not worn it could compromise the integrity of the food sanitation. He said this year staff were trained quarterly on wearing hairnets and said [NAME] B was responsible for ensuring staff wore hair nets. Record review of the facility's policy titled Personal Hygiene dated 9/4/2015 read in part, .Guidelines for personal hygiene to promote a safe and sanitary department must be followed . Procedure: .3. Head covering worn a. wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered .

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #138) of 8 residents reviewed for infection control. -CNA B failed to wear appropriate PPE and change her gloves when she provided incontinence care to Resident #138, who was on Enhanced Barrier Precautions. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings include: Record review of Resident #138's undated face sheet revealed he was a [AGE] year-old male admitted on [DATE] with diagnoses cerebral infarction (stroke), acute endocarditis (inflammation/infection of the lining of the heart chambers and valves), muscle weakness, and lack of coordination. Record review of Resident #138's Admission MDS assessment dated [DATE] was not completed yet. Record review of Resident #138's Care Plan dated 8/14/24, revealed a Focus: Resident has actual or is at risk for possible endocarditis (inflammation/infection of the lining of the heart chambers and valves) (Initiated: 8/14/24). Goal: Resident will be free of infection (Initiated: 8/14/24 Target: 11/12/24). Interventions: Infection precautions per physician. IV per MD order. Notify Infection Preventionist. Observe for signs and symptoms of worsening infection. Record review of Resident #138's previous hospital records from 8/14/24 at 11:38 a.m., revealed the resident had blood cultures positive for Abiotrophia Defectiva (type of bacteria that causes endocarditis), he would need 6 weeks of IV antibiotic therapy, and he would receive a PICC (long tube inserted into vein in arm and passed through large veins near heart) line prior to transferring to the SNF. Record review of Resident #138's Physician Orders revealed the following orders from MD D, read in [NAME] . -Change PICC (long tube inserted into vein in arm and passed through large veins near heart) dressing PRN. Note any complications, every 24hrs as needed. Ordered 8/14/24. -Flush PICC (long tube inserted into vein in arm and passed through large veins near heart) catheter with 10ml NS before IV med administration & flush with 10ml NS after IV med administration, every shift. Ordered 8/15/24. -Flush unused PICC (long tube inserted into vein in arm and passed through large veins near heart) line lumen with 10ml NS qshift, every shift. Ordered 8/15/24. -Observe PICC (long tube inserted into vein in arm and passed through large veins near heart) site and document in progress notes as indicated; Every 2 hours during continuous therapy. Every shift. Ordered 8/15/24. -Vancomycin 2000mg/20ml (antibiotic), 2gm IV QHS for endocarditis. Ordered 8/15/24. -F/U with Infectious Diseases in two weeks re: Endocarditis. Ordered on 8/16/24. -Ceftriaxone 2gm (antibiotic), 1 application IV QD for endocarditis. Ordered 8/16/24 . Record review of Resident #138's Nursing Progress Notes revealed a note from 8/18/24 at 8:05 p.m., that said a new PICC (long tube inserted into vein in arm and passed through large veins near heart) line was placed to the LUA without any issues and IV antibiotics would resume. Interview with CNA C on 8/18/24 at 9:57 a.m., she said EBP were for resident's who had open wounds or lines. She said there would be an isolation cart outside of their room. CNA C said she only had to wear gloves for PPE in EBP. In an observation on 8/18/24 at 1:30 p.m., Resident #138 had an EBP isolation sign on his door. Interview and observation on 8/18/24 at 1:36 p.m., CNA B performed incontinence care on Resident #138. She entered the room and did not don any PPE when he was on EBP. She changed his soiled brief and threw it away in the trash can. She did not take off her dirty gloves and sanitize her hands and proceeded to put on his clean brief. After she was finished changing him, she touched his call bell, bed remote, and other items with her dirty gloves still on. CNA B said she forgot to change her gloves and it could cause infection control issues. She said EBP was when a resident had lines or a wound. She said she did not know what she was supposed to wear, and no one had ever told her what to do. There was an isolation cart and an isolation sign on the door, but the CNA said it did not signal anything to her. She said she knew the resident was on EBP, but she did not know she was supposed to wear anything. Interview on 8/20/24 at 12:03 p.m., LVN W said EBP was for any resident with an IV, peg tube (tube into stomach for nutrition), wounds, or a foley (tube into bladder to drain urine). She said before entering their room staff would have to don a gown, gloves, and a face mask and it was to prevent giving or getting something from the resident. She said if a staff member went to change a resident, they would need to wear PPE for EBP. Interview on 8/21/24 at 9:34 a.m., the DON said EBP was for residents who had indwelling devices, wounds, or foleys (tube into bladder to drain urine). She said staff were expected to wear a gown and gloves with high contact care. The DON said an indwelling device includes a PICC line, catheter (tube into bladder to drain urine), or PEG tube (tube into stomach for nutrition). She said high contact care included peri care (washing genitals), showering, and transferring. She said EBP was to prevent the spread of germs from both parties and to prevent infection into a wound, PICC line (long tube inserted in vein in arm and passed through large veins near heart), and catheter (tube into bladder to drain urine). The DON said when a staff member is providing peri care (washing genitals) they should change gloves and perform hand hygiene, when they were done with the dirty part of the brief change. She said the hand hygiene and glove changing was to prevent cross contamination. She also said she performs in-services and training and all the staff had training on infection control and EBP, but they had started in-servicing again. Record review of the facility's policy and procedure on Handwashing/Hand Hygiene (Revised August 2015) read in part: The facility considers hand hygiene the primary means to prevent the spread of infection. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap .and water for the following situations: .Before and after direct contact with residents; Before moving from a contaminated body site to a clean body site during resident care; After contact with blood or bodily fluids; Before and after entering isolation precaution settings .The use of gloves does not replace hand washing/hand hygiene . Record review of the facility's policy and procedure on Enhanced Barrier Precautions (Revised 3/22/24) read in part: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied before performing the high-contact resident care activity .Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .providing hygiene .changing briefs or assisting with toileting .EBPs are indicated .for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk .Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available near or outside of the resident rooms .

Based on observation, interview, and record review, the facility failed to assess the resident for risk of entrapment, reviewed the benefits of bed rails with resident and resident representative, obtained Physician consent prior to use for 2 of 8 residents (Resident #11 and Resident #3) reviewed for bed rails. -The facility failed to obtain a physician's order, assess the need for, and consent for Resident #11's bed rails. -The facility failed to obtain a physician's order and consent for Resident #3's bed rails. This failure could place residents with bed rails at risk of restricted movement, entrapment, decline in ADLs function, and psychological distress. The findings include: Resident #11 -Record review of Resident #11's undated face sheet revealed she was a [AGE] year-old female admitted [DATE], with an original admitted [DATE]. She had diagnoses of fracture of T7-T8 vertebra (fracture of the vertebra in the mid-back), muscle weakness, and osteoporosis (bone mineral density and bone mass decreases). Record review of Resident #11's Admission MDS assessment dated [DATE], revealed a BIMS score of 15 out of 15 which indicated normal cognition. The MDS revealed she had a fracture of her T7 and T8 and had spinal surgery involving fusion of spinal bones (surgery to connect bones in part of the spine). The MDS did not mention her having bed rails. Record review of Resident #11's Care Plan dated 7/11/24, had a Focus: Resident has an ADL self-care performance deficit and limited mobility (Initiated: 7/24/24, Revised: 7/24/24). Goal: Resident will improve in ADL functional status by next review date (Initiated: 7/24/24, Revised: 8/20/24, Target: 9/30/24). Interventions: Resident needs assist with ADLs. Focus: Resident has potential for injury secondary to bed rail use (Initiated: 8/20/24, Revised: 8/20/24). Goal: Resident will not sustain injury related to bed rail use (Initiated: 8/20/24, Revised: 8/20/24, Target: 9/30/24). Interventions: Complete bed rail assessment. Obtain physician order for bed rail use. Obtain resident and/or representative consent for bed rails. The focus for bed rails was added to the care plan after facility found out. Record review of Resident #11's August 2024 Physician Orders revealed the following orders from MD E, read in part . -Monitor bed rail safety q-shift; if safety concerns observed, lower side rail, notify the Director of Nursing, and complete a new bed rail assessment, every shift for side rails in use. Ordered on 8/20/24. -Use of bed rails authorized per bed rail assessment for 2 swing side rail(s) related to resident's safety and security, every shift. Ordered on 8/21/24 . Record review of Resident #11's chart revealed a bed rail assessment filled out by the DON on 8/20/24 at 5:07 p.m. Record review of Resident #11's August 2024 MAR-TAR revealed the orders for bed rails started 8/20/24 on the night shift and were not signed off for any other date in August 2024. In an observation of Resident #11 on 8/18/24 at 10:37 a.m., she was sitting in a wheelchair in her room. Her bed had siderails on both sides of the bed. In an observation of Resident #11 on 8/19/24 at 11:48 p.m., she was asleep in bed with side rails up on both sides of the bed. Interview and observation of Resident #11 on 8/20/24 at 11:46 a.m., she said she received the bed rails the first day she got to the facility and needed them to help turn in bed. Resident #3 Record review of Resident #3's undated face sheet revealed she was a [AGE] year-old female admitted on [DATE], with diagnoses of peripheral vascular disease (narrowing/blockage in the blood vessels), muscle weakness, vascular dementia (changes to memory, thinking, and behavior from conditions that affect blood vessels in the brain), unspecified psychosis (symptoms that happen when person is disconnected from reality), anxiety (feeling of fear, dread, and uneasiness), major depression (lasting sad, anxious, or empty mood), TIA (mini stroke), memory deficit, and cerebral infarction due to occlusion/stenosis of small artery (stroke due to blockage of the small artery). Record review of Resident #3's Admission MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 which indicated normal cognition. The MDS revealed the resident was completely dependent with all ADLs. According to the MDS, the resident had major surgery in the 100 days prior to admission and required active care during the SNF stay. Bed rails were not checked off on the MDS. Record review of Resident #3's Care Plan dated 2/29/16, revealed a Focus: Resident has a potential for injury secondary to bed rail use (Initiated: 12/7/23 Revised: 6/18/24). Goal: Resident will not sustain injury related to bed rail use (Initiated: 12/7/23 Revised: 8/20/24). Interventions: Complete bed rail assessment for bed rail use upon initial use. Obtain physician order for bed rail use. Obtain resident and/or RP consent for bed rails. Record review of Resident #3's chart revealed a bed rail assessment from 4/29/24 at 2:51 p.m. by the DON. Record review of Resident #3's Physician Orders on 8/20/24 from MD D, revealed no orders for bed rails. In an observation of Resident #3 on 8/18/24 at 10:45 a.m., she was asleep in bed with side rails up on both sides of the bed. In an observation of Resident #3 on 8/19/24 at 11:48 p.m., the resident was asleep in bed with both side rails up on the bed. Interview with LVN W on 8/20/24 at 12:03 p.m., she said bed rails must have an assessment, physician's order, and a physical consent. She said those things were necessary to ensure the resident needed them. Interview with the DON on 8/21/24 at 9:34 a.m., she said bed rails must have an assessment, a physician order, a consent, and it must be on the care plan. She said the reason for those things was to ensure the resident/RP knew the advantages and disadvantages of the bed rails. Record review of the facility's policy and procedure on Bed Safety (Revised December 2007) read in part: .If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security .Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails .

Based on interview, observation, and record review the facility failed to prepare food in accordance with professional standards for food service safety in 1 of 3 kitchens in that: The facility failed to ensure that all dietary personnel in the food preparation area wore a hair restraint or head covering. This failure could place residents that consume facility prepared meals at risk for physical contamination of food by hair. Findings include: Observation on 6/27/2023 at 8:45am revealed Dietary A preparing salads without a hairnet. Interview with Dietary A on 6/27/2023 at 8:47am, stated that she was aware that she should have had on a hairnet. She was not wearing a hairnet today because she was in a hurry and simply forgot. She said that wearing a hairnet prevents hair from getting in food. Interview with the DM on 6/27/2023 at 8:50am, stated all staff in food preparation should have a hairnet to prevent hair from contaminating the food. He stated as dietary manager, he is responsible for ensuring kitchen staff is adhering to policy. Interview with Dietary B on 6/28/2023 at 10:55am, stated any personnel in food prep area should wear a hair restraint to prevent hair from contaminating the food. Interview with Administrator on 6/29/2023 at 1:37 pm, stated all staff in food prep should wear a hairnet to prevent hair from getting into food. Record review of Personal Hygiene Policy (9/14/2015) revealed: .3. Head Covering Worn . a. Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered. b. Head covering must be clean.

Based on observation , interview, and record review, the facility failed to obtained laboratory services as ordered by the physician and report results in accordance with facility policy and procedures for notification for 1 of 7 residents (Resident #1) reviewed for notification of lab results. - The facility failed to notify the physician of Resident #1's elevated TSH of 26.750 uIU/ml (indicating [CONDITION(S)] disease) for 14 days (07/27/22 to 08/12/22) resulting in the resident's TSH level increasing to a critical value of 56.296 uIU/ml causing the resident experience fatigue which hindered his ability to complete therapy as well as suffering from cold intolerance and depressed mood. This deficient practices could place residents at risk of decline in health from not having their laboratory tests identified and addressed promptly and a deterioration of health. Findings Include: Record review of Resident #1's face sheet dated 08/16/22 revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's face sheet did not have a recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admitting MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no symptoms of feeling down, depressed or hopeless, no symptoms of little interest or pleasure in doing things, no presence of thoughts that you would be better off dead, or hurting yourself in some way, no potential indicators of [CONDITION(S)], no behavioral symptoms present, no rejection of care present, a worsening of change in behavior of other symptoms, extensive assistance with most ADLs, wheelchair use, walker use, and occasionally incontinent of both bladder and bowel. Resident #'s MDS did not have [CONDITION(S)] Disorder (e.g. [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]) selected under the list of active metabolic diagnoses. Record review of Resident #21's Care Plan initiated 07/19/22 revealed, Focus- anticoagulant therapy, risk of falls, impairment to skin integrity, [CONDITION(S)] and impaired cognitive function related to dementia. On 08/04/22 a focus area of antidepressant medication use related to depression, Goal- free from discomfort or adverse reactions related to antidepressant therapy; Interventions- give antidepressant medications ordered by physician was initiated. On 08/18/22 a focus of [CONDITION(S)]; Goal- free from s/sx of [CONDITION(S)], will have no complication related to [CONDITION(S)]; Intervention- give [CONDITION(S)] replacement therapy as ordered, obtain and monitor lab/diagnostic work as ordered was initiated. On 08/30/22 a focus of anti-anxiety medications r/t anxiety disorder; Goal- decreased episodes of s/sx of anxiety through the review date; Intervention- give anti-anxiety medication ordered by physician. Record review of Resident #1's Hospital Rehabilitation Consultation Report dated 07/13/22 revealed, resident was an [AGE] year-old male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's General Medicine (Hospital) Progress Note dated 07/14/22 which was included in the residents discharge documentation revealed, Assessment/Plan 4- [CONDITION(S)], Home Medication: TSH 0.57, continue current regimen. Will adjust if clinically indicated. Lab Results- TSH 0.57. Record review of the Hospital Medication List printed on 07/19/22 at 12:17 PM that was provided to the facility upon Resident #1's admission revealed, a list of medications the resident was supposed to start taking, continue taking and stop taking. The medication list had check marks by all the listed oral formulation medications indicating review except the [MEDICATION(S)]. The [MEDICATION(S)] order stated Take these medications AS PRESCRIBED. Do not change the dosage on your own. Call your health care provider if you have any questions . [MEDICATION(S)] 150 mcg tablet, commonly known as : [MEDICATION(S)] TAKE 1 TABLET 150 MCG BY MOUTH DAILY. There was no check mark present by the order of the [MEDICATION(S)]. Record review of Resident #1's Physician Order dated 07/24/22 revealed, Lab: CBC, BMP, TSH and A1c. Confirmation C 0160A, communication method- phone ordered by the NP. Record review of Resident #1's Physician Order dated 07/25/22 revealed, Psych consult due to anxiety disorder. Record review of Resident #1's Lab Results Report dated 07/26/22 at 06:27 PM revealed, the specimen was collected on 07/25/22 at 9:37 PM and the resident had a high TSH3 result of 26.750 uIU/ml (indicative of [CONDITION(S)]) with the normal range of 0.450 - 5.330. The report included a note saying Although Normal TSH readings are now defined as 4-6 uIU/mL in elderly patients, levels up to 10 uIU/mL may be physiological and do not necessarily need to need to be treated unless clinically indicated. Record review of Resident #1's Progress Notes from 07/26/22 to 07/27/22 revealed, no record of the resident's Lab Report indicating an elevated TSH or notification to Resident #1's physician. Record review of Resident #1's Progress Notes dated 08/02/22 at 6:24 PM signed by the DON revealed, Family Member #1 came into office with concerns about the resident and his therapy and that she has not seen him do therapy since his admission . Resident is currently in room and does not want to get up at the time to do therapy. Therapy encouraged resident to get up and do therapy, resident still refusing to do therapy. Therapist will try again to encourage resident again after lunch to see if resident is in better mod to participate . Educated and encourage spouse to help motivate resident to participate in therapy. Record review of Resident #1's Progress Notes dated 08/11/22 at 7:17 PM signed by RN A revealed, Resident's Family Member #1 called concerning [MEDICATION(S)] on med list from hospital and facility med list. Medication was not on facility med list, NP notified and stated to put order in for [MEDICATION(S)] 150 mcg by mouth daily. Record review of Resident #1's Physician Order dated 08/11/22 entered by RN A revealed, [MEDICATION(S)] 150 mcg by mouth one time a day for [CONDITION(S)]. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed, Patient seen for follow up visit in the nursing home for mood and medications. On last visit 08/2/22, [MEDICATION(S)] ordered for agitation and anxiety in context of depressed mod/dementia . Per patient, he is reporting that he no longer feels anxious. Denies worsening of depressed mood Record review of Resident #1's Lab Results Report dated 08/17/22 at 3:34 PM revealed, TSH CRITICAL! TSH Verified by repeat analysis and/or delta check SS. 08/17/22, 3:33 PM. Result 56.296 Unit uIU/ml. Record review of Resident #1's Physician's Progress Noted dated 08/17/22 signed by MD A revealed, Patient still very weak and debilitated requiring 2 person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Record review of Resident #1's Physician Order dated 08/17/22 revealed, [MEDICATION(S)] Sodium Tablet 175 MCG give 1 tablet orally in the morning for [CONDITION(S)] entered by Record review of Resident #1's Progress Notes dated 08/17/22 at 04:07 PM signed by the DON revealed, critical lab for TSH called in at 4:04 PM, received by this nurse. MD A notified. See new orders Record review of Resident #1's Physician Order dated 08/18/22 revealed, TSH level in 2 weeks one time only for TSH level for 1 day entered by MD A. In an interview on 08/30/22 at 10:00 AM the Administrator said that the facility became aware that Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1identified that the resident had not his [CONDITION(S)] medication. He said that the Family Member #1 was concerned because he was not returning to his baseline mental state following his surgery and admission into the facility. The Administrator said that the facility's investigation revealed that the admitting nurse (RN A) failed to enter Resident #1's [MEDICATION(S)] from the hospital records from admission and the resident did not receive his [MEDICATION(S)] for approximately 3 weeks, from his admission (07/19/22) to when Family Member #1 #1 identified the missing medication around 08/12/22. An observation and interview on 08/30/22 at 11:32 AM with Resident #1 and Family Member #1 revealed, Resident #1 sitting in a chair with a back brace on with Family #1 cutting his hair. The resident appeared well groomed and in no immediate distress, when the surveyor asked questions Family Member #1 answered with the resident intervening rarely and at times nodding in agreement. Family Member #1 said that after Resident #1 admitted to the facility his recovery was taking longer than expected. She said the resident had dementia and initially she believe that he had anesthesia related dementia but as time went, he didn't seem to get better. Family Member #1 said Resident #1 was tired, had no appetite, was always nauseated and was always cold, sometimes using 2 to 3 blankets so she called his general practitioner who informed her that the resident was showing symptoms associated to [CONDITION(S)]. She said after she talked to Resident #1's GP she asked to see the resident's medication list and that is when she identified that he was not receiving his [MEDICATION(S)]. Family Member #1 #1 said that she believe the lack of [MEDICATION(S)] played a part in the resident's recent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said when he didn't receive his [MEDICATION(S)] the resident was so tired that he could not successfully complete his therapy and after the facility started administering his [MEDICATION(S)] his energy levels got better and his therapy sessions were more successful. Family Member #1 #1 said the facility's failure to administer Resident #1's [MEDICATION(S)] impaired the resident's recovery not only by leaving him cold, tired, confused, having depressed mood but also wasted much of his first therapies sessions because the resident was not in the right state of mind to successfully complete his therapy and now he has used almost all the therapy days covered by his insurance. She said prior to his admission to the facility, Resident #1 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 08/30/22 at 12:14 PM, CNA A said that initially Resident #1 was not responsive and lethargic but he has gotten better. She said she remembered an incident in which the resident was using multiple blankets and his FAMILY MEMEBR #1 reported he was cold but has no knowledge of current lethargy or cold intolerance. In an interview on 08/30/22 at 12:30 PM, NP A said she was unaware that Resident #1 did not receive his [MEDICATION(S)] from 07/19/22 to 08/11/22. She said symptoms of [CONDITION(S)] were fatigue, altered mental status in which the resident appears down, depression, elevated HR, cold intolerance, hair loss and weight loss. In an interview on 08/30/22 at 2:25 PM, NP B said on 8/2/22 Resident #1 was started on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] PRN due to symptoms of depression and anxiety. She said on her last visit she discontinued his prescription for [MEDICATION(S)] and [MEDICATION(S)] because their use did not lead to any improvement in the resident and the benefits did not out way the risk, so he was started on [MEDICATION(S)]. NP B said that Resident #1's depression had gotten better since her last visit on 8/16/22 and she was not notified that the resident suffered from [CONDITION(S)]. NP B said she normally she would draw a TSH level prior to starting a resident on psychiatric medications because [CONDITION(S)]/low [CONDITION(S)] hormone can give the impression of depression. She said she did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 08/30/22 at 2:37 PM, the DON said that when a MD or nurse practitioner gives an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the lab system is integrated in their EMR so when results come out they are immediately populated in the record and can also be viewed under the Lab Results tab in the EMR. The DON said it is every nurses responsibility to check the EMR on their shift for any pending lab records. She said all abnormal results required provider notification with critical results called in to the provider immediately and non-critical results being communicated to the provider in the physician binder by the next business day. She said she was unaware that Resident #1 had a sample ordered on 07/24/22 that resulted with an elevated TSH of 26.750 uIU/ml. She said that high TSH levels meant that the individual was not producing enough [CONDITION(S)] hormone and a level of 26.750 uIU/ml indicated that Resident #1 had [CONDITION(S)] disease. The DON said an individual with low [CONDITION(S)] hormone would suffer from weight gain, sensitivity to cold and poor mental health. She said the first time she became aware of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 brought the discrepancy she had observed when reviewing Resident #1's medication list. She said once notified the provider was notified and MD A immediately placed a lab order for TSH and once the results came out indicating a critically high TSH of 56.296 uIU/ml he started Resident #1 on [MEDICATION(S)] on 08/16/22. The DON said since the resident started his [MEDICATION(S)] he seemed more alert but could not single handedly attribute it to the medication. She said failure to follow up and notify providers of abnormal lab values could place residents at risk of delay in care. In an interview on 08/30/22 at 3:11 PM, MD A said that he just took over the role of attending physician on 08/15/22 and on that day the unit manager informed him that that the nursing staff did not carry over Resident #1's [MEDICATION(S)] when entering the resident's medication on admission so he called in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's critically high TSH of 56.296 uIU/ml he questioned the nursing staff and he learned that the medication was missed for several weeks. MD A said after receiving the results he went to see the resident, who was clinically stable, and increased his [MEDICATION(S)] dose to 175 mcg to compensate for the weeks of missed medications. He said that the expectation is that nursing staff notify the NP/MD of critical labs immediately and all other abnormal labs by the next business day per the protocol lab notification binder. MD A said on Monday through Thursday the Physicians and nurse practitioners are here on alternating days so they are easily available to nursing staff. He said he was unaware of Resident #1's ordered TSH on 07/24/22 of 26.750 uIU/ml and that levels that high indicated the resident had [CONDITION(S)] disease. MD A said the nursing staff should have immediately notified the resident's Physician or Nurse Practitioner and if action was taken then the resident most likely would not have had a critical level on 08/16/22. He said failure to administer [CONDITION(S)] hormone ([MEDICATION(S)]) to a resident with [CONDITION(S)] could place them at risk of withdrawn mood, fatigue, behaviors and deterioration of clinical condition. In an interview on 08/31/22 at 08:59 AM, the Administrator said that he was unaware of Resident #1's lab results that was ordered on 07/24/22. He said that the facility had begun System Management, that they were reviewing their admissions/ lab notification process and the task had been assigned to the ADON. The Don said that when lab results are out the facility did not receive a fax and all results immediately updated in the EMR and the fax number the lab had on their account would not yield a print out of lab results. He said since he became aware of the missed TSH for Resident #1 he contacted the lab company to ensure that the fax number is correct and the facility is making changes so that lab results will print at the fax located at the nursing station. The Administrator said the previous DON was responsible for ensuring abnormal lab values were communicated to the provider and Resident #1's elevated TSH result ordered on 07/24/22 fell through the crack because the previous nurse practitioner used to check on labs in the EMR. He said the facility was transitioning between attending physicians during when Resident #1's lab result was missed. In an interview on 08/31/22 at 9:40 AM, the DON said normally after lab results are out it is the DON/designees responsibility to sign off on the record in the EMR after ensuring that the appropriate follow-up occurred with the resident's provider but when she started her position as DON there were a lot of unreviewed Lab results that she signed off on without verifying that follow-up was taken because they were old and she assumed someone had already taken care of it. She said even though the record shows she reviewed Resident #1's lab report showing a high TSH of 26.750 uIU/ml on 08/01/22, she was not aware of the sample that was ordered on 07/24/22 until the surveyor brought it to her attention. The DON said that failure to review lab results places residents at risk for delay in treatment, side effects and deterioration of health status. In an interview on 08/31/22 at 10:36 AM, the ADON said that she became aware on Resident #1's elevated TSH ordered on 07/24/22 on 08/17/22 when she was reviewing the new results that showed a critical high level collected on 8/16/22, she said she had the two lab results side by side. She said nursing staff are expected to check the lab results dashboard located in the EMR on their shift and to notify the physician of any abnormal lab results. The ADON said the previous DON was responsible for reviewing lab results to ensure the appropriate follow up occurred and she did not know why the physician was not notified of the previous elevated TSH. She said since Resident #1 started receiving his [MEDICATION(S)] he has become more alert/oriented in comparison to his admission. The ADON said failure to insufficient supplementation of [CONDITION(S)] hormone can cause an initial appearance of depression in the resident and failure to promptly notify providers of abnormal lab results could place residents at risk of delay in care. In an interview on 08/31/22 at 12:15 PM, the Director of Therapy Resident #1's first therapy sessions were tough because he was very confused and tired. She said he was slow to get therapy because of his disease state and after his cognition got better his therapy began to progress better. In an interview on 08/31/22 at 01:54 PM, MD B said he said the facility became aware of Resident #1's missing [MEDICATION(S)] when the resident's FAMILY MEMEBR #1 reviewed his med and noticed that he was missing his [CONDITION(S)] medication. He said that he never received an alert of the resident's elevated TSH that was ordered on 07/24/22 and the expectation is for nursing staff to call providers immediately for critical values and notify providers by the next business days for all other abnormal lab values. He said per his records no provider at his practice was notified of elevated TSH levels on 07/25/22. Record review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol revised 11/2018 revealed, Review by Nursing Staff: 1- When test results are reported to the facility, a nurse will first review the results; a- if staff who first receive or review lab and diagnostic test results cannot follow up the remainder of this procedure for reporting and documenting the results and their implication, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. Identifying Situations that Warrant Immediate Notification: 1- nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results . whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for Physician Notification: 1- a physician must be notified by phone, fax, voicemail, e-mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff); a- facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as individual's overall situation, current symptoms, advance directives, prognosis, etc. b- direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification . c- for information that does not need immediate physician response, staff may use alternative such as faxing, voicemail, or a clipboard in the facility. Record review of the facility provided document titled Laboratory Notification Parameters/Vital Sign Parameters with no revision date revealed, Test/Procedure- Chemistry; Report Immediately- BUN (>60), Calcium (>12.5), Potassium (any value outside of reference range), Sodium (<125, >155), Blood glucose ( >300, <70). Report Next Work Day- Other chemistry values. Record review of facility provided document titled MD A Notification Manual with no revision date revealed, that for non-immediate notification nursing staff should put the information in clinical notification manual while in cases of immediate notification contact numbers for NP A and MD A were listed and after hours weekends/holidays were included.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 of 7 residents (Resident #1) reviewed for quality of life. -The facility failed to ensure Resident #1 received his [MEDICATION(S)] to treat his [CONDITION(S)]. resulting in a decreased quality of life due to the resident suffering from fatigue, cold intolerance, depressed mood and hindrance in his ability to complete his physical therapy as ordered. This failure could place residents at risk of not maintaining their highest practicable physical, mental and psychosocial well-being and a decreased quality of life. Findings included: Record review of Resident #1's face sheet dated 08/16/22 revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's face sheet did not have a recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's admitting MDS assessment dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no symptoms of feeling down, depressed or hopeless, no symptoms of little interest or pleasure in doing things, no presence of thoughts that you would be better off dead, or hurting yourself in some way, no potential indicators of [CONDITION(S)], no behavioral symptoms present, no rejection of care present, a worsening of change in behavior of other symptoms. Resident #1 required extensive assistance with most ADLs, wheelchair use, walker use, and occasionally incontinent of both bladder and bowel. Resident #1's MDS did not have [CONDITION(S)] Disorder (e.g. [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]) selected under the list of active metabolic diagnoses. Record review of Resident #1's care plan initiated 07/19/22 revealed, Focus- anticoagulant therapy, risk of falls, impairment to skin integrity, [CONDITION(S)] and impaired cognitive function related to dementia. On 08/04/22, a care plan was developed with a focus area of antidepressant medication use related to depression, Goal- free from discomfort or adverse reactions related to antidepressant therapy; Interventions- give antidepressant medications ordered by physician was initiated. On 08/18/22, a care plan was developed with a focus of [CONDITION(S)]; Goal- free from s/sx of [CONDITION(S)], will have no complication related to [CONDITION(S)]; Intervention- give [CONDITION(S)] replacement therapy as ordered, obtain and monitor lab/diagnostic work as ordered was initiated. On 08/30/22, a care plan was developed with a focus of anti-anxiety medications r/t anxiety disorder; Goal- decreased episodes of s/sx of anxiety through the review date; Intervention- give anti-anxiety medication ordered by physician. Record review of Resident #1's Hospital Rehabilitation Consultation Report dated 07/13/22 revealed, resident was an [AGE] year-old male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's General Medicine (Hospital) Progress Note dated 07/14/22 which was included in the residents discharge documentation revealed, Assessment/Plan 4- [CONDITION(S)], Home Medication: TSH 0.57, continue current regimen. Will adjust if clinically indicated. Lab Results- TSH 0.57. Record review of Resident #1's Hospital Medication List printed on 07/19/22 at 12:17 PM that was provided to the facility upon Resident #1's admission revealed, a list of medications the resident was supposed to start taking, continue taking and stop taking. The medication list had check marks by all the listed oral formulation medications indicating review except the [MEDICATION(S)]. The [MEDICATION(S)] order stated Take these medications AS PRESCRIBED. Do not change the dosage on your own. Call your health care provider if you have any questions . [MEDICATION(S)] 150 mcg tablet, commonly known as : [MEDICATION(S)] TAKE 1 TABLET 150 MCG BY MOUTH DAILY. There was no check mark present by the order of the [MEDICATION(S)]. Record review of Resident #1's Progress Notes dated 08/02/22 at 6:24 PM, signed by the DON, revealed [FAMILY MEMEBR #1] came into office with concerns about the resident and his therapy and that she has not seen him do therapy since his admission . Resident is currently in room and does not want to get up at the time to do therapy. Therapy encouraged resident to get up and do therapy, resident still refusing to do therapy. Therapist will try again to encourage resident again after lunch to see if resident is in better mod to participate . Educated and encourage spouse to help motivate resident to participate in therapy. Record review of Resident #1's Progress Notes dated 08/11/22 at 7:17 PM, signed by RN A, revealed Family Member #1 called concerning the [MEDICATION(S)] on his med list from hospital and the facility's med list. Medication was not on facility med list, NP notified and stated to put order in for [MEDICATION(S)] 150 mcg by mouth daily. Record review of Resident #1's MAR from 08/01/22 to 08/11/22 revealed, resident did not receive [MEDICATION(S)]. Record review of Resident #1's Physician Order dated 08/11/22 entered by RN A, revealed [MEDICATION(S)] 150 mcg by mouth one time a day for [CONDITION(S)]. Record review of Resident #1's MAR from 08/12/22 to 08/16/22 revealed, resident received [MEDICATION(S)] 150 mcg daily from 08/12/22 to 08/17/22. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed, Patient seen for follow up visit in the nursing home for mood and medications. On last visit 08/2/22, [MEDICATION(S)] ordered for agitation and anxiety in context of depressed mod/dementia . Per patient, he is reporting that he no longer feels anxious. Denies worsening of depressed mood. Record review of Resident #1's Physician's Progress Noted dated 08/17/22 signed by MD A revealed, Patient still very weak and debilitated requiring 2 person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Record review of Resident #1's Physician Order dated 08/17/22 entered by the DON revealed, [MEDICATION(S)] Sodium Tablet 175 MCG give 1 tablet orally in the morning for [CONDITION(S)]. Record review of Resident #1's Physician's Progress Noted dated 08/17/22 signed by MD A revealed, History: Patient still very weak and debilitated requiring 2-person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Diagnosis, Assessment and Plan: Restart [MEDICATION(S)] at 175 mcg daily In an interview on 08/30/22 at 10:00 AM, the Administrator said that the facility became aware that Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1that the resident had not received his [CONDITION(S)] medication. He said that the Family Member #1was concerned because he was not returning to his baseline mental state following his surgery and prior admission into the facility. The Administrator said that the facility's investigation revealed that the admitting nurse (RN A) failed to enter Resident #1's [MEDICATION(S)] from the hospital records from admission, and the resident did not receive his [MEDICATION(S)] for approximately 3 weeks, from his admission (07/19/22) to when Family Member #1 #1 identified the missing medication around 08/12/22. An observation and interview on 08/30/22 at 11:32 AM with Resident #1 and Family Member #1 revealed, Resident #1 sitting in a chair with a back brace on with Family #1 cutting his hair. The resident appeared well groomed and in no immediate distress. When the surveyor asked questions Family Member #1 #1 answered with the resident intervening rarely and at times nodding in agreement. Family Member #1 #1 said that after Resident #1 admitted to the facility his recovery was taking longer than expected. She said the resident had dementia and initially she believed that he had anesthesia related dementia but as time went on, he didn't seem to get better. Family Member #1 #1 said Resident #1 was tired, had no appetite, was always nauseated and was always cold; sometimes using 2 to 3 blankets. She stated she called his general practitioner who informed her that the resident was showing symptoms associated to [CONDITION(S)]. She said after she talked to Resident #1's General Practitioner she asked to see the resident's medication list and that was when she identified that he was not receiving his [MEDICATION(S)]. Family Member #1 #1 said that she believed the lack of [MEDICATION(S)] played a part in the resident's recent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said when he didn't receive his [MEDICATION(S)], the resident was so tired that he could not successfully complete his therapy and after the facility started administering his [MEDICATION(S)] his energy levels got better and his therapy sessions were more successful. Family Member #1 #1 said the facility's failure to administer Resident #1's [MEDICATION(S)], impaired the resident's recovery not only by leaving him cold, tired, confused, having depressed mood but also wasted much of his first therapies sessions because the resident was not in the right state of mind to successfully complete his therapy and now he used almost all the therapy days covered by his insurance. She said prior to his admission to the facility, Resident #1 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 08/30/22 at 12:14 PM, CNA A said that initially Resident #1 was not responsive and lethargic, but he had gotten better. She said she remembered an incident in which the resident was using multiple blankets and his Family Member #1 reported he was cold, but had no knowledge of current lethargy or cold intolerance. In an interview on 08/30/22 at 12:30 PM, NP A said she was unaware that Resident #1 did not receive his [MEDICATION(S)] from 07/19/22 to 08/11/22. She said symptoms of [CONDITION(S)] were fatigue, altered mental status in which the resident appears down, depression, elevated HR, cold intolerance, hair loss and weight loss. In an interview on 08/30/22 at 2:25 PM, NP B said on 08/02/22 Resident #1 was started on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] PRN due to symptoms of depression and anxiety. She said on her last visit, she discontinued his prescription for [MEDICATION(S)] and [MEDICATION(S)] because their use did not lead to any improvement in the resident and the benefits did not outweigh the risk, so he was started on [MEDICATION(S)]. NP B said that Resident #1's depression had gotten better since her last visit on 8/16/22 and she was not notified that the resident suffered from [CONDITION(S)]. NP B said normally she would draw a TSH level prior to starting a resident on psychiatric medications because [CONDITION(S)]/low [CONDITION(S)] can give the impression of depression. She said she did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 08/30/22 at 2:37 PM, the DON said an individual with low [CONDITION(S)] would suffer from weight gain, sensitivity to cold, and poor mental health. She said the first time she became aware of Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 brought up the discrepancy she observed when reviewing Resident #1's medication list. The DON said once MD A immediately placed a lab order for TSH and the results came out indicating a critically high TSH of 56.296 uIU/ml, he started Resident #1 on [MEDICATION(S)] on 08/17/22. The DON said since the resident started his [MEDICATION(S)], he seemed more alert but could not single handedly attribute it to the medication. In an interview on 08/30/22 at 3:11 PM, MD A said that he just took over the role of attending physician on 08/15/22 and on that day the unit manager informed him that that the nursing staff did not carry over Resident #1's [MEDICATION(S)] when entering the resident's medication on admission. So he called in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's critically high TSH of 56.296 uIU/ml, he questioned the nursing staff and he learned that the medication was missed for several weeks. MD A said after receiving the results, he went to see the resident, who was clinically stable, and increased his [MEDICATION(S)] dose to 175 mcg to compensate for the weeks of missed medications. He said the failure to administer [CONDITION(S)] ([MEDICATION(S)]) to a resident with [CONDITION(S)] could place them at risk of withdrawn mood, fatigue, behaviors, and deterioration of clinical condition. In an interview on 08/31/22 at 12:15 PM, the Director of Therapy revealed Resident #1's first therapy sessions were tough because he was very confused and tired. She said he was slow to get therapy because of his disease state and after his cognition got better his therapy began to progress better. In a phone interview on 09/07/22 at 08:31 AM, RN A said he did not remember Resident #1 missing his [MEDICATION(S)] at admission. He said when a resident is admitted the admitting nurse informs the NP/MD of the resident's hospital medications and the provider then approves the medications. He said he received 1on1 training regarding admissions because some of his admissions documentation was incomplete because he had missed diagnoses, Gender and room information on some resident's but he had never missed medications. Record review of RN A's training record dated 08/12/22 revealed performed by the ADON, RN A received 1on1 training on the admissions process and the clinical admissions checklist. Record review of a blank facility form titled Clinical Admission Checklist revised 08/2015, Physician order completed- Clinical/Orders. Verify appropriate diagnosis, right route and reconcile against referring community orders e.g. hospital D/C orders. Print Order Summary- Order/Reports/Order Summary. Signature Line 2. Second nurse to verify and reconcile against referring community orders e.g. hospital D/C orders. Second Nurse Signature required. Copy placed in chart and original MD folder for signature. Record review of the facility policy document titled Admission Assessment and Follow Up: Role of the Nurse revised 09/2012 revealed, 11- reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 7 residents (Resident #1) reviewed for quality of care. -The facility failed to accurately transcribe Resident #1's Hospital discharge medications upon admission and to notify the physician of Resident # 1 resulting in the resident not receiving his [MEDICATION(S)] from 07/19/22 to 08/11/22 . - The facility failed to notify the physician of Resident #1's elevated TSH of 26.750 uIU/ml (indicating [CONDITION(S)] disease) for 14 days (07/27/22 to 08/12/22) resulting in the resident's TSH level increasing to a critical value of 56.296 uIU/ml which caused the resident experience cold intolerance, depressed mood, fatigue which hindered his ability to complete his physical therapy and the resident's TSH level increasing to a critical level. These failures could place residents at risk of inadequate medication therapy, delay in treatment, and adverse reactions. Findings Included Resident #1Record review of Resident #1's face sheet dated 08/16/22 revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's face sheet did not have a recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admitting MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no symptoms of feeling down, depressed or hopeless, no symptoms of little interest or pleasure in doing things, no presence of thoughts that you would be better off dead, or hurting yourself in some way, no potential indicators of [CONDITION(S)], no behavioral symptoms present, no rejection of care present, a worsening of change in behavior of other symptoms, extensive assistance with most ADLs, wheelchair use, walker use, and occasionally incontinent of both bladder and bowel. Resident #'s MDS did not have [CONDITION(S)] Disorder (e.g. [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]) selected under the list of active metabolic diagnoses. Record review of Resident #21's Care Plan initiated 07/19/22 revealed, Focus- anticoagulant therapy, risk of falls, impairment to skin integrity, [CONDITION(S)] and impaired cognitive function related to dementia. On 08/04/22 a focus area of antidepressant medication use related to depression, Goal- free from discomfort or adverse reactions related to antidepressant therapy; Interventions- give antidepressant medications ordered by physician was initiated. On 08/18/22 a focus of [CONDITION(S)]; Goal- free from s/sx of [CONDITION(S)], will have no complication related to [CONDITION(S)]; Intervention- give [CONDITION(S)] replacement therapy as ordered, obtain and monitor lab/diagnostic work as ordered was initiated. On 08/30/22 a focus of anti-anxiety medications r/t anxiety disorder; Goal- decreased episodes of s/sx of anxiety through the review date; Intervention- give anti-anxiety medication ordered by physician. Record review of Resident #1's Hospital Medication List printed on 07/19/22 at 12:17 PM that was provided to the facility upon Resident #1's admission revealed, a list of medications the resident was supposed to start taking, continue taking and stop taking. The medication list had check marks by all the listed oral formulation medications indicating review except the [MEDICATION(S)]. The [MEDICATION(S)] order stated Take these medications AS PRESCRIBED. Do not change the dosage on your own. Call your health care provider if you have any questions . [MEDICATION(S)] 150 mcg tablet, commonly known as : [MEDICATION(S)] TAKE 1 TABLET 150 MCG BY MOUTH DAILY. There was no check mark present by the order of the [MEDICATION(S)]. Record review of Resident #1's Admission assessment dated [DATE] completed by RN A revealed, Section EE Summary of Medications was blank. Record review of Resident #1's MAR from 07/19/22 to 07/31/22 revealed, resident did not receive [MEDICATION(S)]. Record review of Resident #1's Physician Order dated 07/24/22 revealed, Lab: CBC, BMP, TSH and A1c. Confirmation C 0160A, communication method- phone ordered by the NP. Record review of Resident #1's Physician Order dated 07/25/22 revealed, Psych consult due to anxiety disorder Record review of Resident #1's Lab Results Report dated 07/26/22 at 06:27 PM revealed, the specimen was collected on 07/25/22 at 9:37 PM and the resident had a high TSH3 result of 26.750 uIU/ml (indicative of [CONDITION(S)]) with the normal range of 0.450 - 5.330. The report included a note saying Although Normal TSH readings are now defined as 4-6 uIU/mL in elderly patients, levels up to 10 uIU/mL may be physiological and do not necessarily need to need to be treated unless clinically indicated. Record review of Resident #1's Progress Notes from 07/26/22 to 07/27/22 revealed, no record of the resident's Lab Report indicating an elevated TSH or notification to Resident #1's physician. Record review of Resident #1's Progress Notes dated 08/02/22 at 6:24 PM signed by the DON revealed, Family Member #1 came into office with concerns about the resident and his therapy and that she has not seen him do therapy since his admission . Resident is currently in room and does not want to get up at the time to do therapy. Therapy encouraged resident to get up and do therapy, resident still refusing to do therapy. Therapist will try again to encourage resident again after lunch to see if resident is in better mod to participate . Educated and encourage spouse to help motivate resident to participate in therapy. Record review of Resident #1's MAR from 08/01/22 to 08/11/22 revealed, resident did not receive [MEDICATION(S)]. Record review of Resident #1's Progress Notes dated 08/11/22 at 7:17 PM signed by RN A revealed, Family Member #1 called concerning [MEDICATION(S)] on med list from hospital and facility med list. Medication was not on facility med list, NP notified and stated to put order in for [MEDICATION(S)] 150 mcg by mouth daily. Record review of Resident #1's Physician Order dated 08/11/22 revealed entered by RN A, [MEDICATION(S)] 150 mcg by mouth one time a day for [CONDITION(S)]. Record review of Resident #1's MAR from 08/12/22 to 08/16/22 revealed, resident received [MEDICATION(S)] 150 mcg daily from 08/12/22 to 08/17/22. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed, Patient seen for follow up visit in the nursing home for mood and medications. On last visit 08/2/22, [MEDICATION(S)] ordered for agitation and anxiety in context of depressed mod/dementia . Per patient, he is reporting that he no longer feels anxious. Denies worsening of depressed mood. Record review of Resident #1's Lab Results Report dated 08/17/22 at 3:34 PM revealed, TSH CRITICAL! TSH Verified by repeat analysis and/or delta check SS. 08/17/22, 3:33 PM. Result 56.296 Unit uIU/ml. Record review of Resident #1's Physician's Progress Noted dated 08/17/22 signed by MD A revealed, Patient still very weak and debilitated requiring 2 person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Record review of Resident #1's Physician Order dated 08/17/22 entered by the DON revealed, [MEDICATION(S)] Sodium Tablet 175 MCG give 1 tablet orally in the morning for [CONDITION(S)]. Record review of Resident #1's Physician's Progress Noted dated 08/17/22 signed by MD A revealed, History: Patient still very weak and debilitated requiring 2 person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Diagnosis, Assessment and Plan: Restart [MEDICATION(S)] at 175 mcg daily Record review of Resident #1's Physician Order dated 08/17/22 revealed, [MEDICATION(S)] Sodium Tablet 175 MCG give 1 tablet orally in the morning for [CONDITION(S)]. Record review of Resident #1's Progress Notes dated 08/17/22 at 04:07 PM signed by the DON revealed, critical lab for TSH called in at 4:04 PM, received by this nurse. MD A notified. See new orders. Record review of Resident #1's MAR from 08/18/22 to 08/31/22 revealed, resident received [MEDICATION(S)] 175 mcg daily. Record review of Resident #1's Physician Order dated 08/18/22 revealed, TSH level in 2 weeks one time only for TSH level for 1 day entered by MD A. In an interview on 08/30/22 at 10:00 AM the Administrator said that the facility became aware that Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 identified that he the resident had not received his [CONDITION(S)] medication. He said that the Family Member #1 was concerned because he was not returning to his baseline mental state following his surgery and prior admission into the facility. The Administrator said that the facility's investigation revealed that the admitting nurse failed (RN A) to enter Resident #1's [MEDICATION(S)] from the hospital records from admission and the resident did not receive his [MEDICATION(S)] for approximately 3 weeks, from his admission (07/19/22) to when Family Member #1 #1 identified the missing medication around 08/12/22. An observation and interview on 08/30/22 at 11:32 AM with Resident #1 and Family Member #1 #1 revealed, Resident #1 sitting in a chair with a back brace on with Family Member #1 #1 cutting his hair. The resident appeared well groomed and in no immediate distress, when the surveyor asked questions Family Member #1 #1 answered with the resident intervening rarely and at times nodding in agreement. Family Member #1 #1 said that after Resident #1 admitted to the facility his recovery was taking longer than expected. She said the resident had dementia and initially she believe that he had anesthesia related dementia but as time went, he didn't seem to get better. Family Member #1 #1 said Resident #1 was tired, had no appetite, was always nauseated and was always cold, sometimes using 2 to 3 blankets so she called his general practitioner who informed her that the resident was showing symptoms associated to [CONDITION(S)]. She said after she talked to Resident #1's GP she asked to see the resident's medication list and that was when she identified that he was not receiving his [MEDICATION(S)]. Family Member #1 #1 said that she believe the lack of [MEDICATION(S)] played a part in the resident's recent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said when he didn't receive his [MEDICATION(S)] the resident was so tired that he could not successfully complete his therapy and after the facility started administering his [MEDICATION(S)] his energy levels got better and his therapy sessions were more successful. Family Member #1 #1 said the facility's failure to administer Resident #1's [MEDICATION(S)] impaired the resident's recovery not only by leaving him cold, tired, confused, having depressed mood but also wasted much of his first therapies sessions because the resident was not in the right state of mind to successfully complete his therapy and now he has used almost all the therapy days covered by his insurance. She said prior to his admission to the facility, Resident #1 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 08/30/22 at 12:14 PM, CNA A said that initially Resident #1 was not responsive and lethargic but he has gotten better. She said she remembered an incident in which the resident was using multiple blankets and his Family Member #1 reported he was cold but has no knowledge of current lethargy or cold intolerance. In an interview on 08/30/22 at 12:30 PM, NP A said she was unaware that Resident #1 did not receive his [MEDICATION(S)] from 07/19/22 to 08/11/22. She said symptoms of [CONDITION(S)] were fatigue, altered mental status in which the resident appears down, depression, elevated HR, cold intolerance, hair loss and weight loss. In an interview on 08/30/22 at 2:25 PM, NP B said on 8/2/22 Resident #1 was started on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] PRN due to symptoms of depression and anxiety. She said on her last visit she discontinued his prescription for [MEDICATION(S)] and [MEDICATION(S)] because their did not lead to any improvement in the resident and the benefits did not out way the risk, so he was started on [MEDICATION(S)]. NP B said that Resident #1's depression had gotten better since her last visit on 8/16/22 and she was not notified that the resident suffered from [CONDITION(S)]. She aid normally she would draw a TSH level prior to starting a resident on psychiatric medications because [CONDITION(S)]/low [CONDITION(S)] hormone can give the impression of depression. She said she did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 08/30/22 at 2:37 PM, The DON said an individual with low [CONDITION(S)] hormone would suffer from weight gain, sensitivity to cold and poor mental health. She said the first time she became aware of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 brought the discrepancy she had observed when reviewing Resident #1's medication list. Th DON said once notified MD A immediately placed a lab order for TSH and once the results came out indicating a critically high TSH of 56.296 uIU/ml he started Resident #1 on [MEDICATION(S)] on 08/17/22. The DON said since the resident started his [MEDICATION(S)] he seemed more alert but could not single handedly attribute it to the medication. She said failure to enter discharge medications could place residents at risk for delay in treatment. In an interview on 08/30/22 at 3:11 PM, MD A said that he just took over the role of attending physician on 08/15/22 and on that day the unit manager informed him that that the nursing staff did not carry over Resident #1's [MEDICATION(S)] when entering the resident's medication on admission so he called in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's critically high TSH of 56.296 uIU/ml he questioned the nursing staff and he learned that the medication was missed for several weeks. MD A said after receiving the results he went to see the resident, who was clinically stable, and increased his [MEDICATION(S)] dose to 175 mcg to compensate for the weeks of missed medications. He said that the expectation is that nursing staff notify the NP/MD of critical labs immediately and all other abnormal labs by the next business day per the protocol lab notification binder. MD A said on Monday through Thursday the Physicians and nurse practitioners are here on alternating days so they are easily available to nursing staff. He said he was unaware of Resident #1's ordered TSH on 07/24/22 of 26.750 uIU/ml and that levels that high indicated the resident had [CONDITION(S)] disease. MD A said the nursing staff should have immediately notified the resident's Physician or Nurse Practitioner and if action was taken then the resident most likely would not have had a critical level on 08/16/22. He said failure to administer [CONDITION(S)] hormone ([MEDICATION(S)]) to a resident with [CONDITION(S)] could place them at risk of withdrawn mood, fatigue, behaviors and deterioration of clinical condition. In an interview on 08/31/22 at 08:59 AM, the Administrator said that he was unaware of Resident #1's lab results that was ordered on 07/24/22. He said that the facility had begun System Management, that they were reviewing their admissions/ lab notification process and the task had been assigned to the ADON. The Don said that when lab results are out the facility did not receive a fax and all results immediately updated in the EMR and the fax number the lab had on their account would not yield a print out of lab results. He said since he became aware of the missed TSH for Resident #1 he contacted the lab company to ensure that the fax number is correct and the facility is making changes so that lab results will print at the fax located at the nursing station. The Administrator said the previous DON was responsible for ensuring abnormal lab values were communicated to the provider and Resident #1's elevated TSH result ordered on 07/24/22 fell through the crack because the previous nurse practitioner used to check on labs in the EMR. He said the facility was transitioning between attending physicians during when Resident #1's lab result was missed. In an interview on 08/31/22 at 09:40 AM, the DON said that once a resident arrives at the facility the nurse verifies the hospital discharge orders with the physician and enters them into the EMR. She said that when Resident #1 was admitted to the facility on [DATE], the facility did not have a system in place to verify that admissions orders were reconciled correctly. The DON said she started a process in which the ADON will audit the admission records to ensure that no medication orders or wound care orders were missed by the admitting nurse. She said facility staff were re-trained on using the admissions checklist to ensure that no orders were missed and RN A specifically received 1on1 training regarding his admissions process. The the DON said normally after lab results are out it is the DON/designees responsibility to sign off on the record in the EMR after ensuring that the appropriate follow-up occurred with the resident's provider but when she started her position as DON there were a lot of unreviewed Lab results that she signed off on without verifying that follow-up was taken because they were old and she assumed someone had already taken care of it. She said even though the record shows she reviewed Resident #1's lab report showing a high TSH of 26.750 uIU/ml on 08/01/22, she was not aware of the sample that was ordered on 07/24/22 until the surveyor brought it to her attention. The DON said that failure to properly reconcile discharge medication lists and admissions orders and review lab results places residents at risk for delay in treatment, side effects and deterioration of health status. In an interview on 08/31/22 at 10:36 AM, the ADON said that she became aware on Resident #1's elevated TSH ordered on 07/24/22 on 08/17/22 when she was reviewing the new results that showed a critical high level collected on 8/16/22, she said she had the two lab results side by side. She said nursing staff are expected to check the lab results dashboard located in the EMR on their shift and to notify the physician of any abnormal lab results. The ADON said the previous DON was responsible for reviewing lab results to ensure the appropriate follow up occurred and she did not know why the physician was not notified of the previous elevated TSH. She said since Resident #1 started receiving his [MEDICATION(S)] he has become more alert/oriented in comparison to his admission. The ADON said failure to insufficient supplementation of [CONDITION(S)] hormone can cause an initial appearance of depression in the resident and failure to promptly notify providers of abnormal lab results could place residents at risk of delay in care. In an interview on 08/31/22 at 12:15 PM, the Director of Therapy Resident #1's first therapy sessions were tough because he was very confused and tired. She said he was slow to get therapy because of his disease state and after his cognition got better his therapy began to progress better. In an interview on 08/31/22 at 01:54 PM, MD B said he said the facility became aware of Resident #1's missing [MEDICATION(S)] when the resident's FAMILY MEMEBR #1 reviewed his med and noticed that he was missing his [CONDITION(S)] medication. He said that he never received an alert of the resident's elevated TSH that was ordered on 07/24/22 and the expectation is for nursing staff to call providers immediately for critical values and notify providers by the next business days for all other abnormal lab values. He said per his records no provider at his practice was notified of elevated TSH levels on 07/25/22. In a phone interview on 09/07/22 at 08:31 AM, RN A said he did not remember Resident #1 missing his [MEDICATION(S)] at admission. He said when a resident is admitted the admitting nurse informs the NP/MD of the resident's hospital medications and the provider then approves the medications. He said he received 1on1 training regarding admissions because some of his admissions documentation was incomplete because he had missed diagnoses, Gender and room information on some resident's but he had never missed medications. Record review of RN A's training record dated 08/12/22 revealed performed by the ADON, RN A received 1on1 training on the admissions process and the clinical admissions checklist. Record review of the facility's Nursing Orientation Competency Review Form with no revision date revealed, 4- Admission Process, a- Admissions checklist, b- consents. Record review of a blank facility form Clinical Admission Checklist revised 08/2015, Physician order completed- Clinical/Orders. Verify appropriate diagnosis, right route and reconcile against referring community orders e.g. hospital D/C orders. Print Order Summary- Order/Reports/Order Summary. Signature Line 2. Second nurse to verify and reconcile against referring community orders e.g. hospital D/C orders. Second Nurse Signature required. Copy placed in chart and original MD folder for signature. Record review of the facility document titled Admission Assessment and Follow Up: Role of the Nurse revised 09/2012 revealed, 11- reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures. Record review of the facility policy titled Lab and Diagnostic Test Results- Clinical Protocol revised 11/2018 revealed, Review by Nursing Staff: 1- When test results are reported to the facility, a nurse will first review the results; a- if staff who first receive or review lab and diagnostic test results cannot follow up the remainder of this procedure for reporting and documenting the results and their implication, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure. Identifying Situations that Warrant Immediate Notification: 1- nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results . whether the result should be conveyed to a physician regardless of other circumstances (that is, the abnormal result is problematic regardless of any other factors); whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison. Options for Physician Notification: 1- a physician must be notified by phone, fax, voicemail, e-mail, pager, or a telephone message to another person acting as the physician's agent (for example, office staff); a- facility staff should document information about when, how, and to whom the information was provided and the response. This should be done in the Progress Notes section of the medical record and not on the lab results report, because test results should be correlated with other relevant information such as individual's overall situation, current symptoms, advance directives, prognosis, etc. b- direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification . c- for information that does not need immediate physician response, staff may use alternative such as faxing, voicemail, or a clipboard in the facility. Record review of the facility provided document titled Laboratory Notification Parameters/Vital Sign Parameters with no revision date revealed, Test/Procedure- Chemistry; Report Immediately- BUN (>60), Calcium (>12.5), Potassium (any value outside of reference range), Sodium (<125, >155), Blood glucose ( >300, <70). Report Next Work Day- Other chemistry values. Record review of facility provided document titled MD A Notification Manual with no revision date revealed, that for non-immediate notification nursing staff should put the information in clinical notification manual while in cases of immediate notification contact numbers for NP A and MD A were listed and after hours weekends/holidays were included.

Based on observation, interview and record review, the facility failed to ensure that the facility provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 out of 7 residents (Resident #1) reviewed for medication administration. - The facility failed to ensure Resident #1 received his [MEDICATION(S)] ([CONDITION(S)]) from 07/19/22 to 8/11/22 as listed in his hospital discharge medication list causing the resident experience cold intolerance, depressed mood, fatigue which hindered his ability to complete his physical therapy and the resident's TSH level increasing to a critical level. This failure could place residents at risk for adverse reactions, inadequate therapy, decreased quality of life and hospitalization . Findings included: Record review of Resident #1's face sheet dated 08/16/22 revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: spinal stenosis, muscle weakness, cognitive communication deficit, Afib, dementia without behavioral; disturbance, hypertension, [CONDITION(S)] and Secondary diagnoses that developed during stay of Anxiety (08/09/22) and Major Depressive Disorder(08/04/22). Resident #1's face sheet did not have a recorded diagnoses of low [CONDITION(S)] or any form of [CONDITION(S)] disease. Record review of Resident #1's Admitting MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no symptoms of feeling down, depressed or hopeless, no symptoms of little interest or pleasure in doing things, no presence of thoughts that you would be better off dead, or hurting yourself in some way, no potential indicators of [CONDITION(S)], no behavioral symptoms present, no rejection of care present, a worsening of change in behavior of other symptoms, extensive assistance with most ADLs, wheelchair use, walker use, and occasionally incontinent of both bladder and bowel. Resident #'s MDS did not have [CONDITION(S)] Disorder (e.g. [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]) selected under the list of active metabolic diagnoses. Record review of Resident #21's Care Plan initiated 07/19/22 revealed, Focus- anticoagulant therapy, risk of falls, impairment to skin integrity, [CONDITION(S)] and impaired cognitive function related to dementia. On 08/04/22 a focus area of antidepressant medication use related to depression, Goal- free from discomfort or adverse reactions related to antidepressant therapy; Interventions- give antidepressant medications ordered by physician was initiated. On 08/18/22 a focus of [CONDITION(S)]; Goal- free from s/sx of [CONDITION(S)], will have no complication related to [CONDITION(S)]; Intervention- give [CONDITION(S)] replacement therapy as ordered, obtain and monitor lab/diagnostic work as ordered was initiated. On 08/30/22 a focus of anti-anxiety medications r/t anxiety disorder; Goal- decreased episodes of s/sx of anxiety through the review date; Intervention- give anti-anxiety medication ordered by physician. Record review of Resident #1's Hospital Medication List printed on 07/19/22 at 12:17 that was provided to the facility upon Resident #1's admission revealed, a list of medications the resident was supposed to start taking, continue taking and stop taking. The medication list had check marks by all the listed oral formulation medications indicating review except the [MEDICATION(S)]. The [MEDICATION(S)] order stated Take these medications AS PRESCRIBED. Do not change the dosage on your own. Call your health care provider if you have any questions . [MEDICATION(S)] 150 mcg tablet, commonly known as : [MEDICATION(S)] TAKE 1 TABLET 150 MCG BY MOUTH DAILY. There was no check mark present by the order of the [MEDICATION(S)]. Record review of Resident #1's Admission assessment dated [DATE] completed by RN A revealed, Section EE Summary of Medications was blank. Record review of Resident #1's MAR from 07/19/22 to 07/31/22 revealed, resident did not receive [MEDICATION(S)]. Record review of Resident #1's Physician Order dated 07/25/22 revealed, Psych consult due to anxiety disorder. Record review of Resident #1's Lab Results Report dated 07/26/22 at 06:27 PM revealed, the specimen was collected on 07/25/22 at 9:37 PM and the resident had a high TSH3 result of 26.750 uIU/ml (indicative of [CONDITION(S)]) with the normal range of 0.450 - 5.330. The report included a note saying Although Normal TSH readings are now defined as 4-6 uIU/mL in elderly patients, levels up to 10 uIU/mL may be physiological and do not necessarily need to need to be treated unless clinically indicated. Record review of Resident #1's Progress Notes dated 08/02/22 at 6:24 PM signed by the DON revealed, Family Member #1 came into office with concerns about the resident and his therapy and that she has not seen him do therapy since his admission . Resident is currently in room and does not want to get up at the time to do therapy. Therapy encouraged resident to get up and do therapy, resident still refusing to do therapy. Therapist will try again to encourage resident again after lunch to see if resident is in better mod to participate . Educated and encourage spouse to help motivate resident to participate in therapy. Record review of Resident #1's Progress Notes dated 08/11/22 at 7:17 PM signed by RN A revealed, Family Member #1 called concerning [MEDICATION(S)] on med list from hospital and facility med list. Medication was not on facility med list, NP notified and stated to put order in for [MEDICATION(S)] 150 mcg by mouth daily. Record review of Resident #1's MAR from 08/01/22 to 08/11/22 revealed, resident did not receive [MEDICATION(S)]. Record review of Resident #1's Physician Order dated 08/11/22 revealed entered by RN A, [MEDICATION(S)] 150 mcg by mouth one time a day for [CONDITION(S)]. Record review of Resident #1's MAR from 08/12/22 to 08/16/22 revealed, resident received [MEDICATION(S)] 150 mcg daily from 08/12/22 to 08/17/22. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed, Patient seen for follow up visit in the nursing home for mood and medications. On last visit 08/2/22, [MEDICATION(S)] ordered for agitation and anxiety in context of depressed mod/dementia . Per patient, he is reporting that he no longer feels anxious. Denies worsening of depressed mood. Record review of Resident #1's Physician's Progress Noted dated 08/17/22 signed by MD A revealed, Patient still very weak and debilitated requiring 2 person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Record review of Resident #1's Lab Results Report dated 08/17/22 at 3:34 PM revealed, TSH CRITICAL! TSH Verified by repeat analysis and/or delta check SS. 08/17/22, 3:33 PM. Result 56.296 Unit uIU/ml. Record review of Resident #1's Physician Order dated 08/17/22 entered by the DON revealed, [MEDICATION(S)] Sodium Tablet 175 MCG give 1 tablet orally in the morning for [CONDITION(S)]. Record review of Resident #1's Physician's Progress Note dated 08/17/22 signed by MD A revealed, History: Patient still very weak and debilitated requiring 2-person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Diagnosis, Assessment and Plan: Restart [MEDICATION(S)] at 175 mcg daily Record review of Resident #1's Progress Notes dated 08/17/22 at 04:07 PM signed by the DON revealed, critical lab for TSH called in at 4:04 PM, received by this nurse. MD A notified. See new orders. Record review of Resident #1's MAR from 08/18/22 to 08/31/22 revealed, resident received [MEDICATION(S)] 175 mcg daily. Record review of Resident #1's Physician Order dated 08/18/22 revealed, TSH level in 2 weeks one time only for TSH level for 1 day entered by MD A. In an interview on 08/30/22 at 10:00 AM the Administrator said that the facility became aware that Resident #1 had a diagnosis of [CONDITION(S)] when his Family Member #1 identified that the resident had not received his [CONDITION(S)] medication. He said that the Family Member #1 was concerned because he was not returning to his baseline mental state following his surgery and prior to admission into the facility. The Administrator said that the facility's investigation revealed that the admitting nurse failed to enter Resident #1's [MEDICATION(S)] from the hospital records from admission and the resident did not receive his [MEDICATION(S)] for approximately 3 weeks, from his admission (07/19/22) to when Family Member #1 identified the missing medication around 08/12/22. An observation and interview on 08/30/22 at 11:32 AM with Resident #1 and Family Member #1 #1 revealed, Resident #1 sitting in a chair with a back brace on with Family #1 cutting his hair. The resident appeared well groomed and in no immediate distress, when the surveyor asked questions Family Member #1 answered with the resident intervening rarely and at times nodding in agreement. Family Member #1 said that after Resident #1 admitted to the facility his recovery was taking longer than expected. She said the resident had dementia and initially she believe that he had anesthesia related dementia but as time went, he didn't seem to get better. Family Member #1 said Resident #1 was tired, had no appetite, was always nauseated and was always cold, sometimes using 2 to 3 blankets so she called his general practitioner who informed her that the resident was showing symptoms associated to [CONDITION(S)]. She said after she talked to Resident #1's GP she asked to see the resident's medication list and that is when she identified that he was not receiving his [MEDICATION(S)]. Family Member #1 said that she believe the lack of [MEDICATION(S)] played a part in the resident's recent diagnoses of anxiety and depression because once he started receiving his [MEDICATION(S)] again he became more alert and interactive. She said when he didn't receive his [MEDICATION(S)] the resident was so tired that he could not successfully complete his therapy and after the facility started administering his [MEDICATION(S)] his energy levels got better and his therapy sessions were more successful. Family Member #1 said the facility's failure to administer Resident #1's [MEDICATION(S)] impaired the resident's recovery not only by leaving him cold, tired, confused, having depressed mood but also wasted much of his first therapies sessions because the resident was not in the right state of mind to successfully complete his therapy and now he has used almost all the therapy days covered by his insurance. She said prior to his admission to the facility, Resident #1 did not have a diagnosis of depression or anxiety. In an interview on 08/30/22 at 12:14 PM, CNA A said that initially Resident #1 was not responsive and lethargic but he has gotten better. She said she remembered an incident in which the resident was using multiple blankets and his Family Member #1 reported he was cold but has no knowledge of current lethargy or cold intolerance. In an interview on 08/30/22 at 12:30 PM, NP A said she was unaware that Resident #1 did not receive his [MEDICATION(S)] from 07/19/22 to 08/11/22. She said symptoms of [CONDITION(S)] were fatigue, altered mental status in which the resident appears down, depression, elevated HR, cold intolerance, hair loss and weight loss. In an interview on 08/30/22 at 2:25 PM, NP B said on 8/2/22 Resident #1 was started on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] PRN due to symptoms of depression and anxiety. She said on her last visit she discontinued his prescription for [MEDICATION(S)] and [MEDICATION(S)] because their use did not lead to any improvement in the resident and the benefits did not out way the risk, so he was started on [MEDICATION(S)]. NP B said that Resident #1's depression had gotten better since her last visit on 8/16/22 and she was not notified that the resident suffered from [CONDITION(S)]. She aid normally she would draw a TSH level prior to starting a resident on psychiatric medications because [CONDITION(S)]/low [CONDITION(S)] can give the impression of depression. She said she did not know if Resident #1 had a history of anxiety and depression prior to admission into the facility. In an interview on 08/30/22 at 2:37 PM, The DON said an individual with low [CONDITION(S)] would suffer from weight gain, sensitivity to cold and poor mental health. She said the first time she became aware of the resident's diagnoses of [CONDITION(S)] and his missing prescription for [MEDICATION(S)] after Family Member #1 brought the discrepancy she had observed when reviewing Resident #1's medication list. She said once notified MD A immediately placed a lab order for TSH and once the results came out indicating a critically high TSH of 56.296 uIU/ml he started Resident #1 on [MEDICATION(S)] on 08/17/22. The DON said since the resident started his [MEDICATION(S)] he seemed more alert but could not single handedly attribute it to the medication. She said failure to enter discharge medications could place residents at risk for delay in treatment. In an interview on 08/30/22 at 3:11 PM, MD A said that he just took over the role of attending physician on 08/15/22 and on that day the unit manager informed him that that the nursing staff did not carry over Resident #1's [MEDICATION(S)] when entering the resident's medication on admission so he called in an order for TSH. He said his communication with the charge nurse initially gave the impression that the resident had not received his [MEDICATION(S)] for a few days but once he saw Resident #1's critically high TSH of 56.296 uIU/ml he questioned the nursing staff and he learned that the medication was missed for several weeks. MD A said after receiving the results he went to see the resident, who was clinically stable, and increased his [MEDICATION(S)] dose to 175 mcg to compensate for the weeks of missed medications. He said failure to administer [CONDITION(S)] ([MEDICATION(S)]) to a resident with [CONDITION(S)] could place them at risk of withdrawn mood, fatigue, behaviors and deterioration of clinical condition. In an interview on 08/31/22 at 12:15 PM, the Director of Therapy Resident #1's first therapy sessions were tough because he was very confused and tired. She said he was slow to get therapy because of his disease state and after his cognition got better his therapy began to progress better. In an interview on 08/31/22 at 01:54 PM, MD B said he said the facility became aware of Resident #1's missing [MEDICATION(S)] when the resident's Family Member #1 reviewed his med and noticed that he was missing his [CONDITION(S)] medication. In a phone interview on 09/07/22 at 08:31 AM, RN A said he did not remember Resident #1 missing his [MEDICATION(S)] at admission. He said when a resident is admitted the admitting nurse informs the NP/MD of the resident's hospital medications and the provider then approves the medications. He said he received 1on1 training regarding admissions because some of his admissions documentation was incomplete because he had missed diagnoses, Gender and room information on some resident's but he had never missed medications.

Based on interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 3 of 7 residents (Residents #1, Resident #2, CR #1) for professional standards. -The facility failed to accurately transcribe Resident #1's Hospital discharge medications upon admission resulting in the resident not receiving his [MEDICATION(S)] from 07/19/22 to 08/11/22 causing the resident experience cold intolerance, depressed mood, fatigue which hindered his ability to complete his physical therapy and the resident's TSH level increasing to a critical level. - The facility failed to enter wound care orders for Resident #2, upon admission, resulting in the resident not receiving wound care for 6 days. - The facility failed to enter wound monitoring orders, upon admission, and complete a wound care consult for CR #1, resulting in the resident not receiving wound care for a week following admission. These failures could place residents at risk of inadequate medication therapy, delay in treatment, and adverse reactions. Findings Included Resident #1 Record review of Resident #1's face sheet dated 08/16/22 revealed, an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's face sheet did not have a recorded diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admitting MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, no symptoms of feeling down, depressed or hopeless, no symptoms of little interest or pleasure in doing things, no presence of thoughts that you would be better off dead, or hurting yourself in some way, no potential indicators of [CONDITION(S)], no behavioral symptoms present, no rejection of care present, a worsening of change in behavior of other symptoms, extensive assistance with most ADLs, wheelchair use, walker use, and occasionally incontinent of both bladder and bowel. Resident #'s MDS did not have [CONDITION(S)] Disorder (e.g. [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]) selected under the list of active metabolic diagnoses. Record review of Resident #1's Care Plan initiated 07/19/22 revealed, Focus- anticoagulant therapy, risk of falls, impairment to skin integrity, [CONDITION(S)] and impaired cognitive function related to dementia. On 08/04/22 a focus area of antidepressant medication use related to depression, Goal- free from discomfort or adverse reactions related to antidepressant therapy; Interventions- give antidepressant medications ordered by physician was initiated. On 08/18/22 a focus of [CONDITION(S)]; Goal- free from s/sx of [CONDITION(S)], will have no complication related to [CONDITION(S)]; Intervention- give [CONDITION(S)] replacement therapy as ordered, obtain and monitor lab/diagnostic work as ordered was initiated. On 08/30/22 a focus of anti-anxiety medications r/t anxiety disorder; Goal- decreased episodes of s/sx of anxiety through the review date; Intervention- give anti-anxiety medication ordered by physician. Record review of Resident #1's Hospital Rehabilitation Consultation Report dated 07/13/22 revealed, resident was an [AGE] year-old male with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's General Medicine (Hospital) Progress Note dated 07/14/22 which was included in the residents discharge documentation revealed, Assessment/Plan 4- [CONDITION(S)], Home Medication: TSH 0.57, continue current regimen. Will adjust if clinically indicated. Lab Results- TSH 0.57. Record review of Resident #1's Hospital Medication List printed on 07/19/22 at 12:17 PM that was provided to the facility upon Resident #1's admission revealed, a list of medications the resident was supposed to start taking, continue taking and stop taking. The medication list had check marks by all the listed oral formulation medications indicating review except the [MEDICATION(S)]. The [MEDICATION(S)] order stated Take these medications AS PRESCRIBED. Do not change the dosage on your own. Call your health care provider if you have any questions . [MEDICATION(S)] 150 mcg tablet, commonly known as : [MEDICATION(S)] TAKE 1 TABLET 150 MCG BY MOUTH DAILY. There was no check mark present by the order of the [MEDICATION(S)]. Record review of Resident #1's MAR from 07/19/22 to 07/31/22 revealed, resident did not receive [MEDICATION(S)]. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Confirmation C 0160A, communication method- phone ordered by the NP. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's Lab Results Report dated 07/26/22 at 06:27 PM revealed, the specimen was collected on 07/25/22 at 9:37 PM and the resident had a high TSH3 result of 26.750 uIU/ml (indicative of [CONDITION(S)]) with the normal range of 0.450 - 5.330. The report included a note saying Although Normal TSH readings are now defined as 4-6 uIU/mL in elderly patients, levels up to 10 uIU/mL may be physiological and do not necessarily need to need to be treated unless clinically indicated. The lab result was signed off by the DON on 08/01/22 at 3:26 PM with the note Reviewed by [DON] on 08/01/22 15:26. Record review of Resident #1's Progress Notes dated 08/02/22 at 6:24 PM signed by the DON revealed, Family Member #1 came into office with concerns about the resident and his therapy and that she has not seen him do therapy since his admission . Resident is currently in room and does not want to get up at the time to do therapy. Therapy encouraged resident to get up and do therapy, resident still refusing to do therapy. Therapist will try again to encourage resident again after lunch to see if resident is in better mod to participate . Educated and encourage spouse to help motivate resident to participate in therapy. Record review of Resident #1's Progress Notes dated 08/11/22 at 7:17 PM signed by RN A revealed, Family Member #1 called concerning [MEDICATION(S)] on med list from hospital and facility med list. Medication was not on facility med list, NP notified and stated to put order in for [MEDICATION(S)] 150 mcg by mouth daily. Record review of Resident #1's MAR from 08/01/22 to 08/11/22 revealed, resident did not receive [MEDICATION(S)]. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's MAR from 08/12/22 to 08/16/22 revealed, resident received [MEDICATION(S)] 150 mcg daily from 08/12/22 to 08/17/22. Record review of Resident #1's Psychiatric Subsequent assessment dated [DATE] revealed, Patient seen for follow up visit in the nursing home for mood and medications. On last visit 08/2/22, [MEDICATION(S)] ordered for agitation and anxiety in context of depressed mod/dementia . Per patient, he is reporting that he no longer feels anxious. Denies worsening of depressed mood. Record review of Resident #1's Lab Results Report dated 08/17/22 at 3:34 PM revealed, TSH CRITICAL! TSH Verified by repeat analysis and/or delta check SS. 08/17/22, 3:33 PM. Result 56.296 Unit uIU/ml. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Physician's Progress Noted dated 08/17/22 signed by MD A revealed, History: Patient still very weak and debilitated requiring 2 person assist with transfers out of bed. Patient also recently restarted [MEDICATION(S)]. TSH lab reviewed with nursing staff, level elevated at 56. Patient had inadvertently stopped his [MEDICATION(S)] for the last 3 weeks. We will review resume [MEDICATION(S)] at an increased dose, 175 mcg every morning. We will recheck TSH level in 1-2 weeks. Diagnosis, Assessment and Plan: Restart [MEDICATION(S)] at 175 mcg daily Record review of Resident #1's Progress Notes dated 08/17/22 at 04:07 PM signed by the DON revealed, critical lab for TSH called in at 4:04 PM, received by this nurse. MD A notified. See new orders. Record review of Resident #1's MAR from 08/18/22 to 08/31/22 revealed, resident received [MEDICATION(S)] 175 mcg daily. Record review of Resident #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Admission assessment dated [DATE] completed by RN A revealed, Section EE Summary of Medications was blank. In an interview on 08/30/22 at 10:00 AM the Administrator said that the facility became aware that Resident #1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #1 identified that he the resident had not received his [CONDITION(S)] medication. He said that the Family Member #1 was concerned because he was not returning to his baseline mental state following his surgery and prior admission into the facility. The Administrator said that the facility's investigation revealed that the admitting nurse failed (RN A) to enter Resident #1's [MEDICATION(S)] from the hospital records from admission and the resident did not receive his [MEDICATION(S)] for approximately 3 weeks, from his admission (07/19/22) to when Family Member #1 #1 identified the missing medication around 08/12/22. An observation and interview on 08/30/22 at 11:32 AM with Resident #1 and Family Member #1 revealed, Resident #1 sitting in a chair with a back brace on with Family Member #1 cutting his hair. The resident appeared well groomed and in no immediate distress, when the surveyor asked questions Family Member #1 #1 answered with the resident intervening rarely and at times nodding in agreement. Family Member #1 said that after Resident #1 admitted to the facility his recovery was taking longer than expected. She said the resident had dementia and initially she believe that he had anesthesia related dementia but as time went, he didn't seem to get better. Family Member #1 said Resident #1 was tired, had no appetite, was always nauseated and was always cold, sometimes using 2 to 3 blankets so she called his general practitioner who informed her that the resident was showing symptoms associated to [CONDITION(S)]. She said after she talked to Resident #1's GP she asked to see the resident's medication list and that was when she identified that he was not receiving his [MEDICATION(S)]. Family Member #1 said that she believe the lack of [MEDICATION(S)] played a part in the resident's recent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said when he didn't receive his [MEDICATION(S)] the resident was so tired that he could not successfully complete his therapy and after the facility started administering his [MEDICATION(S)] his energy levels got better and his therapy sessions were more successful. Family Member #1 said the facility's failure to administer Resident #1's [MEDICATION(S)] impaired the resident's recovery not only by leaving him cold, tired, confused, having depressed mood but also wasted much of his first therapies sessions because the resident was not in the right state of mind to successfully complete his therapy and now he has used almost all the therapy days covered by his insurance. She said prior to his admission to the facility, Resident #1 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 08/30/22 at 12:14 PM, CNA A said that initially Resident #1 was not responsive and lethargic but he has gotten better. She said she remembered an incident in which the resident was using multiple blankets and his Family Member #1 reported he was cold but has no knowledge of current lethargy or cold intolerance. In an interview on 08/30/22 at 12:30 PM, NP A said she was unaware that Resident #1 did not receive his [MEDICATION(S)] from 07/19/22 to 08/11/22. She said symptoms of [CONDITION(S)] were fatigue, altered mental status in which the resident appears down, depression, elevated HR, cold intolerance, hair loss and weight loss. In an interview on 08/30/22 at 2:25 PM, NP B said on 8/2/22 Resident #1 was started on [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] PRN due to symptoms of depression and anxiety. She said on her last visit she discontinued his prescription for [MEDICATION(S)] and [MEDICATION(S)] because their did not lead to any improvement in the resident and the benefits did not out way the risk, so he was started on [MEDICATION(S)]. NP B said that Resident #1's depression had gotten better since her last visit on 8/16/22 and she was not notified that the resident suffered from [CONDITION(S)]. She aid normally she would draw a TSH level prior to starting a resident on psychiatric medications because [CONDITION(S)]/low [CONDITION(S)] can give the impression of depression. She said she did not know if Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 08/30/22 at 2:37 PM, The DON said an individual with low [CONDITION(S)] would suffer from weight gain, sensitivity to cold and poor mental health. She said the first time she became aware of the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #1 brought the discrepancy she had observed when reviewing Resident #1's medication list. Th DON said once notified MD A immediately placed a lab order for TSH and once the results came out indicating a critically high TSH of 56.296 uIU/ml he started Resident #1 on [MEDICATION(S)] on 08/17/22. The DON said since the resident started his [MEDICATION(S)] he seemed more alert but could not single handedly attribute it to the medication. She said failure to enter discharge medications could place residents at risk for delay in treatment. In an interview on 08/31/22 at 09:40 AM, the DON said that once a resident arrives at the facility the nurse verifies the hospital discharge orders with the physician and enters them into the EMR. She said that when Resident #1 was admitted to the facility on [DATE], the facility did not have a system in place to verify that admissions orders were reconciled correctly. The DON said she started a process in which the ADON will audit the admission records to ensure that no medication orders or wound care orders were missed by the admitting nurse. She said facility staff were re-trained on using the admissions checklist to ensure that no orders were missed and RN A specifically received 1on1 training regarding his admissions process. The DON said normally after lab results are out it is the DON/designees responsibility to sign off on the record in the EMR after ensuring that the appropriate follow-up occurred with the resident's provider but when she started her position as DON there were a lot of unreviewed Lab results that she signed off on without verifying that follow-up was taken because they were old and she assumed someone had already taken care of it. She said even though the record shows she reviewed Resident #1's lab report on 08/01/22 showing a high TSH of 26.750 uIU/ml, she was not aware of the sample that was ordered on 07/24/22 until the surveyor brought it to her attention. The DON said that failure to review lab results places residents at risk for delay in treatment, side effects and deterioration of health status. Resident #2 Record review of Resident #2's face sheet dated 08/31/22 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Admission MDS assessment dated [DATE] revealed intake cognition as indicated by a BIMS score of 15 out of 15, worsening of behavior, limited assistance with most ADLs, wheelchair and walker use, occasionally incontinent of bladder and frequently incontinent of bowel. Record review of Resident #2's care plan revealed, Initiated on 08/17/22 Focus- actual impairment to skin integrity, surgical wound to the right hip; experiencing pain. Intervention- Resident #2 will have no signs/symptoms of infection at the surgical site right hip through review date. Interventions- provide treatment per physician order. Record review of Resident #2's Admission assessment dated [DATE] revealed, the resident admitted due to a right hip fracture, with a right hip surgical wound post hip fracture that was dry and clean covered in steri strips that showed no sign of infection. Record review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with dry dressing. Monitor for signs/symptoms of infection as needed for wound care. Cleanse right hip with NS pat dry. Cover with dry dressing. Monitor for signs/symptoms of infection. Every day shift, every other day for wound care. In an interview on 09/01/22 at 12:04 PM, the DON said that when a resident admits to a facility with a wound, the admitting nurse is responsible for entering wound care orders as specified by the physician. She said Resident #2 admitted to the facility with steri strips to her right hip surgical incision site. After reviewing the resident's chart, she said that Resident #2 did not have wound care or monitoring orders from her admission on 08/16/22 to 08/22/22. The DON said that she caught Resident #2's missing wound care order during her weekly audit of new admission records on 08/22/22. So she added the wound care orders to the resident's orders. CR #1 Record review of CR #1's face sheet dated 08/31/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged from the facility on 06/23/22. Record review of CR #1's MDS dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, extensive assistance with most ADLs, manual wheelchair use, frequently incontinent of both bladder and bowel, prior surgery requiring active SNF care, repair fractures of the pelvis, hop, leg, knee or ankle, risk of pressure ulcers/injuries no recorded pressure ulcers/injuries, skin and ulcer/injury treatments of pressure reducing device for bed and applications of ointments/medications other than to feet. Record review of CR #1's Care Plan initiated on 05/26/22 revealed, Focus- Resident has actual impairment to skin integrity. Surgical wound to right side. Interventions- provide treatment as ordered, keep skin clean and dry. Use lotion on dry skin. Do not apply to area of skin breakdown, wound or between toes. Record review of CR #1's Extended Care Facility Form dated 05/26/22 provided by the hospital upon admissions revealed, the resident had an wrap to her right lower extremity. Record review of CR #1's facility Admission assessment dated [DATE] revealed, the resident admitted with a surgical incision to her right groin and a surgical incision to her right knee that was wrapped in ACE bandage and non-removable dressing. Record review of CR #1's Order Summary Report dated 05/27/22 revealed, no orders for wound care for the resident's right knee surgical incision. Record review of CR #1's History and Physical completed on 05/27/22 by her MD revealed, right peri knee area with 4 areas with 2 staples each. Right knee/lower leg/ food area in a wrap dressing. Left Buttock DTI noted. Diagnosis, Assessment and Plan: obtain site care instructions from ortho, currently has ACE wrap dressing in place . Pressure induced deep tissue damage of left buttock will benefit from an air mattress, offload and reposition per facility protocol, skin protective cream for now, wound MD consult. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? Clean with NS pat dry, apply xeroform/dry dressing QD and PRN, and Orthopedic consult needed. Obtain care for sutures. There were no orders for wound care to CR #1's surgical incision on her right knee. The order summary report was signed by the NP on 05/30/22. Record review of CR #1's Skin Check dated 05/31/22 and signed by the ADON revealed, the resident had an incision to her right groin area and right knee. Record review of CR #1's May 2022 TAR printed 08/31/22 revealed, the resident did not receive wound care or monitoring for her surgical incision to her knee the month of May. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pat dry, dry dressing QD and PRN. Record review of CR #1's 07/2022 TAR printed 08/31/22 revealed, the resident started receiving wound care right surgical site clean with NS, pat dry, dry dressing QD and PRN; every day shift for surgical incision on 06/08/22. Record review of CR #1's entire EMR (Progress notes, History and Physical) revealed no record of the resident receiving a wound consult or receiving care from a wound doctor. In an interview on 08/31/22 at 3:08 PM, the DON said when a resident admits with a surgical incision the facility either enters to care for the site or orders to monitor the site until the resident receives the appropriate consult. She said any wound care orders or results of a wound care/orthopedic consult would be documented in the resident's EMR under the progress notes. The DON said she was not employed at the facility during CR #1's residency, but from her review of the records she could not locate any wound care or monitoring orders for care to the CR #1's right knee surgical incision from admissions (05/26/22) to 06/07/22. She said after reviewing CR #1's EMR she could not find any documentation of any wound care or orthopedic consults in the resident's progress notes. She said failure to reconcile medication lists and admissions orders placed residents at risk for delay in treatment and adverse reactions. Record review of the facility's Nursing Orientation Competency Review Form with no revision date revealed, 4- Admission Process, a- Admissions checklist, b- consents. Record review of a blank facility form Clinical Admission Checklist revised 08/2015, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .g. hospital D/C orders. Print Order Summary- Order/Reports/Order Summary. Signature Line 2. Second nurse to verify and reconcile against referring community orders e.g. hospital D/C orders. Second Nurse Signature required. Copy placed in chart and original MD folder for signature. Record review of RN A's training record dated 08/12/22 revealed performed by the ADON, RN A received 1on1 training on the admissions process and the clinical admissions checklist. Record review of the facility document titled Admission Assessment and Follow Up: Role of the Nurse revised 09/2012 revealed, 11- reconcile the list of medications from the medication history, admitting orders, the previous MAR (if available), and the discharge summary from the previous institution, according to established procedures.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 staff members (OTA A, LPN A and PT A) reviewed for infection control. - LPN A, OTA A, PT A failed to wear appropriate PPE while on the nursing floor. These failures could place residents at risk for the transmission of COVID-19. Findings included: An observation and interview on 08/30/22 at 11:18 AM revealed, OTA A and PT A in the PT room. OTA was in the PT Room pushing her cart toward the exit with her N95 below her chin while PT A stood directly outside the PT room door with her surgical mask under her nose. At the time of the surveyor's observations there were staff inside the PT room and residents/staff in the hallway. OTA A said she had to remove her mask because she had asthma and couldn't breathe while PT A said her mask had slipped under her nose. An observation on 08/30/22 at 11:20 AM revealed, LPN A sitting at the computer in the nursing station with her mask under her chin. The surveyor alerted her to her mask and the LPN pulled her mask up to cover both her nose and mouth. At the time of the surveyor's observation there were staff in the nursing station along with LPN A and a resident approximately 10 feet away on her left. An observation on 08/30/22 at 11:29 AM revealed, PT A walking down the hallways with her mask below her nose and then entered into a resident room. The resident was present at the time PT A entered the room. She moved a walker in the resident's room, still with her mask under her nose, and right before exiting, she entered into the resident's bathroom. PT A came out of the resident's bathroom with her mask covering her nose and then exited the room with the walker in hand. In an interview on 08/30/22 at 11:51 PM, LPN A said facility staff were expected to wear masks at all times covering both their nose and masks with no exceptions, on the nursing floor. She said masks were being worn to prevent the spread of COVID and failure to wear a mask appropriately placed residents at risk of contracting COVID. In an interview on 08/30/22 at 12:00 PM, the DON said employees must wear masks covering both their nose and mouth at all times when on the nursing floor. She said staff were also expected to wear masks in the PT area and that staff had a break room they could go to if they needed to remove their mask. She said staff were wearing masks to prevent the spread of COVID-19 and that failure to wear masks correctly or at all, placed residents at risk of contracting COVID. In an interview on 08/30/33 at 12:43 PM, the Director of Physical Therapy said PT staff were expected to wear their masks, covering both their nose and mouth, at all times, when in the facility with the exception being eating or drinking. She said that the staff were fit tested for masks and acknowledge OTA A had a respiratory problem. The Director of Physical Therapy said since PT A's surgical mask kept slipping she would require her to wear a N95 mask because those were more secure. She said facility staff were wearing masks due to the COVID-19 pandemic and failure to wear masks properly placed residents at risk of contracting COVID. Record review of the facility policy titled Personal Protective Equipment- Using Face Masks revised 09/2022 revealed, Objectives- 1, to prevent transmission of infectious agents through the air. Miscellaneous- 2, be sure that face mask covers the nose and mouth while performing treatment or services for the patient.

Based on interview and record review, the facility failed to provide necessary treatment and services to promote healing and prevent worsening pressure sores for 1 of 7 residents (CR#1) reviewed for pressure sores. -The facility failed to get a wound care consult for CR #1's deep tissue injury to the left buttock as ordered by the admitting MD on 05/27/22 until 06/20/22 when the resident was observed with a macerated (skin with prolonged exposure to moisture that appears to be soggy and soft) left buttock. This failure could place residents at risk of worsening of current sores or the development of new pressure sores. Finding Included: Record review of CR #1's face sheet dated 08/31/22 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident discharged from the facility on 06/23/22. Record review of CR #1's MDS assessment dated [DATE] revealed, moderately impaired cognition as indicated by a BIMS score of 10 out of 15, extensive assistance with most ADLs, manual wheelchair use, frequently incontinent of both bladder and bowel, prior surgery requiring active SNF care, repair fractures of the pelvis, hop, leg, knee or ankle, risk of pressure ulcers/injuries no recorded pressure ulcers/injuries, skin and ulcer/injury treatments of pressure reducing device for bed and applications of ointments/medications other than to feet. Record review of CR #1's care plan initiated on 05/26/22 revealed, Focus- potential for pressure ulcer development r/t bowel incontinence, immobility, urinary incontinence. Goal- will have intact skin, free of redness blisters or discoloration. Record review of CR #1's facility Admission assessment dated [DATE] revealed, the resident admitted with a red pressure sore to the left buttock Record review of CR #1's History and Physical, completed on 05/27/22 by her MD, revealed right peri knee area with 4 areas with 2 staples each. Right knee/lower leg/ foot area in an elastic bandage wrap dressing. Left Buttock DTI noted . Pressure induced deep tissue damage of left buttock will benefit from an air mattress, offload and reposition per facility protocol, skin protective cream for now, wound MD consult. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply skin protectant ointment to L buttock Qshift and PRN every shift for wound care Record review of CR #1's History and Physical dated 05/30/22 revealed, Diagnosis, assessment and plan: Pressure-induced deep tissue damage of left buttock. Wound care evaluate and treat skin care every shift and as needed. Record review of CR #1's Skin Check dated 05/31/22 and signed by the ADON revealed, the resident had discoloration to her left buttock.The document did not provide descriptions of the DTI to the buttocks or staging. Record review of CR #1's Skin Check dated 06/07/22 and signed by the ADON revealed, the resident had discoloration to her left buttock. The document did not provide descriptions of the DTI to the buttocks or staging to determine wound progression or deterioration from the previous assessment. Record review of CR #1's Skin Check dated 06/14/22 and signed by the ADON revealed, the resident had discoloration to her left buttock. The document did not provide descriptions of the DTI to the buttocks or staging to determine wound progression or deterioration from the previous assessment. Record review of CR #1's Progress Notes dated 06/20/22 revealed, during incontinent care, nurse observed resident with macerated buttocks. Cleaned area with NS, pat dry, cover with dry dressing. Notified ADON and NP. ADON evaluated buttocks with the nurse. NP approved to apply calcium alginate with wound care and to administered [MEDICATION(S)] 4mg Q6H X 3 days for loose stools. Record review of CR #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Every day shift for Macerated. Record review of CR #1's entire EMR (Progress notes, History and Physical) revealed no record of the resident receiving a wound consult or receiving care from a wound doctor prior to 06/21/22. Record review of CR #1's Skin Check dated 06/22/22 and signed by the ADON revealed, the resident had discoloration to her left buttock. The document did not provide descriptions of the DTI to the buttocks or staging to determine wound progression or deterioration from the previous assessment. In an interview on 08/31/21 at 12:14 PM, CNA A said she could not remember if CR #1 had a pressure ulcer. In an interview on 08/31/22 at 2:03 PM, RN B said she worked with CR #1 but could not remember if she had a pressure ulcer but knew the resident had a right knee incision. In an interview on 09/01/22 at 10:51 PM, LPN A said she worked with CR #1 but could not remember if she had a pressure ulcer. In an interview on 08/31/22 at 3:08 PM , the DON said when a resident admitted with a pressure ulcer, the facility either enters to care for the site or orders to monitor the site until the resident receives the appropriate consult. She said any wound care orders or results of a wound care/orthopedic consult would be documented in the resident's EMR under the progress notes. The DON said she was not employed at the facility during CR #1's residency, but from her review of the records she could not locate any wound care or monitoring orders for care to the CR #1's right knee surgical incision from admissions (05/26/22) to 06/07/22. She said after reviewing CR #1's EMR she could not find any documentation of any wound care or orthopedic consults in the resident's progress notes.

Based on observation, interview and record review,, the facility failed to ensure each resident's drug regimen was free from the administration of unnecessary drugs (in the presence of adverse consequences which indicate the dose should be reduced or discontinued/for excessive duration/without adequate indications for use/duplicate therapy), for 1 of 12 residents (Residents #9) reviewed for unnecessary [CONDITION(S)] medications. 1. Resident #9 was receiving antipsychotic [MEDICATION(S)] for dx of agitation, without adequate indications for its use or inappropriate diagnosis, and the consent form indicated for yelling, screaming. 2. The facility failed to monitor behavior and effectiveness for Resident #9's antipsychotic medication [MEDICATION(S)]. These failures could place residents who receive psychoactive medications at risk of receiving medications without adequate monitoring or indications for use and decline in physical and mental health status. Findings included: Record review of Resident #9's clinical record revealed a 75 yrs year old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses of which included dementia, depression other than [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], urinary tract infection, cerebral infarction without residual deficits and DM. He required 1 staff extensive assist for most ADLs and was able to make his needs known. Record review of nursing progress, order note, dated 02/01/22, revealed the order you have entered [MEDICATION(S)] 0.5 mg 1-tab po q 12 hrs for delusion/aggression. Has triggered the following drug protocol warning(s). Interaction: Additive QT interval prolongation may occur during co-administration and [MEDICATION(S)] tablet 200 mg. Interaction with [MEDICATION(S)]/[MEDICATION(S)] HCl for dementia, may increase extrapyramidal symptoms of [MEDICATION(S)] tab 0.5 mg. Record review of nurses advanced, skilled eval notes, dated 02/21/22, read in part, Neurologic: Resident obeys commands. Alert, oriented x3, communicated verbally, speech clear. Able to understand and be understood. Cognitive impairment: Alert. Mood/Behavior: Mood is pleasant. No unwanted behaviors witnessed. Sleeps through the night. Record review of psychiatric assessment notes, dated 3/04/22, read in part, A,Ox3. Denies worsening depression, anxiety, appetite or sleep. Has poor insight into his mental health. Denies any problems with staff or peers. No suicidal ideation/homicidal ideation indicated by pt or reported by staff. Collateral information: Per nursing, mood fluctuating. Redirectable. Further noted A,Ox3. Does not endorse any psychiatric diagnoses. Includes dx: Dementia, Depression, Harm to others, [CONDITION(S)]. Record review of nurses progress notes, dated 3/22/22, read in part, Neurologic: Resident obeys commands, requires cues, experiencing signs of short-term memory loss. Current state of confusion considered baseline. Cognitive impairment: Mild. Mood is pleasant. No unwanted behaviors witnessed. Admission mode arrived via stretcher. Dx. ESBL of urine. He will be on IV antibiotic [MEDICATION(S)] q 6 hrs until 3/27/22. Record review of nurses advanced- skilled evaluation notes, dated 3/25/22, read in part, Neurologic: Resident obeys commands. Alert and oriented x3. Mood is pleasant. No unwanted behaviors witnessed. Sleeps through the night. Coherent. Resident makes self-understood, understand others. Continues to participate in PT/OT/ST P.T/S.T/O.T rehab therapy as ordered. Record review of Resident #9's consolidated physician order, dated May 2022, revealed to give [MEDICATION(S)] 0.5 mg 1 tab by mouth q 12 hrs , for agitation/ depression, start date 3/22/22. Record review of Resident #9's care plan, dated 4/13/22, revealed he was taking [CONDITION(S)] medication [MEDICATION(S)] for behavioral management. Further noted monitor/ document for side effects and effectiveness. Record review of Resident #9's consent for antipsychotic medication treatment, dated 4/16/22, revealed proposed dosage and frequency, [MEDICATION(S)] 0.5 mg q 12 hrs. Further noted was indicated for agitation, yelling, screaming. Record review of Resident #9's admission MDS assessment, dated 03/28/22, revealed it did not have a check by the disorders [CONDITION(S)], [CONDITION(S)] or [CONDITION(S)], indicating which indicated he did not have these diagnoses. No hallucinations or delusions. No physical or verbal behavioral symptoms directed toward others. No rejection of care behavior. He received routinely for 7 days antipsychotic med along with antidepressant. No other psychiatric disorder was found. His total BIMS score was=12, with which indicated moderate cognitive impairment. Record review of the Cconsultant Pharmacist's med regimen review, dated 4/29/22, revealed Resident #9 has received [MEDICATION(S)] ([MEDICATION(S)]) for the dx of Dementia with behavioral disturbance. [MEDICATION(S)] increased dosage to 0.5 mg q 12 hrs, start date 3/22/22. Further review revealed antipsychotic [MEDICATION(S)] 0.25 mg dose BID, start date on 8/25/21. No recommendation for change of diagnoses for antipsychotic drug use noted. Record review of the Medication Administration Record (MAR), dated May 2022, revealed Resident #9 received [MEDICATION(S)] 0.5 mg 1 tab by mouth q 12 hrs, for agitation/ depression, start date 3/22/22. Further record review of the MAR/TAR revealed there was no documentation of monitoring for behavior and effectiveness. During observation and interview on 5/17/22 at 1:30 p.m., LVN D stated Resident #9 was no harm to himself or others, but he yelled if somebody walked by, and with no aggression, physical or verbal. Observed Resident on contact isolation, (+) ESBL in urine. Resident was redirectable, call light within reach. During interview on 5/18/22 at 10:00 a.m., LVN C stated Resident #9 would yell out if staff were nearby but was redirectable and seemed like he needed company or seeks sought staff attention, but no aggression physical or verbal. During interview on 5/19/22 at 10:35 a.m., the Administrator stated Resident #9's [MEDICATION(S)] dose was increased to 0.5 mg q 12 hrs, start date 2/01/22, and was not reduced from 0.25 mg BID, start date 8/25/21. He stated the family member also had requested antipsychotic medication for the Resident. The Administrator stated currently with ESBL in urine and behavior also exacerbated with dx of UTIs. During interview on 5/19/22 at 11:30 a.m., CNA E stated if Resident #9 yelled, which was related to seeking attention from staff or if unable to reach his remote but was no harm to himself or others and no aggression, either physical or verbal. Record Review of Nursing Progress, Order Note dated 02/01/22, revealed the Order you have entered [MEDICATION(S)] 0.5 mg 1-tab po q 12 hrs for delusion/aggression. Has triggered the following drug protocol warning(s). Interaction: Additive QT interval prolongation may occur during coadministration and [MEDICATION(S)] Tablet 200 mg. Interaction with [MEDICATION(S)]/[MEDICATION(S)] HCl for dementia, may increase extrapyramidal symptoms of [MEDICATION(S)] tab 0.5 mg. Record Review of Nurses Advanced, Skilled Eval Notes dated 02/21/22 read in part, Neurologic: Resident obeys commands. Alert, oriented x3, communicated verbally, speech clear. Able to understand and be understood. Cognitive impairment: Alert. Mood/Behavior: Mood is pleasant. No unwanted behaviors witnessed. Sleeps through the night. Record Review of Nurses Progress Notes dated 3/22/22 read in part, Neurologic: Resident obeys commands, requires cues, experiencing signs of short-term memory loss. Current state of confusion considered baseline. Cognitive impairment: Mild. Mood is pleasant. No unwanted behaviors witnessed. Admission mode arrived via stretcher. Dx. ESBL of urine. He will be on IV antibiotic [MEDICATION(S)] q 6 hrs until 3/27/22. During interview on 5/19/22 at 12:00 p.m., the DON stated Resident #9 occasionally would yell, and moving forward will keep him occupied with activities, such as he liked to watch the golf channel or get him out of bed and would follow-up with the MD. Record Review of Nurses Advanced- Skilled Eval Notes dated 3/25/22 read in part, Neurologic: Resident obeys commands. Alert and oriented x3. Mood is pleasant. No unwanted behaviors witnessed. Sleeps through the night. Coherent. Resident makes self-understood, understand others. Continues to participate in P.T/S.T/O.T rehab therapy as ordered. Record Review of Psychiatric Assessment Notes dated 3/04/22 read in part, A,Ox3. Denies worsening depression, anxiety, appetite, or sleep. Has poor insight into his mental health. Denies any problems with staff or peers. No suicidal ideation/homicidal ideation indicated by pt or reported by staff. Collateral information: Per nursing, mood fluctuating. Redirectable. Further noted A,Ox3. Does not endorse any psychiatric diagnoses. Includes dx: Dementia, Depression, Harm to others, [CONDITION(S)]. Record Review of the facility policy titled, Antipsychotic Medication Use, dated 12/2016, read in part, Antipsychotic meds may be considered for residents with dementia only after medical, physical, functional, psychological, emotional, psych, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic med will be prescribed at the lowest possible dosage for the shortest period of time and are subject to GDR and re-review. Diagnoses alone do not warrant the use of antipsychotic med. In addition .antipsychotic med will generally only be considered if the following conditions are met: a) The behavioral symptoms present a danger to the Resident or others; and: 1.) The symptoms are identified as being due to [CONDITION(S)] or [CONDITION(S)], (such as auditory, visual or other hallucinations, delusions, paranoia or grandiosity.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in that; - There was unlabeled food items in the reach in refrigerator. - There was thawing raw meat above cooked meat. These failures could place 31 residents that eat from the kitchen at risk of serious complications from foodborne illness. Findings include: Observations of the facility's kitchen on 01/22/2020 at 9:15 a.m. revealed: Inside the walk-in fridge a tray with thawing meat on it was above a tray that had a cooked turkey on it. In an interview on 1/22/2019 at about 9:17 a.m., the Director of Dining Services said it should have been above the thawing meat. Observation of the satellite kitchen on 1/23/2020 at 10:13 a.m. revealed 3 glasses of juice on a tray. There was no label or date on the tray. In an interview at that time, Server A said the glasses came from breakfast and Sever B was going to put a label on the tray. Server B then came in the kitchen and confirmed that she was going to put a label on the tray. In an Interview on 1/23/2020 at 1:49 p.m., the Administrator said that food needed to be stored appropriately by labeling and dating. Record review of the facilities policy titled Labeling with a revised date of 5/10 revealed in part all food items must be labeled and dated before storing. All prepared items (i.e. leftovers or prepared for next meal) must have a label with the name of item, date prepared, by whom, and date of discard.

Based on observation and interview, the facility failed to dispose garbage and refuse properly, in that; The facility's food scrap trash cans in the kitchen did not have any lids on them. This failure placed the residents at risk for infection and a decreased quality of life. Findings include: Observation of the kitchen on 1/22/2020 at 9:15 a.m. revealed a long stainless steal prep table with trash cans on either side of the table. Inside the trash cans was food scraps. The area was not in use at time of observation. The trash cans did not have lids on them. In an interview and observation on 1/22/2020 at 9:30 a.m., the Director of Dining Services was asked about the lids to the trash can lids He said they where kept in the washing area of the kitchen. He went to the sink washing area and looked under the sink area for the lids and did not find them there. He then asked the Executive Chef where they kept the lids. the Executive Chef said the kitchen staff never used the lids. The Director of Dining then stepped out of the kitchen and went to the janitor closet that was located right outside of the kitchen and came back with a stack of lids for the trash cans. He then placed them back into the janitor closet. Record review of the facilities policy titled Garbage and Trash cans with a revised date of 8/31/18 revealed All food waste must be place in covered garbage and trash cans.

Based on observation, interview, and record review, the facility failed to provide or arrange services as outlined by the comprehensive plan of care for 1 of 12 residents (Resident # 31) reviewed for physician's orders [REDACTED]. -The facility failed to ensure Resident #31's [MEDICATION NAME] 5 Mg chewable tablet (a [MEDICAL CONDITIONS] and stoke medication) was administered as ordered by his Physician. This failure placed the residents at risk of not receiving the care and services ordered by their physicians and could result in a decline in health status. Resident #31 Findings include: Record review of Resident #31's face sheet revealed he was admitted to the facility on [DATE]. The resident was [AGE] years old. His admission [DIAGNOSES REDACTED]. late onset, neuromuscular dysfunction of bladder, [MEDICAL CONDITION] without lower urinary tract symptom. Record review of Resident #31's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 to indicate his cognitive skills were intact. Resident #31 required extensive assistance of two staff for his bed mobility, transfer and dressing. The resident required extensive assistance of one staff for his toilet use and personal hygiene. Record review of Resident #31's care plans date initiated 01/07/2020 revealed the care plan: Titled: Resident takes [MEDICATION NAME], triagrelor and [MEDICATION NAME] to prevent stokes and [MEDICAL CONDITION]. Goal: Resident will remain free from [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions: Continue taking medications as ordered. Record review of Resident #31's physician's orders [REDACTED]. Give one tablet by mouth two times a day. Order dated 01/07/2020. Record review of the Nurses' Progress Notes dated 01/08/2020 at 12:43 PM written by RN F revealed Pharmacy doesn't have 5 mg [MEDICATION NAME], has to order and send it tomorrow, text dr. said ok. Continued review of the Nurses Progress Notes did not reveal any additional documentation regarding the medication's availability from the pharmacy. Record review of Resident #31's Medication Administration Record [REDACTED] 1/7/2020 at 5:00 PM 1/8/2020 at 9:00 AM and 5:00 PM 1/9/2020 at 9:00 AM and 5:00 PM In a telephone interview on 1/23/2020 at 11:25 AM with a facility contracted pharmacist, she stated the pharmacy received Resident #31's order for [MEDICATION NAME] on 1/07/2020 along with the resident's admission medication orders. She stated the pharmacy did not have that medication at that dose in pharmacy stock, and needed to be ordered. The medication was filled and sent to the facility on the last run at 6:30 PM on 1/09/20. There was no therapeutic substitution ordered by the physician for the drug. In an interview on 1/23/20 at 1:15 PM, RN F stated she was not able to give the medication to the resident on 1/8/2020 and 1/9/2020 because pharmacy did not send it to the facility. She stated she notified the doctor and he told her it was alright to miss it until pharmacy sends the medicine out. In an interview on 1/24/2020 at 8:30 AM, the Administrator stated when residents were admitted , it was the responsibility of the physician to review the medications and approve them. If any follow-up was required, it was also the physician's responsibility. The nurse checked the orders and medications that arrived from the pharmacy to ensure accuracy. When a medication was not sent by the pharmacy, facility staff checked the autonomous medication machine for availability of the medication. If the medication was not available, the resident's physician was to be notified. The physician could put the medication on hold or order a therapeutic substitution. In an interview with the Interim DON on 01/24/20 at 8:57 AM regarding administering the resident's ordered medications, the DON stated the resident's physician needed to order what he wanted us to do while waiting for the medication to be available. The doctor could put the medication on hold or prescribe a therapeutic substitution. The DON said that the facility followed the physicians orders. In an observation and interview on 1/24/20 at 11:23 AM, Resident #31 was sitting in his room in a wheelchair with his legs elevated. He had mulipondus boots on both feet. In an interview with the resident he stated he did not remember having any complaints or problems getting his medicines. A request for the facility's policy and procedure for following physician's orders [REDACTED]. None was provided by exit.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 12 residents (Resident # 31) reviewed for pharmacy services. -The facility failed to ensure the pharmacy provided Resident #31 his [MEDICATION NAME] 5 Mg chewable tablet (a [MEDICAL CONDITIONS] and stoke medication) as ordered by his Physician. This failure placed the residents at risk of not receiving the care and services ordered by their physicians and could result in a decline in health status. Findings include: Resident #31 Record review of Resident #31's face sheet revealed he was admitted to the facility on [DATE]. The resident was [AGE] years old. His admission [DIAGNOSES REDACTED]. late onset, neuromuscular dysfunction of bladder, [MEDICAL CONDITION] without lower urinary tract symptom. Record review of Resident #31's Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 to indicate his cognitive skills were intact. Resident #31 required extensive assistance of two staff for his bed mobility, transfer and dressing. The resident required extensive assistance of one staff for his toilet use and personal hygiene. Record review of Resident #31's care plans date initiated 01/07/2020 revealed the care plan: Titled: Resident takes [MEDICATION NAME], triagrelor and [MEDICATION NAME] to prevent stokes and [MEDICAL CONDITION]. Goal: Resident will remain free from [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions: Continue taking medications as ordered. Record review of Resident #31's physician's orders [REDACTED]. Give one tablet by mouth two times a day. Order dated 01/07/2020. Record review of Resident #31's Medication Administration Record [REDACTED] 1/7/2020 at 5:00 PM 1/8/2020 at 9:00 AM and 5:00 PM 1/9/2020 at 9:00 AM and 5:00 PM Record review of the Nurse's Progress Notes dated 01/08/2020 at 12:43 PM written by RN F revealed Pharmacy doesn't have 5 mg [MEDICATION NAME], has to order and send it tomorrow, text dr. said ok. Continued review of the Nurses Progress Notes did not reveal any additional documentation regarding the medication's not being available from the pharmacy. Record review of the Omnicell's (a medication dispensing machine) Inventory stocked medication list on 1/23/2020 at 9:42 AM revealed no [MEDICATION NAME] listed on the inventory list. In a telephone interview on 1/23/2020 at 11:25 AM with a facility contracted pharmacist from the facility's pharmacy, she stated the pharmacy received Resident #31's order for [MEDICATION NAME] on 1/07/2020 along with the resident's admission medication orders. She stated the pharmacy did not have that medication at that dose in pharmacy stock. The pharmacy had to order it. The medication was filled and sent to the facility on the last run at 6:30 PM on 1/09/20. There was no therapeutic substitution ordered by the physician for the drug. In an interview on 1/23/20 at 1:15 PM, RN F stated she was not able to give the medication to the resident on 1/8/2020 and 1/9/2020 because pharmacy did not sent it to the facility. She stated she spoke to the DON who was here at the time, but she was no longer here. RN F stated she called the pharmacy and was told they did not have the medicine and would have to order it. She stated she notified the doctor and he told her it was alright to miss it until pharmacy sent the medicine out. RN F stated the contracted pharmacy company was very hard to get medicines from and we often do not have medications we needed from them. In an interview on 1/24/2020 at 8:30 AM, the Administrator stated when residents were admitted , it was the responsibility of the physician to review the medications and approve them. If any follow-up was required, it was also the physician's responsibility. The nurse checked the orders and medications that arrived from the pharmacy to ensure accuracy. When a medication was not sent by the pharmacy, facility staff checked the autonomous medication machine for availability of the medication. If the medication was not available, the resident's physician was to be notified. The physician could put the medication on hold or order a therapeutic substitution. In an interview with the Interim DON on 01/24/20 at 8:57 AM, regarding acquiring resident's ordered medications from pharmacy, he stated when the medication was not available from the pharmacy facility staff called the physician to notify him and the DON should be notified. He stated he was not the DON at the time, but he was working here and he was not aware the resident missed five doses of his medications. The DON stated the resident did not have any adverse effects of missing the doses. The DON stated the resident's physician needed to order what he wanted the facility to do while waiting for the medication to be available such as putting the medication on hold or a therapeutic substitution. In an observation and interview on 1/24/20 at 11:23 AM Resident #31 was sitting in his room in a wheelchair with his legs elevated. He had mulipondus boots on both feet. In an interview with the resident he stated he did not remember having any complaints or problems getting his medicines. Review of the facility titled Medical Management Overview: effective date 07/2015 last revised 03/2019 read in part . [NAME] Medication management services include but are not limited to: Delivering medications to resident within acceptable time parameters .

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure ulcers and to promote the healing of pressure ulcers for 1 of 3 residents (Resident #15) who were reviewed for pressure ulcer care and management as evidenced by: Resident #15 developed multiple pressure ulcers while at the facility. Resident # 15 was not care planned for any of the wounds she acquired in the facility which prevented the development of specific interventions to alleviate and prevent further wound development. These failures affected 1 resident and placed an additional 4 residents with pressure ulcers at risk for a decline in health, not receiving adequate treatment to prevent wound development, and to promote healing. Findings Include: Resident # 15 Record review of the clinical record face sheet revealed Resident # 15 was admitted on [DATE] in independent living following hospitalization was readmitted to skill on 09/10/2011. [DIAGNOSES REDACTED]. she was [AGE] year olds. Record review of Resident # 15's annual MDS assessment dated [DATE] revealed no BIMs score, no pressure ulcer, but formal assessment instrument/tool (such as Braden scale) and clinical assessment were being performed and pressure reducing devices for chair and bed were being used and nothing else. The care area triggered for pressure ulcer. Treatments were pressure reducing device for bed and chair, ulcer care with application of nonsurgical dressings. With all 3 MDS, turning and reposition program was not checked off as well as nutrition or hydration intervention to manage skin problems. According to this MDS Resident #15 needed extensive assistance with transfer, dressing, and hygiene/bathing. For eating she was totally dependent on staff. Record review of physician consult for Resident # 15 dated 11/22/15 revealed wound # 1 right heel stage 3 measuring 0.3 cm L by 0.3 cm W not healed; wound # 2 right buttock measuring 3.5 cm L by 2.4 cm W not healed; wound # 3 left buttock measuring 2.2 cm L by 0.4 cm W. Record review of weekly skin integrity review dated 12/12/15 revealed Resident # 15 had a rash, redness, and pressure ulcer to right and left buttock. Record review of nutrition at risk dated 12/15/15 for Resident # 15 read in part resident requires total assistance, uses an adult sip with cup with a lid and handle for liquids. Resident had adequate PO intake, intake meets needs. There was no mention of pressure ulcer or any supplement recommended to assist with wound healing. Record review of Resident # 15's quarterly MDS assessment dated [DATE] revealed no BIMs score, a stage 1 or greater (a stage 4) pressure ulcer; un-stageable-slough and /or eschar; measuring 0.2 cm (centimeter) long, by 0.3 cm wide with a depth of 0.1 cm. According to this MDS, Resident #15 was always incontinent of bowel and bladder and required extensive assistance to totally dependent on staff for ADLS. Record review of care plan initiated on 12/16/15 revised on 12/23/15 revealed Resident # 15 had no pressure ulcer or any specific plan/treatments for pressure ulcers. Record review of weekly wound data collection dated 12/23/15 revealed Resident # 15 acquired in house a right heel pressure ulcer measuring 0.4 cm length (L) by 0,3 cm width (W), 0 depth (D), and un-stageable identified on 9/30/15. A right buttock type other measuring 5 cm in length by 5 cm width, and depth of 0.2 cm a stage II, identified on 11/23/15. The intervention was wheel chair cushion and treatment order to cleanse wound with saline, protect peri-wound with skin protectant, and apply alginate to wound bed, then [MEDICATION NAME], cover wound with bordered gauze, change daily. A left buttock type other measuring 5 L by 5.2 W with a D of 0.2 a stage II identified on 11/23/15. Record review of weekly wound data collection dated 12/29/15 revealed the sizes of the wound mentioned above remained the same. Record review of physician consult for Resident # 15 dated 12/29/15 revealed wound # 1 right heel stage 3 measuring 0.4 cm L by 0.3 cm W; wound # 2 right buttock measuring 5 cm L by 5 cm W by 0.2 cm D not healed; wound # 3 left buttock measuring 5 cm L by 5.2 cm W by 0.2 cm D. Record review of weekly skin integrity review dated 1/2/16 for Resident # 15 read in part redness, incontinent associated [MEDICAL CONDITION], a left gluteal fold open area stage 3, treatment in place, and right gluteal fold area with redness with multiple open areas stage 3, treatment in place. Record review of treatment record for Resident #15 dated 1/2016 revealed treatment orders for the following wounds: #1 right buttock clean with normal saline apply [MEDICATION NAME] to wound bed, then apply alginate to wound bed, cover with bordered gauze daily and as needed; Wound # 2 right heel- clean with normal saline apply [MEDICATION NAME] to wound bed, then apply alginate to wound bed, cover with bordered gauze daily and as needed Wound # 3 left buttock- clean with normal saline protect peri wound with skin protectant. Apply Boudreaux butt paste to wound bed, cover with bordered gauze daily and as needed. Observation and interview during wound care with LVN E on 1/5/15 at 1:55 pm revealed Resident #15 had 4 wounds. Wound # 1 right heel was pinkish red with moderated amount of sero-sangguineous drainage on the gauze. No odor was noted. LVN E said she thought it was a stage 2, no measurements done. Wound # 2 right foot plantar section of the great toe a wound appeared yellowish-white in color with small amount of sero-sangguineous drainage on the gauze. LVN E said she thought it was a stage 3, but no measurements were done. Wound # 3 coccyx area was very red and appeared irritated/excoriated extended to both side of the gluteal with multiple openings that resembled skin peeling off with small amount of sero-sangguineous drainage on the gauze. No odor was noted. LVN E said she thought it was a stage 4, no measurement was done. Wound # 4 left hip/low back area the area looked pinkish red with small amount of sero-sangguineous drainage on the gauze. No odor was noted. An interview with LVN E at this time she said she did not know about the wound on the plantar section of the right great toe it was new to her. She did not do any wound measurements. She said the wound care practitioner did the wound measurements when he made weekly wound round every Monday. An interview with the ADON on 1/6/16 at 4:25pm she said she did the care plan and revised them quarterly or when she needed to add something. She did not see a care plan for pressure ulcers in the Resident comprehensive plan of care. She said she was going to check to see in other files. An interview with the DON on 1/6/16 at 3:30 pm she said she did not see the care plan either for pressure ulcers. She said they usually made referral to the dietician for consult. The resident was seen by the dietician, but she did not see and dietary supplement recommendation to assist with wound healing. She said they added air mattress in the last week as an intervention, and the Resident was only getting out of bed for meals. She said there was a new wound discovered this week. She further stated the wound measurements were done by her and Nurse Practitioner who came in once a week as a consultant. The DON said she did not know how the previous wound were acquired because she was not the DON during that time. Record review of the facility 's policy effective 3/2009 and revised on 5/2014 read in part Charge nurses will observe the condition of the resident ' s skin on admission and on a routine basis. This system also provides a communication process for the nursing assistant to report residents with skin changes to the Charge Nurse. A. Upon admission: 4. Initiate treatment intervention 5. Initiate plan of care. B. the Charge Nurses should 4. Update plan of care with each intervention. According to the CMS form 672 there were 5 residents with pressure ulcers in the facility.

Based on observation, interview, and record review the facility failed to ensure one of five residents (CR#1) was free from accidents and hazards. The facility failed to ensure one of three drivers (Driver #1) was trained to operate the rented van ' s equipment and emergency procedures before transporting residents to prevent injury. CR#1 sustained a cervical fracture while being transported by the facility ' s rented van on 9/15/14. CR#1 ' s wheelchair was not properly secured in the rented van and while being transported, the resident and wheelchair flipped backwards. Driver #1 was not trained by the facility staff on the equipment of the rented van, before transporting residents. He failed to notify 911 before moving the resident and failed to notify his supervisor or administration of the incident. This failure affected one discharged resident and placed 31 residents who required wheelchairs for ambulation at an increased risk of injuries from the lack of training and supervision. Findings include: Intake # 7 CR#1 Record review of CR#1 ' s face sheet revealed she was admitted to the facility on [DATE] and was discharged on [DATE] to the hospital. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she lived in the independent living, located on the same property as the skilled nursing facility. Interview on 10/2/14 at 10:25 AM, the DON stated CR#1 had an accident while being transported by Driver #1 in the rented van back to the facility from a medical appointment. She stated CR#1 had sustained a head injury and a broken neck, due to the accident. She stated Driver #1 failed to notify her of the incident when it occurred. She said she learned of the incident by Driver #2 after CR#1 was taken to the hospital. She stated when Driver #1 returned to the facility she questioned him about the incident. She was told he had secured CR #1 in the rented van and when he had accelerated the van, he heard a loud thump and a scream. She stated Driver #1 informed her that CR#1 ' s wheelchair had flipped backwards and he saw her feet were in the air. CR#1 ' s family member was also in the rented van when the incident occurred. In the same interview the DON stated Driver #1 had stopped the van and went to help CR#1. He lifted the resident in her wheelchair up and noticed blood on the van floor and the resident ' s head. Driver #1 then transported CR #1 to the local hospital. She stated when Driver #1 returned to the facility, she had him do a demonstration of how he secured CR#1 into the rented van. She further stated Driver #1 failed to secure the front wheels of CR#1 ' s wheelchair, which caused her to flip backwards in her wheelchair; failed to notify the facility of the incident; and failed to have CR#1 assessed before moving/sitting her up and transporting her to the hospital. She further stated the van that was used was a rented van, due to the other facility bus was being repaired. Record review of the DON ' s observation and interview with Driver #1, dated 9/15/14, read " Driver #1 proceeded to fasten the rear wheels of the wheelchair with the tie downs from the back of the van. He then showed that he could not fasten the front wheels with the tie downs that were positioned in the front of the van because they would not reach... " Observation and interview on 10/2/14 at 12:00 PM in the resident's independent living apartment located on the same property as the skilled nursing facility revealed CR#1 was with her private caregiver and her family member. CR#1 was sitting in her wheelchair, wearing a neck brace and an immobilizer. She was well groomed, odor free, and was interviewable. CR#1 stated she was nervous to ride in any more vehicles. She stated she had a broken neck due to the accident. She stated she was ordered to wear the neck brace and immobilizer until 12/2014 and stated she would " rejoice " once the collar came off. She further stated she felt Driver #1 did not know what he was doing and that was the reason she was hurt. Interview on 10/2/14 at 12:00 PM, CR#1 ' s family member stated she was in the rented van when Driver #1 was transporting CR#1 back to the facility after an appointment. She stated Driver #2 had transported them using the facility ' s van to the appointment and Driver #1 picked them up in a rented van to return them to the facility. She stated Driver #2 had transported them before and there were no problems with the facility ' s van. She stated this was the first time they had rode with Driver #1 and the rented van. She stated she did not watch Driver #1 place CR#1 in the van. She stated she sat in the passenger seat of the rented van, while CR#1 was sitting in her wheelchair at the back of the van. She stated she " trusted " Driver #1 knew how to properly secure CR#1. She stated Driver #1 had come to a stop and when he accelerated the van, she heard a loud " thump " . She stated she looked back and saw CR#1 ' s legs were in the air. In the same interview CR #1's family member stated once Driver #1 stopped the van, they went back to help CR#1. She stated CR#1 was crying and yelling and stated she was hurt. She stated Driver #1 then lifted CR#1 in the wheelchair upright and stated he was going to take her to the hospital. She stated when he again accelerated the van, she saw the wheelchair move and shouted " she (CR#1) is going to flip over again". CR#1 ' s family member stated she went to the back of the van and stood behind CR#1 to ensure she would not flip over again. She stated Driver #1 did not secure the front wheels after the initial incident. She further stated Driver #1 was neglectful because he did not secure CR#1 in the van properly. She stated CR#1 was admitted to the hospital and had sustained a broken neck and laceration to the back of her head. She further stated this accident caused fear in her mother and anxiety when riding in a vehicle. Interview on 10/2/14 at 1:15 PM, Driver #2 stated he had been employed at the facility since 2/2014. He stated he called Driver #1 to inform him that he would pick up CR#1 and her family member from the medical appointment. He stated Driver #1 answered his phone and stated there was an accident and CR#1 was in the hospital. He stated the van that Driver #1 was using was a rented van. He stated he had driven the rented van previously and stated it was difficult to use and to strap the residents in properly. He stated he was uncomfortable using the rented van and requested to use only the facility ' s van. He further stated the only way the wheelchair could have flipped backwards was if the front straps were not attached properly to the front wheels. He further stated he had been given verbal instructions by the rented van company on how the equipment worked. He stated Driver #1 was not trained by the rented van company because he was not there when the staff picked the van up from the company. He further stated he was unsure if anyone had trained Driver #1 on how to properly use the rented van's equipment. He further stated he had been trained not to move a resident if an incident or accident occurred, call for emergency services, and to call to notify the facility of the incident/accident. Interview on 10/2/14 at 2:00 PM, the Director of Plant Operations stated the facility ' s bus was in for repairs and the facility had rented another van to help with transportation. He stated Driver #1 was not working for transportation when the rented van was picked up. He stated Driver #2 and Driver #3 were both instructed on the equipment in the rented van. He stated Driver #3 was going on leave and they had asked Driver #1 if he could fill in. He stated Driver #1 was originally hired for transportation but had been promoted to another department. He stated he had learned about the incident with CR#1 from Driver #1. He stated Driver #1 was sitting in the lobby area waiting on the next transportation when Driver #1 called him over to talk. He stated the two of them went outside. Driver #1 told him there was an accident. The driver reported that CR#1 had fell over backwards in the wheelchair while being transported in the rented van. He was told that CR#1 had a cut to the forehead and he had taken her to the hospital, but that she was okay. He stated he and Driver #1 went to notify administration of the incident. He further stated Driver #1 came back to the facility, had washed the van, cleaned up the blood, and was sitting in the lobby waiting on the next scheduled transportation, before informing the facility of what had happened. He further stated before Driver #3 went on leave, he had asked Driver #3 to train Driver #1 on the use of the rented van's equipment. He stated he had assumed that Driver #3 had trained Driver #1. Telephone Interview on 10/2/14 at 2:51 PM, Driver #1 stated he had never driven the rented van and had not been trained on the equipment before transporting residents. When asked about any additional training concerning emergency services, Driver #1 stated he had to hang up and the phone became disconnected. Repeated attempts to interview Driver #1 were unsuccessful. An interview with Driver #3 was not possible due to him being out of the country and could not be interviewed by telephone. Record review of the CR#1 ' s Accident/Incident Report, dated 9/15/14, revealed the DON wrote the report. CR#1 had a fall in the facility ' s rented van. CR#1 was transferred to the hospital by Driver #1. The report read " Driver #1 immediately took CR#1 to the hospital ... Driver #1 reported the incident to other driver and then returned to facility " . Record review of Driver #1 ' s witness statement, dated 9/16/14, read " I stopped at a stop sign, and after I pulled off I heard a bang, her daughter looked back and said CR#1 was on her back ... I went back and picked the wheelchair up by the handle, then her daughter came to the back and held the wheelchair while I drove her to the emergency room ... " Record review of the facility ' s Provider Investigation Report, dated 9/19/14, revealed under the section titled Description of the Allegation, read " ... (Driver #1) loaded (CR#1) in her wheelchair in the back of handicapped accessible (rented) van. He fastened the wheelchair with the van equipped tie downs ...Driver #1 accelerated following a stop sign and the wheelchair CR#1 was sitting in tipped over backwards. CR#1 hit the back of her head on the van floor " . Further review of the same form revealed her injuries included a laceration to the back of the head, minimally displaced fracture of C7 with mild subluxation of right C6 to C7 joint. Record review of Driver #1 ' s employee file revealed he was hired 10/1/2013 as a PRN (as needed) Driver. He had a valid driver ' s license that did not expire until 6/18/2020. Further review revealed he was terminated on 9/30/14 due to policy/procedure violation and performance transgression. Driver #1 " failed to secure the wheelchair in the proper manner, moved the injured resident and transported to the hospital versus contacting 911..." . Record review of Driver Meeting in-service, dated 11/15/13, revealed Driver #1 and Driver #3 were both trained on scheduling, safety, and vehicle monthly checks. No other documented training's were found in Driver #1's employee file. Record review of the facility ' s Driver Job Description, dated 6/25/12, revealed the driver would provide transportation to clients, assist in boarding and departing from vehicle and ensure that they arrive at their destinations safely. Further review revealed the general functions of the driver was to provide transportation for clients through the use of Agency vehicles to and from the center, doctor appointments, and scheduled outings. Record review of the facility ' s Agency Vehicles policy, dated 5/2007, revealed under the section titled Accidents, the driver was to " notify necessary authorities to provide for emergency aid to individuals; ... In an accident involving personal injuries, wait at the scene until police arrive; ...notify your supervisor, director or administrator as soon as possible " . A copy of the the facility's rental agreement for the van was requested, but was not provided prior to exit. The facility ' s census was 35.

Based on observation, interview, and record review, the facility failed to implement the written policy and procedures to prohibit neglect for one of five residents (CR#1) reviewed for neglect. Driver #1 was not trained to use the rented van's equipment or procedures to follow when a resident sustained [REDACTED].#1. CR #1 was injured when her wheelchair flipped backwards causing a laceration to the back of her head, minimally displaced fracture of C7 (7th cervical vertebrae in the neck) with mild subluxation (partial dislocation) of the right C6 to C7 (cervical vertebrae in the neck) joint. This affected one discharged resident and placed 31 residents who required wheelchairs for mobility at risk for abuse, neglect, and injuries. Findings include: Intake # 7 CR#1 Record review of CR#1 ' s face sheet revealed she was admitted to the facility on [DATE] and was discharged on [DATE] to the hospital. She was [AGE] years old and was diagnosed with [REDACTED]. Further review revealed she lived in the independent living, located on the same property as the skilled nursing facility. Interview on 10/2/14 at 10:25 AM, the DON stated CR#1 had an accident while being transported by Driver #1 in the rented van back to the facility from a medical appointment. She stated CR#1 had sustained a head injury and a broken neck, due to the accident. She stated Driver #1 failed to notify her of the incident when it occurred. She said she learned of the incident by Driver #2 after CR#1 was taken to the hospital. She stated when Driver #1 returned to the facility she questioned him about the incident. She was told he had secured CR #1 in the rented van and when he had accelerated the van, he heard a loud thump and a scream. She stated Driver #1 informed her that CR#1 ' s wheelchair had flipped backwards and he saw her feet were in the air. CR#1 ' s family member was also in the rented van when the incident occurred. In the same interview the DON stated Driver #1 had stopped the van and went to help CR#1. He lifted the resident in her wheelchair up and noticed blood on the van floor and the resident ' s head. Driver #1 then transported CR #1 to the local hospital. She stated when Driver #1 returned to the facility, she had him do a demonstration of how he secured CR#1 into the rented van. She further stated Driver #1 failed to secure the front wheels of CR#1 ' s wheelchair, which caused her to flip backwards in her wheelchair; failed to notify the facility of the incident; and failed to have CR#1 assessed before moving/sitting her up and transporting her to the hospital. She further stated the van that was used was a rented van, due to the other facility bus was being repaired. Record review of the DON ' s observation and interview with Driver #1, dated 9/15/14, read " Driver #1 proceeded to fasten the rear wheels of the wheelchair with the tie downs from the back of the van. He then showed that he could not fasten the front wheels with the tie downs that were positioned in the front of the van because they would not reach... " Observation and interview on 10/2/14 at 12:00 PM in the resident's independent living apartment located on the same property as the skilled nursing facility revealed CR#1 was with her private caregiver and her family member. CR#1 was sitting in her wheelchair, wearing a neck brace and an immobilizer. She was well groomed, odor free, and was interviewable. CR#1 stated she was nervous to ride in any more vehicles. She stated she had a broken neck due to the accident. She stated she was ordered to wear the neck brace and immobilizer until 12/2014 and stated she would " rejoice " once the collar came off. She further stated she felt Driver #1 did not know what he was doing and that was the reason she was hurt. Interview on 10/2/14 at 12:00 PM, CR#1 ' s family member stated she was in the rented van when Driver #1 was transporting CR#1 back to the facility after an appointment. She stated Driver #2 had transported them using the facility ' s van to the appointment and Driver #1 picked them up in a rented van to return them to the facility. She stated Driver #2 had transported them before and there were no problems with the facility ' s van. She stated this was the first time they had rode with Driver #1 and the rented van. She stated she did not watch Driver #1 place CR#1 in the van. She stated she sat in the passenger seat of the rented van, while CR#1 was sitting in her wheelchair at the back of the van. She stated she " trusted " Driver #1 knew how to properly secure CR#1. She stated Driver #1 had come to a stop and when he accelerated the van, she heard a loud " thump " . She stated she looked back and saw CR#1 ' s legs were in the air. In the same interview CR #1's family member stated once Driver #1 stopped the van, they went back to help CR#1. She stated CR#1 was crying and yelling and stated she was hurt. She stated Driver #1 then lifted CR#1 in the wheelchair upright and stated he was going to take her to the hospital. She stated when he again accelerated the van, she saw the wheelchair move and shouted " she (CR#1) is going to flip over again". CR#1 ' s family member stated she went to the back of the van and stood behind CR#1 to ensure she would not flip over again. She stated Driver #1 did not secure the front wheels after the initial incident. She further stated Driver #1 was neglectful because he did not secure CR#1 in the van properly. She stated CR#1 was admitted to the hospital and had sustained a broken neck and laceration to the back of her head. She further stated this accident caused fear in her mother and anxiety when riding in a vehicle. Interview on 10/2/14 at 1:15 PM, Driver #2 stated he had been employed at the facility since 2/2014. He stated he called Driver #1 to inform him that he would pick up CR#1 and her family member from the medical appointment. He stated Driver #1 answered his phone and stated there was an accident and CR#1 was in the hospital. He stated the van that Driver #1 was using was a rented van. He stated he had driven the rented van previously and stated it was difficult to use and to strap the residents in properly. He stated he was uncomfortable using the rented van and requested to use only the facility ' s van. He further stated the only way the wheelchair could have flipped backwards was if the front straps were not attached properly to the front wheels. He further stated he had been given verbal instructions by the rented van company on how the equipment worked. He stated Driver #1 was not trained by the rented van company because he was not there when the staff picked the van up from the company. He further stated he was unsure if anyone had trained Driver #1 on how to properly use the rented van's equipment. He further stated he had been trained not to move a resident if an incident or accident occurred, call for emergency services, and to call to notify the facility of the incident/accident. Interview on 10/2/14 at 2:00 PM, the Director of Plant Operations stated the facility ' s bus was in for repairs and the facility had rented another van to help with transportation. He stated Driver #1 was not working for transportation when the rented van was picked up. He stated Driver #2 and Driver #3 were both instructed on the equipment in the rented van. He stated Driver #3 was going on leave and they had asked Driver #1 if he could fill in. He stated Driver #1 was originally hired for transportation but had been promoted to another department. He stated he had learned about the incident with CR#1 from Driver #1. He stated Driver #1 was sitting in the lobby area waiting on the next transportation when Driver #1 called him over to talk. He stated the two of them went outside. Driver #1 told him there was an accident. The driver reported that CR#1 had fell over backwards in the wheelchair while being transported in the rented van. He was told that CR#1 had a cut to the forehead and he had taken her to the hospital, but that she was okay. He stated he and Driver #1 went to notify administration of the incident. He further stated Driver #1 came back to the facility, had washed the van, cleaned up the blood, and was sitting in the lobby waiting on the next scheduled transportation, before informing the facility of what had happened. He further stated before Driver #3 went on leave, he had asked Driver #3 to train Driver #1 on the use of the rented van's equipment. He stated he had assumed that Driver #3 had trained Driver #1. Telephone Interview on 10/2/14 at 2:51 PM, Driver #1 stated he had never driven the rented van and had not been trained on the equipment before transporting residents. When asked about any additional training concerning emergency services, Driver #1 stated he had to hang up and the phone became disconnected. Repeated attempts to interview Driver #1 were unsuccessful. An interview with Driver #3 was not possible due to him being out of the country and could not be interviewed by telephone. Record review of the CR#1 ' s Accident/Incident Report, dated 9/15/14, revealed the DON wrote the report. CR#1 had a fall in the facility ' s rented van. CR#1 was transferred to the hospital by Driver #1. The report read " Driver #1 immediately took CR#1 to the hospital ... Driver #1 reported the incident to other driver and then returned to facility " . Record review of Driver #1 ' s witness statement, dated 9/16/14, read " I stopped at a stop sign, and after I pulled off I heard a bang, her daughter looked back and said CR#1 was on her back ... I went back and picked the wheelchair up by the handle, then her daughter came to the back and held the wheelchair while I drove her to the emergency room ... " Record review of the facility ' s Provider Investigation Report, dated 9/19/14, revealed under the section titled Description of the Allegation, read " ... (Driver #1) loaded (CR#1) in her wheelchair in the back of handicapped accessible (rented) van. He fastened the wheelchair with the van equipped tie downs ...Driver #1 accelerated following a stop sign and the wheelchair CR#1 was sitting in tipped over backwards. CR#1 hit the back of her head on the van floor " . Further review of the same form revealed her injuries included a laceration to the back of the head, minimally displaced fracture of C7 with mild subluxation of right C6 to C7 joint. Record review of Driver #1 ' s employee file revealed he was hired 10/1/2013 as a PRN (as needed) Driver. He had a valid driver ' s license that did not expire until 6/18/2020. Further review revealed he was terminated on 9/30/14 due to policy/procedure violation and performance transgression. Driver #1 " failed to secure the wheelchair in the proper manner, moved the injured resident and transported to the hospital versus contacting 911..." . Record review of Driver Meeting in-service, dated 11/15/13, revealed Driver #1 and Driver #3 were both trained on scheduling, safety, and vehicle monthly checks. No other documented training's were found in Driver #1's employee file. Record review of the facility ' s Driver Job Description, dated 6/25/12, revealed the driver would provide transportation to clients, assist in boarding and departing from vehicle and ensure that they arrive at their destinations safely. Further review revealed the general functions of the driver was to provide transportation for clients through the use of Agency vehicles to and from the center, doctor appointments, and scheduled outings. Record review of the facility ' s Abuse Prevention, Reporting and Investigation policy, no date, revealed Neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. It further revealed each resident of the licensed Nursing Home has the right to be free from neglect. A copy of the facility's rental agreement for the van was requested, but was not provided prior to exit. The facility ' s census was 35.

Based on observation, record review, and interview, the facility failed to ensure 2 of 2 sampled residents (# ' s 31 and 8) with limited ROM to their arms and hands, were assessed and received appropriate treatment and services to increase their ROM and to prevent further decline. The facility failed to: Resident # 31 was discharged from therapy services and was placed on restorative services. The resident's condition declined. The resident was no longer able to feed herself and her ambulation with a walker declined. Therapy did not reassess or treat. Provide Resident # 8 passive range of motion exercises, splints /hand rolls, or positioning devices for her hand contractures to prevent further decline in movement. These failures caused 1 resident to loose usage of her right hand and 1 resident's contractures to increase. These failures placed 5 residents at risk of having their contractures to increase. Findings include: Resident # 31 Record review of Resident # 31 ' s face sheet revealed she was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Record review of the resident's Nursing Admission Assessment & Review dated 12/15/10 revealed: severe debilitation, history right broken wrist, and no contractures. Observation made on 5/10/11 at 10:34 A.M., during initial tour, Resident # 31 was seen in her room. She was well dressed, groomed and sitting on a chair in front of her television. It was observed that both hands were clinched together with her finger inwardly curved and lapping over each other. Resident # 31 tried and stretched out her fingers partially but could not stretch them out or hold them out. One foam hand roll was found on the table. The DON stated at this time that Resident # 31 did not have any contractures. Record review of Resident # 31 ' s Care Plan dated 12/22/10 revealed she required extensive assistance with bed mobility, personal hygiene, and bathing; total assistance with transfers, dressing, and toileting; and limited assistance with eating. Record review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 31 was admitted to the facility with no range of motion limitations to either right or left side. Voluntary movement was recorded as no loss. Record review of Occupational Therapy Discharge note dated 3/1/11 revealed short term goal of increasing the ability to feed herself and her ability to perform grooming. Current status as of 3/1/11 revealed resident still needed encouragement in these areas. Documented discharge reason given was " goals partially met " . Record review of the resident's Quarterly MDS assessment dated [DATE] revealed Resident # 31 had no limitations to either side of her body. Record review of the physician's order [REDACTED]. Record review of the Daily Skilled Nurse ' s Note dated 3/17/11 revealed the resident required limited assistance with bed mobility, transfer, locomotion. The note revealed that the resident was able to eat independently once the meal was set up for her by staff. Record review of the Daily Skilled Nurse ' s Note dated 4/17/11 revealed the Resident #31 required extensive to total assistance and was dependent on staff for bathing, bed mobility, transfer, locomotion, dressing, eating, and personal hygiene. Record review of Resident # 31 ' s Care Plans dated 12/22/10 and 3/11/11 revealed no contractures or decline in physical functioning. Record review of Skilled Nursing Daily Assessments dated 3/17/11 through 4/17/11 revealed documented decline in functioning ability and no contractures. No documentation concerning any resident information communicated to therapy or the physician. Record review of Physician ' s Progress Note dated 5/11/11 revealed deconditioning in the resident, an unsteady gait with left foot drop and the need to " continue therapy " . Observation on 5/12/11 at 9:40 a.m. revealed Resident # 31 seated in her wheelchair. Two black hand rolls were on the bedside table. She had limited range of motion in both arms. She was unable to move her arms up past her chest area. Both hands were tightly clinched. Her right hand was more clinched than the left. A pulley exercise system was on her bathroom door. Interview on 5/12/11 at 9:40 a.m. the Resident stated she no longer received therapy services due to an end of coverage period. Her therapy had ended on 3/11/11. She was told if the need arose after 30 days she could be reassessed for further services. She had not been reassessed and did not know why. She felt she was losing the progress she had gained in therapy. Resident #31 stated it was difficult to raise her right arm, lift her arm and hand, and to use her fingers. She stated she could no longer feed herself. She stated her hand, especially her right hand, had gotten worse. The resident stated she had just started to walk with a walker when therapy was stopped. Some of her caretakers had been walking her and told her they noted some decline in her ambulation. She said she had a device on her bathroom door that she pulls down on to encourage ROM in her shoulders. To use this pulley system a staff member had to physically place her hands on the handles and then she could alternate the hands in a downward motion pulling the other arm up. During the interview a therapy aide came into the room and told the resident she needed to borrow the device again to use in therapy that afternoon. Interview on 5/12/11 at 10:45 a.m. the Occupational Therapist (OT ) stated Resident # 31 no longer received therapy services. The OT stated her skilled therapy services days had ended and the resident had a 30-day wait period before Medicare Part B would consider picking up the 80% payment. She said she noticed a decline in the resident's physical functioning and worsening of her hands since the therapy ended. She said the therapy staff was not able to reassess her until nursing had documented a decline in functioning and made a referral for assessment. She said she did not know why nursing had not done so. Interview on 5/12/11 at 11:00 a.m. the DON, with the Corporate Nurse present, stated once therapy had discontinued there was a re-evaluation period in which they could reassess the resident to see if the restorative program was working. He said Therapy was responsible for the Restorative Program. He said if nursing should note a decline in functioning it was their responsibility to make a referral to therapy. He was unable to answer any questions regarding Resident # 31 and her decline in physical function. Review of the facility's Standards & Guidelines Notice of Resident Rights revealed the facility ' s expectation was that each resident " receive all care necessary to have the highest possible level of health " Resident #8 Record review of Resident # 8 ' s face sheet revealed the resident was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Record review of the resident's admission MDS assessment dated [DATE] revealed she had limitations in range of motion to her hands (including wrist or fingers). Voluntary movement was recorded as no loss. Record review of the resident's annual MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed Resident # 8 had limitations in range of motion to her hands (including wrist or fingers). Voluntary movement was recorded as no loss. Review of Resident # 8 ' s Care Plan dated 10/15/10. revealed she was totally dependent on facility and hospice staff for all activities of daily living. This care plan revealed Resident # 8 had a contracture. Contracture location was documented as left upper hand. One of the goals revealed the contracture would not increase. The approaches were for nursing staff to monitor for increased pain/stiffness-provide meds/treatments and assess for relief. Assist with repositioning every two hours using positioning device to maintain proper body alignment, keep contractured area clean and dry, provide passive range of motion, and do not force contractured areas. There were no care plan addressing the right hand contracture. Resident #8 had no Restorative Nursing care plans. Record review of the most recent Quarterly MDS assessment dated [DATE] revealed Resident # 8 had limitations in range of motion to her upper extremities. Resident # 8 required extensive assistance and dependent on the staff for all activities of daily living (ADL). The same MDS revealed the resident was admitted to hospice care on 4/8/11. Observation on 5/10/11 at 10:10 A.M. during initial tour, revealed Resident # 8 in a Geri chair in the television room. Resident # 8 ' s hands were clinched together. Resident could not open her hands or lift then up when requested to by surveyor. Observation on 5/10/11 at 1:10 P.M. revealed the resident in the Geri chair in the dinning room being assisted with feeding by a staff. Both hands were clinched together. No hand rolls or contracture prevention devices were being used. Observation on 5/10/11 at 3:00 P.M. revealed Resident # 8 lying back in the same Geri chair in the television room. No hand rolls were observed. Observation on 5/11/11 at 7: 40 A.M. revealed Resident # 8 lying on her back in bed. There were no roll in either hand. Both hands were clinched together. Observation on 5/11/11 at 7: 30 P.M revealed Resident # 8 in bed. She was not interview able and had impaired cognition. She shook her head when asked questions. She was covered with a comforter and both hands were under the covers. She had no rolls in her hands. Observation on 5/12/11 at 7:20 A.M., 9:00 A.M. and 1:00 P.M. Resident # 8 was observed in the same Geri chair. No hand rolls in her hands. Interview on 5/12/11 at 10:12 A.M. LVN # 1 said residents with limited range of motion / contractures were assessed by the therapy department and the therapy/restorative care plan would be developed and followed. She said therapy staff would obtain orders from the physician and the nurses would be told if continual care was required after hours or at night. Interview on 5/12/11 at 11:00 A.M. the DON said he expected communication between the therapy department and the nurses to continue to provide the required care to the residents. He said his expectations were that the nurses would document and notify appropriate persons if there was progress or decline in any resident ' s functional ability. He did not recall any approaches used to treat/ prevent contracture of the residents. He said he would have to ask the therapy department what approaches were used. He said every resident whether admitted under Hospice or not should receive the required care to attain their highest mental and physical functional levels at all times. Facility standards and guideline manual on accommodation of needs revealed the resident was to be assisted in maintaining and/or achieving independence functioning, dignity and well being to the extent possible in accordance with the resident own preferences, assessment and care plan. The facility's CMS form 672 listed 7 residents with contractures.