Every finding on record at The Villages on MacArthur

Based on observations, interviews, and record review the facility failed to protect the confidentiality of personal and medical records for 7 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7) of 8 residents observed for personal privacy and confidentiality of records.1. The facility failed to ensure the confidentiality of Resident #1's health information when there was a posted sign that reflected, Feeder on Resident #1's door on 06/06/26.2. The facility failed to ensure that the lunch meal tickets for 6 (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7) of 6 residents on the 700 Hall were not in view of the public on 07/29/26.These failures could affect residents by placing them at risk for loss of privacy and dignity.The findings included:During a telephone interview on 07/29/26 at 10:06 AM, with the FM of Resident #1, she stated the resident was at the facility for 4 years. The FM stated she was the RP of Resident #1 and was the resident's POA due to the resident being diagnosed with dementia (a decline in mental ability severe enough to interfere with daily life), and Alzheimer's. The FM stated Resident #1 had a private room during his stay at the facility. The FM stated she visited Resident #1 at the facility at least 3-4 times per week. The FM stated on 06/06/26, she visited Resident #1 at the facility and upon approaching Resident #1's door, there was a white paper posted on the door with green writing with the word, Feeder. The FM stated the posted sign was taped on Resident #1's door. The FM stated she spoke with LVN D at the nurses station and she showed her the posted Feeder sign that was on Resident #1's door. The FM stated LVN D removed the posted Feeder sign that was on Resident #1's door. The FM stated she told LVN D that the posted sign on Resident #1's door was very demeaning and degrading and she did not like the sign on the door and she wanted to ensure Resident #1's had dignity and some privacy due to the resident already being a resident at the facility. The FM stated she did not file a grievance with the Social Worker at the facility regarding the posted Feeder sign being on Resident #1's door. The FM stated she did not file a Grievance due to LVN D removing the Feeder sign on Resident #1's door.Record review of a time and date stamped screenshot received via text message from Resident #1's FM revealed a photograph of Resident #1's door with Resident #1's name beside the door. The screenshot revealed that the photograph was taken on 06/06/26 at 8:28 PM. The photo revealed there was a posted Feeder sign on the front of Resident #1's door with tape. The Feeder sign was a white piece of paper with the word, Feeder in green writing and was on the front of Resident #1's door.Observation of the facility's 700 Hall on 08/06/26 at 12:25 PM, revealed there were 6 lunch meal tickets observed posted behind the name plate of 2 (Resident #5 and Resident #6) residents room. The lunch meal tickets were for 6 residents which included Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7. The observation of the residents meal tickets revealed that the information for each resident included the residents name, room number and dietary notes with special instructions. The 6 resident meal tickets were visible to the public and/or anyone who had access to the 700 Hall.During an interview with CNA E on 07/29/26 at 12:33 PM, she stated she had been employed at the facility for 9 months. CNA E stated on 07/29/26 she was not assigned to the 700 Hall, but assisted staff with the residents on the hall. CNA E stated the residents in the 700 Hall ate in their rooms and the food was brought to them by the kitchen staff. CNA E stated because the residents on the 700 Hall ate in their rooms, the nursing staff placed the residents meal tickets on the wall behind the residents' name plate. CNA E stated the kitchen staff would pick up the residents' meal tickets and would serve the food to the residents according to the information on their meal tickets. CNA E stated she had never observed any signs on any resident's door in the facility that reflected, Feeder. CNA E stated she had previously taken in-service trainings on HIPAA (the United States federal law passed in 1996, it protects private medical information) and PHI (any health data that can identify a person and relates to their past, present, or future healthcare services, it applies whether the data is written on paper) but was unable to recall her last training date. CNA E stated she did not know how to answer the risk and harm questions relating to resident confidentiality and safeguarding medical records.During an interview with CNA F on 07/29/26 at 12:39 PM, she stated she had been employed at the facility for 3 months. CNA F stated on 07/29/26 she was assigned to the 700 Hall. CNA F stated a majority of the residents on the 700 Hall did not leave their rooms and ate all their meals in their rooms. CNA F stated because the residents on the 700 Hall ate in their rooms, the nursing staff fed the residents according to the information of their meal tickets, which were always placed on the wall behind the name plate beside the resident's door. CNA F stated the CNAs placed all the meal tickets for the 700 Hall behind one name plate to make sure that the kitchen staff were serving the proper meals for each resident. CNA F stated she did not know who placed the lunch meal tickets on Resident #5 and Resident #6's room on 07/29/26. CNA F stated she had never observed any signs on any resident's door in the facility that reflected, Feeder. CNA F stated she had previously taken in-service trainings on HIPAA (Health Insurance Portability and Accountability Act) and PHI (Protected Health Information) but was unable to recall her last training date. CNA F stated there was no risk and/or harm to residents with their meal tickets being in line sight for the public relating to confidentiality and safeguarding medical records.During an interview with LVN D on 07/29/26 at 2:58 PM, she stated she had been employed at the facility for 3 1/2 years. LVN D stated that she could not remember the date but remembered Resident #1's FM approached her at the nurses station and told her that she wanted to show her something. LVN D stated Resident #1's FM showed her a white piece of paper that was taped on Resident #1's door. LVN D stated the word, Feeder was written on the white piece of paper that had been on the resident's door. LVN D stated Resident #1's family member was upset because of the sign being on the resident's door. LVN D stated the FM stated that the sign being on Resident #1's door violated the resident's dignity, respect and privacy. LVN D stated she did not know who placed the sign on Resident #1's door but most likely a CNA placed the Feeder sign on Resident #1's door to indicate the resident needed assistance with feeding from staff during meals. LVN D stated she did not see the Feeder sign on Resident #1's room door until it was brought to her attention by [Resident #1's] FM. LVN D stated she removed the Feeder sign from [Resident #1's] room door and placed it in the trash. LVN D was shown the screenshot that was provided by Resident #1's FM of the Feeder sign on the residents door. LVN D confirmed that the screenshot was accurate and was the same sign she had seen and removed from Resident #1's door. LVN D stated she had not observed any [NAME] tickets for the 700 Hall on a resident's name plate. LVN D stated she had previously in-service trainings on HIPAA (Health Insurance Portability and Accountability Act) and PHI (Protected Health Information) but was unable to recall her last training date. LVN D stated with the Feeder sign being placed on Resident #1's room door and the meal tickets for the 700 Hall being placed in public view sight, there was a risk for the residents' privacy and dignity being violated. LVN D stated there was a potential for the residents to be affected psychologically and if someone did not like a person, they could give the person the wrong food on purpose.During an interview with the DON on 07/30/26 at 1:38 PM, she stated she had been employed at the facility for 3 days. The DON stated she was not employed at the facility when the Feeder sign was posted on [Resident #1's room door. The DON stated that was a HIPAA violation and a resident rights issue if a resident's medical information was posted for the public to view. The DON stated she had not observed any Feeder signs or meal tickets posted on resident doors. The DON stated management collaborated and implanted new directives with the meal tickets for all residents. The DON stated the Dietary Manager had made file folders for each resident that would include their meal ticket information. The DON stated the residents' file folders were located at the nurses stations. The DON stated all staff would be educated on the new system for residents' meals and the location of the file folders for each resident. The DON stated all staff would be reeducated and retrained on HIPAA and PHI and the facility's corresponding policies. The DON stated all staff would be educated on not placing Feeder signs on residents' doors. The DON stated the facility and staff would be breaking HIPAA violations if there was a Feeder sign posted and with the residents meal tickets in public view. The DON stated there was a risk of a resident to feel like they did not have any dignity, respect or privacy when their private and confidential information is not properly secured and not available for everyone to see. The DON stated a resident could be harmed emotionally and have some distress, and depression because their dignity was violated. The DON stated that the emotional distress could potentially cause anxiety and make the resident become isolated and not want to leave their room.Record review of the facility's Grievance Logs from March 2026 - July 2026 revealed no concerns regarding any confidentiality of medical records.Record review of the facility's policy, Safeguarding and Storing of Protected Health Information, revised March 21, 2017 reflected:Policy Statement:The purpose of this policy is to provide guidelines for the safeguarding of Protected Health Information (PHI) in the Facility and to limit unauthorized disclosures of PHI that is contained in a resident's Medical Record, while at the same time ensuring that such PHI is easily accessible to those involved in the treatment of the resident.Application:Corporate and All Managed Healthcare Facilities.Provisions:.2. General Policy. a. The policy of this Facility is to ensure, to the extent possible, that PHI is not intentionally or unintentionally used or disclosed in a manner that would violate the HIPAA Privacy Rule or any other federal or state regulation governing confidentiality and privacy of health information. The following procedure is designed to prevent improper uses and disclosures of PHI and limit incidental uses and disclosures of PHI that is, or will be, contained in a resident's Medical Record. At the same time, the Facility recognizes that easy access to all or part of a resident's Medical Record by health care practitioners involved in a resident's care (nurses.) is essential to ensure the efficient quality delivery of health care. b. The Facility Administrator is responsible for the security of all Medical Records. All staff members are responsible for the security of the active Medical Records at the nursing stations. 4. Safeguards for Written PHI. All documents containing PHI should be stored appropriately to reduce the potential for incidental use or disclosure. Documents should not be easily accessible to any unauthorized staff or visitors.

Based on observations, interviews, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 10 residents (Residents #1 and #2) reviewed for resident call light system. 1. The facility failed to ensure Resident #1 had a call light. 2. The facility failed to ensure Resident #2's call light was placed within reach. These failures could place residents at risk of injuries and unmet needs.Findings included: 1. Review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included end stage renal disease (where the kidneys fail to function adequately), hemiplegia (paralysis of one side of the body), and aphasia (a language disorder that impairs the ability to speak, understand, read, and write). Resident #1 had a BIMS score of 12 which indicated his cognition was moderately impaired. The MDS further reflected the resident used a manual wheelchair for mobility and he required partial to moderate assistance with ADLs. Observation and interview on 01/02/26 at 9:52 AM of Resident #1 revealed he was in his room sitting in his wheelchair, and there was no cord attached to the call light system in his room. The resident said he was able to do a lot of things on his own, despite his right-side paralysis, and because he did not have a call light cord, he would yell out at staff if he needed something. Resident #1 stated he never said anything to the staff about his call light cord because he thought they already knew but would like to have access to his call light to alert staff if he needed something. Interview on 01/02/26 at 9:54 AM with CNA A revealed she had only been working with Resident #1 for about a month. The CNA said she did not realize the resident did not have a call light cord in his room, and Resident #1 usually yelled out if he needed something. Interview on 01/02/26 at 1:41 PM with LVN B revealed she was not aware Resident #1 did not have a call light cord in his room. The LVN said the resident usually went to the nurses' station when he needed something. LVN B said it was important for resident to have access to a call light in case of an emergency or they needed something. 2. Review of Resident #2's face sheet printed on 01/02/26 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included encephalopathy (disease in which the functioning of the brain is affected by some agent or condition), sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissue), urinary tract infection, and weakness. Review of Resident #2's baseline care plan dated 12/30/26 reflected the resident was not cognitively impaired, had impaired functional abilities, and required assistance with ADL care and mobility. Observation and interview on 01/02/26 at 12:59 PM with Resident #2 revealed she was in her room sitting in her wheelchair to the left of her bed. There was a blue call light cord tied to the bed repositioning bar on the right side of the bed. Resident #2 said she could not reach her call light cord that was tied to the bed and if she needed something she would wait until staff went in to check on her to tell them what she needed. Resident #2 further stated she would like to have access to her call light at all times in case she needed to use it to call staff. Interview on 01/02/26 at 1:30 PM with CNA A revealed he had noticed that call light cords, that were tied to resident's bed, did not reach the resident if they were sitting in their wheelchairs. The CNA said he thought it was a problem if a resident could not reach the call light in case they needed something, but he had not yet told anyone to fix or untie the call light cords. Interview on 01/02/26 at 3:26 PM with the ADON revealed she was not aware Resident #1 did not have a call light or that Resident #2 could not reach hers. The ADON said the call lights needed to be within resident reach because that was their method of communication in case they needed anything. Interview on 01/02/26 at 4:18 PM with the Administrator revealed he was not aware Resident #1 did not have a call light cord or that Resident #2 did not have hers within reach. The Administrator said his expectation was that all residents had access to their call light in case there was an emergency or need something important. Review of the facility's policy titled Answering the Call Light dated September 2003 reflected the following: PurposeThe purpose of this procedure is to respond to the resident's request and needs.4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #87) reviewed for abuse. The facility failed to ensure Resident #87 had the right to be free from abuse when Resident #3 physically assaulted her on 03/03/25. The noncompliance was identified as PNC. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse. Findings include: Review of Resident #87's Face Sheet, dated 07/02/25, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE]. Review of Resident #87's Quarterly MDS Assessment, dated 05/29/25, reflected she had a BIMS score of 10, which indicated moderate cognitive impairment. Her active diagnoses included stroke (occurs when a blood vessel in the brain leaks or bursts and causes bleeding in the brain), hypertension (high blood pressure), and diabetes (a chronic, metabolic disease characterized by elevated levels of blood glucose). Review of Resident #87's Care Plan, dated 07/02/25, reflected nothing related to the incident that occurred on 03/03/25. Review of Resident #87's Nurses Notes reflected the following: -LVN I on 03/06/25 at 9:51 AM wrote the following for 03/03/25 Around 0708 , [sic] this nurse heard resident's loud voice coming from the dining room and reached immediately. The resident was standing next to the dining kitchen looking on the breakfast tickets and other resident was on the corner of the dining room in her wheelchair. No noise anymore. This nurse asked the resident, Is [sic] she okay and tried to comfort her. [sic] Resident stated, ‘she is not okay. [sic] Other resident had not let me to pick out my ticket and she slapped me on my right face . [sic] Now, i [sic] have a small scratch with burning sensation on it.' Head to Toe assessment was done. Pt. was alert and oriented x3. move [sic] all extremities freely. No bleeding on the face. Light redness on the right cheek. A small scratch close to upper lip. Cleaned the face and pat dried. Applied skin protectant ointment. Refused to take the pain medication. Vital 124/68 pulse 64. o2 [sic] sat 97% resp 18. This incident was witnessed by dietary department Staff [sic] member who was in the kitchen. Notified Abuse coordinator [sic] immediately. Left voice mail for [Resident #87's Family Member] to call back to the facility. Notified Doctor NP and DON. Neuro starts [sic]. Will continue to monitor. Resident ate in the dining room [ROOM NUMBER]% with meal. Around 9 am [sic] resident was walking in the hallway. No complain of pain. No redness and scratched [sic] mark on the right face noted. Calm. Around 10:25 am [sic], resident took her PRN Pain [sic] medication. No Redness [sic] on the right face. A&OX3. Calm. Resident has the order of UA [sic]. COMPLETE URINALYSIS- REFLEX TO URINE CULTURE One [sic] time only per NP. Resident is not ready for urine specimen this time. Notified on coming [sic] nurse to follow up with it. Review of Resident #87's Social Services Note reflected the following:-the Previous SW wrote the following on 03/03/25 at 10:17 AM: Patient was slapped on the cheek by another resident. SW did a wellness check on resident. Nurse gave patient topical for her cheek put patient [sic] declines oral pain pill at this time. She states that she does not know why the other resident slapped her but that she would like a referral to another facility.-the Previous SW wrote the following on 03/05/25 at 1:17 PM: SW assisted patient with making TULIP HHSC suspected elder abuse report.-the Previous SW wrote the following on 03/06/25 at 10:26 AM: SW followed up with patient again today. She states she has mouth pain from the incident but declines medication for the pain. She states she does not feel comfortable going into the main dining room where the incident occurred. SW offered to escort patient to eat in the alternative dining room or in her room. Patient declined. Observation and interview on 07/02/25 at 2:15 PM with Resident #87 revealed she did not have any visible marks to her cheeks or face. Resident #87 said she was slapped by another resident and had pain in her mouth because of what happened. Resident #87 said sometimes it still hurt her mouth now because of how hard she was hit. Resident #87 said it hurt her too much to think about what happened to her when she was slapped and that no one should ever hit seniors like that. Resident #87 said she wanted that person in jail, but she was not sure what happened after the police came to ask her questions because she did not receive a follow-up. Review of Resident #3's Face Sheet, dated 07/02/25, reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #3's Quarterly MDS Assessment, dated 04/04/25, reflected she had a BIMS score of 14, indicating no cognitive impairment. Her active diagnoses included cerebral palsy (a brain disorder that appears in infancy or early childhood that permanently affects body movement and muscle coordination), anxiety disorder (a group of mental disorders characterized by intense feelings of anxiety and fear), and depression (feelings of severe despondency and dejection). Review of Resident #3's Nurses Note reflected the following: -LVN I wrote the following on 03/03/25 at 1:39 PM: Around 0708 , [sic] this nurse heard resident's loud voice coming from the dining room and reached immediately. The resident was Sitting [sic] close to the one corner table in the dining room in her wheelchair and other resident was in front of the dining kitchen with meal tickets. When tried to talk to the resident, she quiet. [sic] No reaction. Notified Charge Nurse 500 hall to follow up with it. Notified Administrator immediately. Notified Family and NP. Notified DON.-LVN A wrote the following on 03/03/25 at 1:11 PM: 0700am: [sic] Resident alert and up in w/c for meals and ADL. 0745am: [sic] Noted resident had a confrontation with another resident in the dinning [sic] area and slapped the other resident per the other nurse report. Approached resident but she would not verbalize what happened but kept quiet. she [sic] was able to allow the writer to check her V/S after she ate her breakfast [sic] 106/66, 69, 18, 97.5%, 96%. Called the resident relative and Dr and they are aware of the incident. Review of Resident #3's Social Services Note reflected the following:-the Previous SW wrote the following on 03/03/25 at 5:40 PM SW interviewed patient after an incident in the dining room this morning where patient slapped another resident on the cheek. Patient states that they were both trying to help pass out meal tickets to the other residents and patient wanted to do the job all by herself. The other resident would not relinquish the meal tickets and patient slapped her on the cheek. Residents will not be allowed to handle other's meal tickets moving forward. Patient has received a psych eval. No changes to orders or medications requested by NP. SW will follow up again tomorrow.-the Previous SW wrote the following on 03/05/25 at 10:23 AM SW checked in on patient again. She states she does not know who she slapped and she does not want to speak to a professional about why the incident happened. Patient does not appear to be in distress of any kind. Review of Resident #3's Care Plan, dated 07/02/25, reflected the following: Care Area/Problem: Physically Aggressive.Related To: Resident can become aggressive when she gets frustrated.Altercation with another resident.Interventions: If resident becomes aggressive, staff to walk calmly away, approach resident later.Intervene before agitation escalates.Remove resident from immediate situation to assure safety. Attempted interview on 07/01/25 at 10:15 AM with Resident #3 was unsuccessful as she avoided answering or acknowledging the surveyor or the surveyor's questions. Observation on 07/01/25 at 12:00 PM of the dining room during a lunch meal service revealed Resident #3 was sitting at a table near the nurse's station with another resident. Resident #87 was sitting at a table across the dining room in the back corner with two other residents. All residents appeared to be calm and did not have any behaviors. Staff were passing out utensils and condiments to each resident. Interview on 07/02/25 on the phone with LVN I revealed the incident that happened between Residents #3 and #87 happened a long time ago in the dining room. LVN I said Resident #3 was in the dining room while she was passing medications to residents on the 600 hallway. LVN I said she saw Resident #87 standing next to the counter where the meal tickets were and Resident #3 was a little bit away from her at her own table where she usually sat every day. LVN I said there was a DA who told her what happened between Residents #3 and #87, which was that Resident #3 had slapped Resident #87. LVN I said she talked to both Residents #3 and #87, Resident #87 told her that Resident #3 slapped her and she had an impression from the slap on her cheek. LVN I said Resident #3 tried to go away from LVN I but did say she did not do anything and nothing was her fault. LVN I said both residents were separated away from each other to be assessed and now were kept a part from each other during meal times. LVN I said she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations. Attempted interview on the phone on 07/02/25 at 3:05 PM with the DA was unsuccessful as he did not answer or call back prior to exit. Interview on 07/03/25 at 2:23 PM with LVN E revealed she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations. Interview on 07/03/25 at 2:25 PM with LVN F revealed she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations. Interview on 07/03/25 at 2:27 PM with CNA G revealed she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations. Interview on 07/03/25 at 2:30 PM with CNA H revealed she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations. Interview on 07/03/25 at 3:22 PM with the DON revealed from what he understood of the incident, Resident #3 usually liked to pass out utensils or the condiment packages that came with a meal in the dining room. The DON said Resident #87 also liked to do those tasks and on this day (03/03/25), both of them wanted to do the same tasks. The DON said both residents were arguing back and forth when Resident #87 said Resident #3 tried to hit her, so the residents were separated. The DON said now, both residents have assigned seats in the dining room where Resident #3 is close to the nurse's station and Resident #87 is on the other side of the dining room near the back corner. The DON said Resident #3 did slap Resident #87 on her face because there was redness, and the DA saw it happen. The DON said he did not recall a previous situation involving Resident #3 being physically aggressive with anyone else before this one. The DON said Resident #3 has very manageable behaviors if she did exhibit any. The DON said Resident #3 had cerebral palsy and staff knew what calmed her down to redirect her if she did have behaviors. The DON said no residents were allowed to assist in passing condiments or utensils out in the dining room for meals so that nothing like this could happen again. The DON said all staff were in-serviced on abuse/neglect and resident-to-resident altercations after the incident occurred. The DON said the incident that happened between Residents #3 and #87 was considered abuse because if someone hits another person was considered physical abuse. The DON said all staff were responsible for making sure abuse did not occur between residents. The DON said all staff knew to immediately report any allegation or actual instance of abuse immediately to the abuse coordinator, who would be the Interim Administrator for now. The DON said staff were constantly monitoring residents to ensure they were free from abuse. The DON said all residents have the right to be free from abuse. The DON said if a resident was not free from abuse, they could suffer from depression, they might not want to be at the facility anymore, or it could affect their day-to-day activities . Interview on 07/03/25 at 5:58 PM with the Interim Administrator revealed she was not aware of any details regarding the incident between Residents #87 and #3. The Interim Administrator said she was currently the Abuse Coordinator for the facility. Review of a Provider Investigation Report reflected the following: Description of the Allegation: [Resident #3] and [Resident #87] became engaged in a verbal altercation over meal tickets when [Resident #3] allegedly slapped [Resident #87] in the face.Description of Assessment.[Resident #87] was Alert & Oriented x3.Light redness on the right cheek. Small scratch close to upper lip. Cleaned the face and pat dried.Provider Action Taken Post-Investigation: [Resident #3] and [Resident #87] to be monitored during meal service to ensure that they remain separated. Safe Surveys of LTC residents concluded. In-Services on Abuse & Neglect and Resident-to-Resident [sic] Altercations concluded. Review of a witness statement, dated 03/03/25, and signed by the DA reflected the following: I went to take Dining [sic] Stuff [sic] and the ticket [Resident #87] was looking for her ticket [sic] and [Resident #3] came didn't [sic] say excuse me or any thing to [Resident #87] so [Resident #3] was pulling [Resident #87] and then she slap [sic] her in face [sic]. Review of an in-service, dated 03/03/25, reflected 32 staff were trained regarding Abuse and Neglect and 31 staff were trained regarding Resident To Resident Altercations. Review of resident safe surveys revealed 4 residents were interviewed and no new concerns were brought up regrading abuse and neglect. Review of the facility's policy, reviewed 02/12/20, and titled Abuse, Neglect, and Exploitation and Misappropriation of Resident Property reflected: 2. Facility Duty to Protect Resident Rights. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.Physical abuse: Includes hitting, slapping, pinching, and kicking.

Based on observation, interview, and record review the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside and toilet and bathing facilities for 7 of 7 Halls checked for functional call light system (Halls 100, 200, 300, 400, 500, 600, and 700). The facility failed to ensure there was a working call light system available to residents to use after a weather-related storm occurred on 06/25/25 which caused the call light system to stop functioning. This failure placed residents at risk of not receiving timely care/assistance, falls, fall related injuries, head trauma, and hospitalization. Findings included: Interview and observation on 07/01/25 at 10:23 AM of Resident #57 revealed she was sitting in her wheelchair next to her bed and had a family member sitting in a chair in front of her. Resident #57 had a ringing bell on her bedside table that was in front of her. Resident #57's Family Member said that he was at the facility every day for hours and noticed a few days ago the resident was given a call bell to use since the call light system was out. Resident #57's Family Member said he was not sure what happened or why the call light system was out. Interview and observation on 07/01/25 at 10:48 AM with Resident #23 revealed she was lying in bed and had her bedside table near her with a call bell on it. Resident #23 said she call light system went out 4 days ago and she was given the call bell to use until it worked again. Interview and observation on 07/02/25 at 2:15 PM with Resident #87 revealed she was sitting on the side of her bed and had a ringing bell tied to a string connected to her bed. Resident #87 said she heard the call light system was out, so she was told to use the bell that was given to her. Resident #87 said the call light system went out a few days ago because of the storm. In a confidential group interview on 07/01/25 at 2:33 PM with 5 total residents revealed the call light system at the facility had not worked for the past 4 days. The residents were told that a blast of thunder during a storm the other night had knocked out the system. The residents said they were told the parts to fix the system were not available right now, so they were all given bells to use to get staff's assistance or attention instead. The residents said the staff were taking a long time to come to help them because it was hard for them to hear where the ringing bell was coming from. One resident explained that she had to go to the doorway of her room, almost out in the hall, to ring her bell so that staff would come to see what she needed help with. Interview on 07/02/25 at 10:41 AM with LVN A revealed a thunderstorm one day last week caused the electricity to go out at the facility and that caused the call light system to stop functioning. LVN A said staff handed out call bells for residents to use in the meantime. LVN A said he was also in-serviced to round on residents every 30 minutes as well. Interview on 07/02/25 at 10:50 AM with ADON B revealed she was on vacation last week but heard that the facility suffered through bad weather which caused the call light system to stop working. ADON B said when she came to work on Tuesday (07/01/25), all the residents had call bells and staff were told to check on their residents every 15-30 minutes. Interview on 07/03/25 at 9:54 AM with the HK Supervisor revealed he received a call from one of the staff on Wednesday night last week (06/25/25) saying the call lights were out on one of the halls. The HK Supervisor said he came to the facility to see which ones were being affected and not working. The HK Supervisor said he found a few rooms on the 300-hall that were not working, and those residents were moved to different rooms in the facility to where the call lights were working. The HK Supervisor said the next day (06/26/25) he came to work at the facility and found that something else happened to the motherboard of the call light system because he found more rooms that were affected all over the building. The HK Supervisor said the facility called their vendor to come and check on the system and were told that it would take two weeks to fix because the part had to be ordered. The HK Supervisor said when the facility was told about that, he said the facility ordered enough call bells for every resident to have one and they were passed out to each resident. The HK Supervisor said each resident received a call bell by Thursday evening (06/26/25). The HK Supervisor said staff were in-serviced to round on residents every 30 minutes because the call light system was not working through the whole facility. Attempted interview on the phone on 07/03/25 at 10:04 AM with the Maintenance Director revealed he did not answer and did not call back prior to exit. Interview on 07/03/25 at 2:19 PM with RN D revealed she was working Wednesday night (06/25/25) when the storm came through the area. RN D said the lights went out and the staff noticed resident call lights were not working all over the building, so they reported it to the maintenance department. RN D said the facility staff began rounding on residents more frequently and checking on them every 15-30 minutes. RN D said the next day, all residents were given call bells to use but the frequent rounds continued. Interview on 07/03/25 at 2:23 PM with LVN E revealed she came on Thursday (06/26/25) and noticed that the call lights in the facility were not working. LVN E said all residents were given hand call bells to use and she was told to round on residents every 15-30 minutes. Interview on 07/03/25 at 2:25 PM with LVN F revealed she knew the call light system in the facility was not working so residents were given call bells to use when they needed something. LVN F said she was also told to round on residents every 15-30 minutes. Interview on 07/03/25 at 2:27 PM with CNA G revealed she was here on Thursday (06/26/25) and was told the call lights at the facility were not working. CNA G said all residents had call bells to use in their rooms when they needed something they would ring it, and staff were rounding on residents every 15-30 minutes. Interview on 07/03/25 at 2:30 PM with CNA H revealed she was working on Wednesday (06/25/25) when lightning struck somewhere close to the facility because it caused the lights to go out around 4:00 PM. CNA H said they heard a loud noise and then all of a sudden the call lights were not working in the facility. CNA H said she and other staff checked on all the residents and noticed that only some of the call lights were working and others were not working. CNA H said then all the call lights in the facility were not working at all. CNA H said residents were given call bells to use and she was told to check on residents frequently, at least every 15-30 minutes. Interview on 07/03/25 at 3:34 PM with the DON revealed the facility's call light system went out on the evening of 06/25/25. The DON said staff told him that they heard a thunderclap and then the lights went out and the call lights stopped working. The DON said staff notified the Maintenance Director and called a vendor to come check the system. The DON said when they realized the call light system was not going to be an easy fix, they provided all residents hand bells to use for call lights. The DON said for the residents who do not have the physical or cognitive ability to use a call bell, staff were told to check on them more frequently, at least every 15-30 minutes. The DON said all residents received a call bell by Thursday (06/26/25) when they realized none of the call lights were working in the facility. The DON said initially, only a few call lights went out on the 300 hallway, so those residents were moved to a different part of the building where they were working at the time. The DON said when the facility verified the call lights for the whole building were out, they began to work on how to fix the issue with the vendor. The DON said the facility was waiting for the parts to come in to fix the call light system, but he was not sure when that would occur. Interview on 07/03/25 at 5:58 PM with the Interim Administrator revealed the call light system stopped working on Wednesday (06/25/25) of last week where there was an interruption in service from a storm occurring that day. The Interim Administrator said originally, she thought the issue was only with a few rooms on the 300 hallway but as time progressed, the motherboard of the call light system continued to spark, and fuses went off. The Interim Administrator said this titration caused a ripple affect to the rest of the building. The Interim Administrator said the next day, Thursday (06/26/25), the staff noticed the call light issue was more widespread, and the facility contacted a vendor to come out and test the system. The Interim Administrator said the facility also ordered a huge amount of call bells and passed them out to the residents. The Interim Administrator said the facility staff were also told to round more frequently on residents, at least every 15-30 minutes. The Interim Administrator said the parts were ordered to fix the call light system, but it would be another 2 weeks before they would be delivered. Interview on 07/03/25 at 6:30 PM with the Administrator revealed the facility did not have a policy addressing call lights.

Based on interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, to include adequate monitoring for four (Residents #1, #33, #45 and #55) of six residents reviewed for unnecessary medications. 1.The facility failed to monitor worsening of depression and behaviors for Resident #1's for the use of Sertraline 50mgs and ramelteon 8 mg tablet (antidepressants medication). 2. The facility did not monitor Resident #33 for side effects of the antidepressant medication, Mirtazapine; the antipsychotic medication, Quetiapine; the antianxiety medication, Trazodone; and the antidepressant medication, Duloxetine. 3.The facility failed to monitor behaviors for Resident 45's for the use of Alprazolam Tablet 0.25 MG for (anti-anxiety), fluoxetine 40mg and Ramelteon 8 mg tablet (antidepressant medications).4.The facility failed to monitor behaviors for Resident #55's for the use of bupropion, mirtazapine (antidepressant medication) and quetiapine (an antipsychotic medication. These failures could place residents at risk of increased behaviors, negative outcomes, and a decline in health. Findings included:1.Record review of Resident #1's quarterly MDS Assessment, dated 03/18/25, reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included depression. The resident BIMS score was 13 indicating his cognition was intact. Section N high risk drug classes indicated he was on an antidepressant.Review of Resident #1's care plan, dated 03/04/25, reflected the following: Focus: Resident #1 on antidepressant evidenced by Sertraline 50mg 1 tablet by mouth per day . Goal: The Resident will be free of any discomfort or adverse side effects. Interventions: Administer medications as ordered. Monitor closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in dosage. Monitor for Interaction/Adverse side effects: Dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite.Record review of Resident #1's Physician's Orders dated 5/14/2025 with a start date of 06/20/25 revealed the following:Sertraline Tablet 50 MG give one tablet by mouth two times a day and Ramelteon 8 mg 1 tablet at bedtime related to depression disorder. The orders did not include any orders to monitor for side-effects related to the use of the Sertraline 50mgs and Ramelteon 8 mg tablet.Record review of Resident #1's June 26, 2025, to July 3, 2025, MAR/TAR revealed he had been receiving the Sertraline 50mgs and Ramelteon 8 mg tablet as ordered each day. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of the SertralineReview of Resident #33's Face Sheet, dated 07/03/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE].Review of Resident #33's Quarterly MDS Assessment, dated 04/08/25, reflected she had a BIMS score of 11 indicating moderate cognitive impairment. Her active diagnoses included non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform daily tasks), anxiety disorder (a group of mental disorders characterized by intense feelings of anxiety and fear), and bipolar disorder (a mental health condition characterized by extreme mood swings that include emotional highs and lows). At the time of the MDS Assessment, Resident #33 received antipsychotic and antidepressant medications. Review of Resident #33's physician orders reflected the following: -Mirtazapine, 15 MG tablet, 1 tab at bedtime-Quetiapine Fumarate, 50 MG tab, 1 tab every 12 hours-Trazodone, 50 MG Tablet, .5 tablet at bedtime for Insomnia-Duloxetine HCL DR, 20 MG Cap, 1 Cap twice a day Review of Resident #33's Care Plan, dated 07/03/25, reflected the following: Care Area/Problem: Antidepressant.Related To: [Resident #33] has a DX of Bipolar.Evidence By: duloxetine as ordered, trazodone as ordered, mirtazapine.Interventions: Anti-Depressant SE: Dry Mouth Blurred Vision Constipation Urinary Retention of Hypotension Appetite Changes Headache Insomnia Weight Changes.Monitor closely.Care Area/Problem: Psychotropic Drug Use.Related To: [Resident #33] has a diagnosis of Bipolar and Psychotic disorder.Evidence By: quetiapine as ordered.Interventions: Observe for possible side effects every shift.Interview on 07/02/25 at 3:41 PM with LVN C revealed she cared for Resident #33 and knew she received anti-depressant, anti-anxiety, and anti-psychotic medications. LVN C said normally with any of those medications, a resident would also be monitored for any side effects related to them. LVN C said the monitoring orders should have been included in Resident #33's orders but she did not see any and did not recall completing the documentation of monitoring it in the resident's chart. LVN C said she was not sure why there were not any monitoring orders included in the resident's chart. LVN C said she had not noticed the orders missing because they were using a new electronic health charting database, and she was not very familiar with it. Interview on 07/03/25 at 3:34 PM with the DON revealed the facility had recently transitioned to using a new electronic health database system on 06/26/25. The DON said staff had been transferring all the orders from one database to the new one slowly. The DON said Resident #33 should have had orders for monitoring the side effects of her anti-depressants, anti-anxiety, and anti-psychotic medications. The DON said he reviewed Resident #33's orders and they did not include the orders for staff to monitor her for side effects of the medications. The DON said it seemed that not all of Resident #33's orders transferred from the old database to the new database. The DON said everyone was responsible for making sure monitoring orders for medications were included. The DON said if a medication was given but the side effects were not monitored, that could mean the resident was getting too strong of a dose if they had adverse effects.3.Record review of Resident #45's quarterly MDS Assessment, dated 05/06/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #45 had diagnoses which included depression and anxiety. The resident BIMS score was 15 indicating her cognition was intact. Section N0415 high risk drug classes indicated she was on antidepressant and antianxiety.Review of Resident #45's care plan, dated 11/01/24, reflected the following: Focus: Resident #45 on antidepressant evidenced Prozac 40 mg capsule (fluoxetine hydrochloride) 1 capsule by mouth 1 time per day and anti-anxiety evidenced by alprazolam 0.25 mg tablet (alprazolam) 1 tablet by mouth 2 times per day. Goal: The Resident will be free of any discomfort or adverse side effects. Interventions: Administer medications as ordered. Monitor closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in dosage. Monitor for Interaction/Adverse side effects: Dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, or increased appetite. Anti-anxiety: -Monitor behaviors every shift. Observe side effects of medication nausea, vomiting, dizziness, ataxia and somnolence (a state of drowsiness, sleepiness, or excessive sleepiness)/lethargyRecord review of Resident #45 Physician's Orders dated 6/16/2025 with a start date of 06/19/25 revealed the following:Alprazolam Tablet 0.25 MG give one tablet by mouth two times a day for anxiety, fluoxetine 40mg 1 capsule daily and ramelteon 8 mg 1 tablet at bedtime related to depression disorder. The orders did not include any orders to monitor for side-effects related to the use of the Alprazolam Tablet 0.25 MG, fluoxetine 40mg and Ramelteon 8 mg tablet.Record review of Resident #45's June 26, 2025 to July 3, 2025 MAR/TAR revealed she had been receiving Alprazolam Tablet 0.25 MG, fluoxetine 40mg 1 capsule and Ramelteon 8 mg tablet as ordered each day. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of Alprazolam Tablet 0.25 MG, fluoxetine 40mg and Ramelteon 8 mg tablet.4. Record review of Resident #55's quarterly MDS Assessment, dated 03/26/25, reflected the Resident #55 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #55 had an active diagnosis of depression disorder (a common mental health condition characterized by persistent sadness and a loss of interest or pleasure in activities), anxiety disorder (a natural human emotion characterized by feelings of worry, nervousness, or unease, typically about an event with an uncertain outcome), schizophrenia (a chronic mental health disorder that affects how a person thinks, feels, and behaves) and the resident had severe cognitive impairment with a BIMS score of 03.Record review of Resident #55's Care plan dated 10/01/24 reflected Focus: Resident on psychotropic drug evidenced by Seroquel 100 mg tablet (quetiapine fumarate) 1 tablet by mouth daily at bedtime and quetiapine 50 mg tablet (quetiapine fumarate) 1 tablet by mouth every morning. Goal: Resident will be free of any discomfort or adverse side effects within the next 90 days. Interventions/Task: Monitor behavior every shift and document. Observe for possible side effects every shift: muscle rigidity, bladder retention, orthostatic hypotension, sedation, dry mouth, balance problem, unsteady gait, restlessness, tremors, Parkinsonism, akinesia (the loss of spontaneous, voluntary muscle movement), dystonia (involves sustained muscle contractions causing twisting and repetitive movements or abnormal postures), akathisia (a subjective feeling of restlessness, often described as an urge to move, with observable restlessness like pacing or fidgeting), tardive dyskinesia (a neurological movement disorder characterized by involuntary, repetitive, and sometimes uncontrollable movements, most commonly affecting the face, mouth, tongue, and limbs), and high fever.Focus: resident on antidepressant , evidence by: bupropion hcl 150 mg tablet,12 hr. sustained release (bupropion hcl) 1 tablet by mouth every morning, mirtazapine 7.5 mg tablet (mirtazapine) 1 tablet by mouth daily at bedtime. Goal: Resident will be free of any discomfort or adverse side effects. Interventions Administer medication as ordered. Monitor closely for worsening of depression and/or suicidal behavior or thinking, especially during initiation of therapy and during any change in dosage. Record review of Resident #55's Physician's Orders dated 6/12/2025 with a start date of 06/19/25 revealed the following:Mirtazapine 7.5mg give one tablet by mouth at bedtime, bupropion 150mgs 1 tablet daily related to depression disorder and quetiapine 50mgs 1 tablet in the morning and quetiapine fumarate 100mg 1 tablet at bedtime (antipsychotic medication). The orders did not include any orders to monitor for side-effects related to the use of the bupropion, mirtazapine (antidepressant medication) and quetiapine (an antipsychotic medication).Record review of Resident #55's June 26, 2025 to July 3, 2025 MAR/TAR revealed she had been given bupropion 150mg , mirtazapine 7.5mg (antidepressant medication) and quetiapine 50mgs in the morning and 100mgs bedtime (antipsychotic medication) as ordered each day. The MAR/TAR did not include documented evidence the facility was monitoring for side-effects related to the use of bupropion 150mg, mirtazapine 7.5mg and quetiapine 50mgs in the morning and 100mgs bedtime.Interview on 07/03/25 at 01:06 PM with LVN A revealed nurses were responsible for documenting behaviors and side effects for residents who took antipsychotic or antidepressant medications. LVN A stated they documented on the MAR and TAR. LVN A and the surveyor reviewed the MAR /TAR and LVN A stated they had not started documenting since the system was changed. LVN A stated he had noticed the monitoring tab did not transfer to the new system and they have not been documenting Resident #1, #45 and #55 behaviors, side effects. LVN A stated the risk of not monitoring behaviors could cause residents to consume unnecessary medication. LVN A stated it was important to document because it helped them know if the resident had an episode of behavior. Interview on 07/03/25 at 12:31 PM with the DON revealed it was the nurses' responsibility to document behaviors and side effects. The DON stated he was not aware that orders and monitoring tab did not transfer to the new system as from 6/26/25 to 07/03/35 and nurses had not reported to him. He stated it was his responsibility with the help from other staffs in management to go through the old system and new system and ensure all orders got transferred. DON stated this failure could cause residents to have side effects from the medications they were taking.Interview on 07/03/25 at 03:24PM with the ADON B revealed it was the nurses' responsibility to document behaviors and side effects. She stated on the old system they had a monitoring tab that popped every shift. She said on the new system she could not see the tab. She said she just reported from vacation, and everything looks new to her she was adjusting to the new system, and she had not noticed there was not tab to document the monitoring of behaviors and side effects. She stated failure to document resident monitoring may lead to side effect sand they will not be able to know whether the resident is benefiting from therapy or not.Review of the facility's policy, dated 01/25, and titled Medication Monitoring reflected: Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This included any drug.without adequate monitoring.

Based on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for one of one pureed meal observed for nutrition. The Dietary Aide failed to ensure the pureed lunch meal on 07/02/25 was prepared according to the recipe to conserve nutritive value and flavor. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake, and unwanted weight loss.Findings included: Observation on 07/02/25 at 10:02 AM of the Dietary Aide preparing the pureed lunch revealed she put breaded chicken fried steak patties into a blender. She then blended the mixture, adding 4 scoops of white gravy. The Dietary Aide then added the mixture to molds. Record review of the recipe titled Pureed Chicken Fried Steak reflected:Ingredients: Beef Chicken Fried Steak, Water, Beef BaseCombine beef base with water to make beef broth. Place prepared fried steaks in a clean and sanitized food processor. Gradually add broth as needed and blend until smooth. *Note: Any liquid specified in the recipe is a suggested amount of liquid (if needed). Some recipe items will require no liquid added to achieve the desired consistency. 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. 2. If the product needs thickening, gradually add a commercial or natural food thickener (ex, potato flakes or baby rice cereal) to achieve a smooth, pudding or soft mashed potato consistency. 3. Follow any facility policies/procedures, such as the puree volume method procedure, to ensure a correct portion is served. Top pureed foods with appropriate sauces or gravies, as needed, to ensure adequate moisture for safe consumption and enhanced flavor. Interview on 07/02/25 at 10:20 AM with the Dietary Aide revealed she was notified by the Dietary Manager that she would prepare the puree with surveyor. The Dietary Aide stated she was instructed to use the gravy with the chicken fried steak to prepare the entre. The Dietary Aide revealed the menu for pureed chicken fried steak called for water and beef base, and that she should have followed the recipe instead of using the gravy. According to The Dietary Aide, not following the recipe would place residents with puree diets at risk of not eating their meal due to the flavor or taste. Observation and interview with Dietary Manger on 07/02/25 at 12:57 PM of lunch trays, both pureed and regular texture, revealed chicken fried steak, mashed potatoes, and spinach and apple crisp and roll. Upon tasting the pureed meal, The Dietary Manager stated the spinach was without any flavor, just tasted like spinach. The Dietary Manager further revealed the pureed chicken fried steak was not smooth, that it contained grizzled parts. When asked about the recipe, The Dietary Manager stated she expected the aide to have followed the recipe and used the beef broth. The Dietary Manger stated the gravy was to add on top prior to serving. The Dietary Manager stated she was responsible for ensuring the staff followed the recipe and ensuring the pureed meal was smooth in texture, not doing so placed residents on pureed diets at risk of choking and refusing to eat when the meal did not have any taste or flavor. Record review of the facility's policy titled Nutrition Services revised 02/06/24 reflected:Recipes will be used when preparing menu items. 1. Recipes (in appropriate portion sizes) for each menu cycle are available and maintained in the facility. 2. Recipes will be printed to scale according to information derived from resident tray tickets and current census. 3. Nutrition Services employees are expected to use and follow the recipes provided.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely for 2 (Resident #314 and Resident #324) of 18 residents observed for medication storage. 1. Resident #314 had a tube of Estradiol cream at her bedside table not locked in a lock box or secured in the medication cart or medication room. 2. Resident #324 had Clotrimazole vaginal antifungal cream on her bedside table not locked in a lock box or secured in the mediation cart or mediation room. This failure could place residents at risk of overmedication or adverse drug reactions.Findings included: 1. Record review of Resident #314's Face Sheet, dated 07/03/25, revealed the resident was a [AGE] year-old female who was admitted on [DATE]. Review of Resident #314's MDS dated [DATE] revealed the resident's cognition was moderately impaired with a BIMS score of 12. Resident #314 had diagnoses that included Stroke, hyperlipidemia (cholesterol and fats in blood), hypertension (high blood pressure), and diabetes mellitus (high blood sugar). Resident #314 required partial/moderate assistance with toileting and occasionally had urinary incontinence. Review of Resident #314's care plan, dated 07/03/25, revealed the resident had use of Antidepressant evidenced by escitalopram 20 mg tablet (Escitalopram Oxalate) 1 tablet by mouth 1 time per day, trazadone 50 mg tablet (Trazodone HCL) 0.5 tablet by mouth at bedtime 14 days as needed for Insomnia. Goal: resident will be free of any discomfort or adverse side effects. Interventions included administer medication as ordered. Monitor closely for worsening of depression and or suicidal behavior or thinking. Monitor dosage, duration, and interaction/adverse side effects. Monitor for risk of falls and report lab results. No mention of Estradiol cream use. Record review of Resident #314's Medication Administration report dated July 2025 revealed physician's order for Estradiol 0.1 MG/1 GM Cream (Estradiol) 1 gram One time daily [Frequency: Weekly on Wednesday, Saturday Time: 08:00 PM] for Hormone treatment Vaginal Use Only. Started 06/17/25-07/02/25 and restarted 07/02/25.0 Observation on interview on 07/01/25 at 10:23 AM revealed Resident #314 with a boxed prescription of cream, used syringe, and used gloves with white cream on the gloves on the nightstand table. According to Resident #314, an unknown staff member (she thought it was a nurse) brought the prescription in the room for her to use. Resident #314 stated she has had it for a couple of days in her room in the drawer, and she administered it herself this morning (07/01/25). Interview on 07/02/25 at 2:21 PM with LVN P stated she worked on 07/01/25 on a 6:00 AM - 2:00 PM shift with Resident #314. LVN P stated she did not think she saw the medication on the table however seen it this morning (07/02/25) and asked Resident #314 where she got the medication and Resident #314 replied my family member brought it to me. LVN P stated Resident #314 had not had any complaints of irritation or change in her condition. LVN P stated she had medication on her cart to administer the mediation for Resident #314, she was surprised to see the medication on the bedside table. LVN P stated residents were not allowed to store medications in their rooms, when staff observed the medications, they should remove it immediately and report it. Allowing medications to be stored in resident rooms placed residents at risk of overuse, overdose which can affect their care. LVN P stated nurses are ultimately responsible to ensure all medications are stored properly. 2. Record review of Resident #324's face Sheet, dated 07/03/24, revealed the resident was a [AGE] year-old female who was admitted on [DATE]. Review of Resident #324's MDS dated [DATE] revealed the resident's cognition was intact with a BIMS score of 15. Resident #324 required assistance with activities of daily living care. MDS indicated Resident #324 was not able to self-administer mediations. Resident #324 had diagnoses that included: Pneumonia (infection in the lungs), high blood sugar, and high blood pressure. Record review of Resident #324's order summary report dated 07/03/25 revealed she did not have an order for Clotrimazole vaginal antifungal cream. Interview on 07/01/25 at 12:25 PM with Resident #324 revealed resident in bed with tube of Clotrimazole vaginal antifungal cream at her bedside table. Resident #324 stated she did not know of the cream at the bedside table, and had a headache and did not want to speak with surveyor at this time. Interview on 07/02/25 at 3:26 PM with LVN O revealed she had worked 6:00 AM -2:00 PM shift on 07/01/25 however, she had not received any reports of Resident #324 itching or skin irritation; she further stated it could be possible that family had brought the medication. LVN O stated she had been in the room with Resident #324 but had not noticed the medication, and CNAs had not reported it in the room. LVN O stated if there were any medications found in residents' rooms, all staff were required to remove the mediation and report it. LVN O stated when residents have medications in their possession it placed them at risk of misuse of medications. Interview on 07/02/25 at 3:51 PM with RN D revealed she worked with both residents on 2-10 shift on 07/01/25. RN D stated all staff were responsible for removing medications seen in residents' rooms. RN D stated allowing residents to administer and store medications in their rooms placed them at risk of overuse. RN D stated Resident #314 or Resident #324 had not complained of irritation or concerns with peri care. RN D stated she made rounds on her shift and did not see any medications at residents' bedside tables. Interview with the DON on 07/03/25 at 3:11 PM revealed medication should not be left or stored in residents' rooms. The DON stated sometimes family members will bring medications, for example Resident #314, it was reported that her family member brought the medication for Resident #314 to use. The DON stated he was unsure about Resident #324 having the medication because there was no order for the use. The DON stated all staff were responsible to remove medications as they see them, report and document the findings. Residents having medications in their rooms placed them at risk of negative interactions with other medications. Review of the facility's current, undated Storage of Medications policy reflected: Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on observations, interviews, and record review, the facility failed to accommodate the needs and preferences for one (Resident #23) of five residents reviewed for accommodation of needs, in that: The facility failed to provide a working communication system, that was easily within reach, that would allow Resident #23 the ability to safely call staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they needed support for daily living. The findings included: Review of Resident #23's Record of Admission, dated 07/02/25, reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #23's Quarterly MDS Assessment, dated 05/16/25, reflected she had a BIMS score of 12, indicating moderate cognitive impairment. Her active diagnoses included heart failure (occurs when the heart muscle did not pump blood as well as it should), diabetes mellitus (a disorder characterized by high blood sugar levels due to the body's inability to produce or respond effectively to insulin), and quadriplegia (characterized by paralysis of all four limbs and the torso). Resident #23's functional abilities revealed she was dependent which meant the helper did all the effort for the resident in regard to dressing, eating, and personal hygiene. Review of Resident #23's care plan, dated 07/02/25, reflected the following: Care Area/Problem: *Fall Risk.Interventions: Keep call light and most frequently used personal items within reach.Care Area/Problem: *At risk for problems with Elimination.Interventions: Keep call light within reach, and remind resident to call for assistance . Observation and interview on 07/01/25 at 10:48 AM with Resident #23 revealed she was laying in her bed and had her bedside table in front of her which had a silver call bell in front of her. Resident #23 was noted to have contractures to both of her hands and had minimal use of her arms. Resident #23 said the call light system at the facility had been out for 4 days now and she was given a call bell to use but she could not use the one that was given to her. Resident #23 said due to her contractures and the way her arms could not raise high enough to use the bell she had no way to call out for help. Resident #23 said her only option was to yell out, but it was unreliable if that would work because she was not sure if staff would be able to hear her yelling. Resident #23 said she normally used a push pad when the call light system for the facility was working. Interview on 07/02/25 at 10:41 AM with LVN A revealed there was a thunderstorm a few days ago which caused the electricity to go out and due to that the call light system failed. LVN A said staff brought out bells to give to residents and began rounding on them every 30 minutes. LVN A said staff had been in-serviced to listen for any bells ringing. LVN A said Resident #23 was an exceptional case because of her contractures, she normally used a push pad call light that was flat and stayed on her chest that she could easily use. LVN A said she was given a dinging bell that was on her bedside table while the call light system was out. LVN A said he knew Resident #23 could not reach or use the one she was provided temporarily while the call light system was out. LVN A said instead, he was checking on Resident #23 every 30 minutes. LVN A did not provide an answer when asked what could happen to Resident #23 in between the every 30 minute checks. LVN A said he was not sure why Resident #23 was given a temporary call bell that she could not use. Interview on 07/02/25 at 10:50 AM with ADON B revealed she was on vacation last week and was not sure what happened to the call light system, but heard that it went out due to bad weather. ADON B said she noticed staff had put out temporary call bells for residents to use. ADON B said if a resident could not use the temporary call bell given to them, they were checked on by staff every 15 to 30 minutes. ADON B said she was not sure about any other temporary call bells offered to Resident #23, but she should have been given one that she could use. Interview on 07/03/25 at 3:34 PM with the DON revealed the facility's call light system went out on 06/25/25 in the evening time. The DON said a thunderclap was heard and then the system stopped working. The DON said Resident #23 was given a bell originally that she could not use, so staff were checking on her frequently. The DON said as of today (07/03/25), Resident #23 was given a different call bell that was modified so that she could use it with ease. The DON said Resident #23 required a call bell that was flat so she could use it, and the facility did not have one at the time the call light system stopped working. The DON said he knew Resident #23 could not press or lift her arm high enough to press the original call bell that she was given. The DON said all residents should have a call device that they could use if they were cognitively able to use one. The DON said Resident #23 was alert and oriented and knew how and when to use a call light or bell. Interview on 07/03/25 at 6:30 PM with the Administrator revealed the facility did not have a policy addressing call lights.

Based on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for one resident (Resident #113) of five residents reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #113. This failure could place residents at risk of not having complete records after permanent discharge from the facility and disruption in the continuity of care. Findings included: Review of Resident #113's Face Sheet, dated 07/02/25, reflected she was a [AGE] year-old female who was originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on 04/08/25. Her diagnoses included bipolar disorder (a mental health condition characterized by extreme mood swings that include emotional highs and lows), schizophrenia (a chronic mental health condition that affects how individuals think, fell, and behave), and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). Review of Resident #113's Nurses Notes reflected the following: - On 04/08/25 at 3:40 PM, RN C wrote: Resident leaving AMA , [sic] V/S normal, alert and oriented*4 [sic], All [sic] medication and belonging [sic] given to resident, resident left facility with uber driver. Review of Resident #113's electronic health record revealed there was not an MDS assessment completed for her. Review of Resident #113's undated Interdisciplinary Discharge Summary reflected it was not completed. The following areas of the form were not filled out or completely filled out: Recapitulation of Resident's Stay, Physician Signature, Social Services Summary of Stay, Activity Summary During Stay, and Therapy Services Summary of Stay. Interview on 07/03/25 at 10:20 AM with the SW revealed he had only been at the facility for two weeks. The SW said he had completed a few discharge summaries for residents and completed his portion of the form for those. The SW said the other departments fill out the rest of the portions for their respective disciplines. The SW said he was only responsible for filling out his portion of the form. Interview on 07/03/25 at 10:35 AM with Medical Records revealed she was responsible for making sure that the discharge summary was completed by each department on the form. Medical Records said normally she checked the discharge summary and if she saw it was not completed by certain departments, she would let them know to make sure to fill it out. Medical Records said she was not sure why the other departments had not filled out Resident #113's discharge summary and she at the time did not catch that it was not completed. Medical Records said normally she checked each discharge summary for completion after a resident discharged . Interview on 07/03/25 at 3:29 PM with the DON revealed Resident #113's discharge summary should have been completed by each department listed on the form. The DON said the discharge summary for a discharged resident should have been completed as soon as possible but he was not sure of a more specific timeline. The DON said each department would have been responsible for their respective section and Medical Records checked the form to ensure that the entire form was completed. The DON said the purpose of a discharge summary form was to give information on what care the resident received at the facility. The DON said if the form was not completed the resident might miss something that should have been follow-up on after they left. The DON said all staff had been trained to fill out their own sections on the discharge summary forms. A discharge summary policy was requested but not provided prior to exit.

Based on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #55) reviewed for PASRR assessments.The facility did not refer Resident #55 to the appropriate state-designated mental health authority for review when she received a new diagnosis of schizophrenia on 10/17/24.This failure could place residents at risk of not being evaluated and receive needed PASRR services.Record review of Resident #55's quarterly MDS Assessment, dated 03/26/25, reflected the Resident #55 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #55 had an active diagnosis of depression disorder (a common mental health condition characterized by persistent sadness and a loss of interest or pleasure in activities), anxiety disorder (a natural human emotion characterized by feelings of worry, nervousness, or unease, typically about an event with an uncertain outcome), schizophrenia (a chronic mental health disorder that affects how a person thinks, feels, and behaves) and the resident had severe cognitive impairment with a BIMS score of 03.Record review of Resident #55's PASRR Level 1 Screening, dated 07/10/24, reflected she did not have a mental illness. PASRR Level 1 screening did not indicate Resident #55 had primary diagnosis of dementia.Interview on 07/03/25 at 04:04PM, the DON stated if a new diagnosis was given to a resident a new PASRR evaluation should have been completed. DON stated when Resident #55 was diagnosed with a new diagnosis on 10/17/24, the MDS nurse was on transition to another facility and was supposed to follow up, but she did not, and she did not let him or the regional MDS nurse know. He stated the MDS nurses were monitored by the Regional Corporate Nurse, and she should be asked about any questions regarding Resident #55's PASRR.Interview on 07/03/25 at 04:42 PM, Regional MDS nurse stated Resident #55 had a negative PASRR Level 1. She stated Resident #55 was negative and she does not understand how the doctor came schizophrenia diagnosis. The Regional MDS Nurse said she reviewed Resident #55's medical chart after she was notified on 07/02/25 by DON and found out Resident #55 had a diagnosis of schizophrenia which she was diagnosed on [DATE] and no new PASRR I screening was done. She stated she was not aware screening was not done, and she will be notifying the authorities. She stated failure to perform screening and involving the authorities, Resident #55 failed to get required assessments and could lead to her not receiving services that could have benefited her. Record review and interview with the Administrator regarding the facility's PASRR policy on 07/03/25 at 05:30PM, she stated the facility had no policy, but they used the State guidelines.

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #33) of 19 residents reviewed for care plans. The facility failed to develop a care plan to address Resident #33's self-transfer to the toilet and stay there for long periods of time, sometimes falling asleep, multiple times a day. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs. Findings included: Review of Resident #33's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] and discharged [DATE]. [VT1] Her diagnoses included anxiety disorder, apraxia (a neurological disorder that affects a person's ability to perform learned purposeful movements even though they have the desire and physical ability to do so), dysphagia (difficulty swallowing foods or liquids), and aphasia (a language disorder that affects the ability to communicate) all following a stroke. The MDS further reflected she has long and short -term memory impairment and required supervision or touching assistance for transfers. Review of Resident #33's care plan dated 05/02/24 reflected the resident had impaired physical mobility. Interventions included to provide the appropriate level of assistance to promote safety of resident. The care plan did not reflect the resident's self-transfer to the toilet without staff assistance and staying on the toilet for long periods of time. Interview on 07/03/25 at 9:43 AM with Resident #33's Family revealed Resident #33 had stroke but was still able to self-transfer to the toilet if she positioned herself just right. Through out the years the resident had a decline and was weaker and the Family did not want her transferring herself anymore. The Family said Resident #33 was transferring herself to the bathroom and would fall asleep on the toilet and she had expressed her concerns to ADON B and the DON during care plan meeting, but they had told the Family the staff had to let the resident have as much independence as she could. Interview on 07/03/25 at 10:17 AM with LVN J revealed Resident #33 had been a resident at the facility for a long time and she appeared to have declined within the last year, but the resident was still able to transfer to the toilet from her wheelchair. The resident was encouraged to call for assistance but Resident #33 preferred to do it on her own and at times would want to sit on the toilet for long periods of time, even thought she was not using the bathroom. All the staff were instructed to check on Resident #33 more frequently to try to prevent any falls or to redirect the resident if she would fall asleep on the toilet. LVN J further stated staff were also directed to try and keep the resident in the common areas but Resident #33 would self-propel her wheelchair back to her room. Interview on 07/03/25 at 10:45 AM with CNA K revealed Resident #33 was almost independent with most ADLs and if staff tried to help, the resident would become upset. Resident #33 would transfer herself to toilet and at times during their rounds, staff would find the resident asleep on the toilet and would have to assist her back into her chair or to bed. CNA K said Resident #33 liked to sit on the toilet for long periods of time and would become upset if they tried to assist her back into her wheelchair during their rounds of the resident. CNA K further stated Resident #33 was encouraged to ask for assistance and they tried to keep her in common areas and all staff would make frequent rounds on the resident. Interview on 07/03/25 at 11:39 AM with CNA L revealed Resident #33 was independent and preferred to do most of her ADLs on her own. She said the resident was able to take herself to the bathroom and transfer to the toilet from her wheelchair. CNA L said staff were instructed to make frequent checks on Resident #33 because she would fall asleep on the toilet, and they would try and assist the resident back to her wheelchair or to bed. Interview on 07/03/25 at 12:37 PM with ADON B revealed Resident #33 was independent enough to take herself to the bathroom even though they encouraged the resident to call for assistance. She said Resident #33 would stay on the toilet for long periods of time and at times would fall asleep. ADON B said the family had concerns about the resident falling asleep on the toilet and they were told staff were making frequent checks on the resident to try to redirect and prevent falls. Interview on 07/03/25 at 4:11 PM with the DON revealed Resident #33 used a wheelchair for mobility and she transferred herself to the bathroom even though she was encouraged to call for assistance. The DON said Resident #33 liked to sit on the toilet for long periods of time and would fall asleep sometimes and if they tried to redirect the resident, she would become upset. The staff were instructed to make frequent checks on the resident if she was in her room to assist as much as they could. The DON further stated Resident #33's Family had concerns about the resident falling asleep on the toilet and they were informed of the pushback they would get from the resident when staff tried to help or redirect. The DON said the resident's behavior of being on the toilet for long periods of time and falling asleep should have been care planned so staff knew what to do. Interview on 07/03/25 at 5:50 PM with the MDS Nurse revealed she was not aware Resident #33 would sit on the toilet for long periods of time and fall asleep. The MDS Nurse said if she had been told, that would have been care planned so staff would be aware of her behaviors and monitor as needed. Review of the facility's policy titled Comprehensive Care Plans revised on February 2020 reflected the following: It is the policy of this facility to develop and implementation a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental psychosocial needs that are identified in the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #8) reviewed for ADL care. The facility failed to provide Resident #8 assistance with timely incontinence care for at least 5 hours. Resident #8 was observed to be soaked and soiled through to her wheelchair padding. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection. Findings included: Record review of Resident #8's face sheet, dated 07/03/25, revealed Resident #8 was admitted to the facility on [DATE].Record review of Resident #8's Comprehensive MDS assessment, dated 05/25/25, revealed Resident #8 had cognition intact with a BIMS score of 15. Resident #8 was noted to be dependent on staff for toileting, with substantial/max assistance with sit to stand, chair to bed transfer, and toilet transfer. Resident #8 was always incontinent of urinary and bowel. Active diagnoses included Stroke, Heart Failure, High Blood Pressure, High Blood Sugar, Hemiplegia or Hemiparesis (paralysis that affects only one side of the body), anxiety disorder and Chronic Obstructive Pulmonary Disease. Review of Resident #8's care plan, dated 07/03/25, revealed Resident #8 had Impaired Physical Mobility related to history of Paraplegia evidenced by general weakness. Goal: Maintain or improve physical function in Bed Mobility, Transfer, Ambulation, Locomotion, and Range of Motion. Intervention: Provide appropriate level of assistance to promote safety of resident. Resident #8 had Self Care Deficit related to limited joint mobility interfered with hygiene, and causing resident to have higher risk of skin breakdown. Goal: Maintain or improve self-care area of dress, grooming, hygiene, and bathing. Intervention: provide assistance with self-care as needed. Resident #8 at risk for problems with elimination evidenced by usual bowel pattern: daily. Goal: Resident's elimination status will be maintained or improved. Intervention: Assist to toilet as needed. Uses a brief. Resident #8 at risk of skin breakdown evidenced by Incontinent of bowel, always incontinent to bladder, confined to bed and chair most of the time, bed mobility and transfers: extensive. Goal: remain clean and intact skin. Interventions: apply protective or barrier lotion after incontinence. Keep skin clean, dry, and free of irritants. Observation on 07/01/25 at 12:11 PM revealed CNA M exiting Resident #8's room with soaked and soiled bedding and briefs. CNA M returned to provide resident with clean bedding. Observation on 07/01/25 at 2:56 PM revealed Resident #8 in her room, ringing her bell to alert staff she needed assistance. Interview on 07/01/25 at 3:02 PM with Resident #8 revealed her saying I will not say I am good because no one comes to help me. Been here 2 months and it has been like this the whole time. I am paralyzed from my stroke on the right side and need help. I need to be changed right now so I can go therapy, and it has been a couple of hours since I was last changed. I think the last time I was changed was around 10:00 am before my therapy. My head nurse came in and I told her I need changed & they still have not come back in (over an hour ago). They do not check on me unless they are giving medications. I do have painful areas on butt from not being changed and laying/sitting all day. Was put in chair around 10 am and left there. This is what happens every day. Interview on 07/01/25 at 3:13 with RN D revealed she did stop to speak with Resident #8 upon her shift shortly after 2:00 PM. RN D stated Resident #8 did ask to be changed. RN D stated she alerted CNA M at the time and would follow up with him to assist Resident #8 with incontinent care. RN D walked away to speak with CNA M. Observation on 07/01/25 at 3:18 PM of CNA M entered Resident #8's room to inform family members that he needed to assist Resident #8 with a brief change. CNA M then left the room stating that he needed to gather supplies and was waiting on another person to assist with care. Interview and observation on 07/01/25 at 3:21 PM with CNA M revealed him stating I changed Resident #8 this morning around 11:00 AM, before she went to therapy. CNA M and CNA N returned, both washed hands in bathroom and donned appropriate personal protection equipment. Observation on 07/01/25 at 3:27 PM revealed staff removed oxygen from Resident #8 to complete transfer to the bed. There was a strong urine odor immediately in room once Resident #8 was laid down. Resident #8's brief soaked through onto a blanket on wheelchair; stool was present. CNA M used Peri wash to clean resident. Resident #8 presented with redness on her lower buttocks/upper thigh area, more significant to left leg. Redness in between legs/right vaginal crease. CNA M cleaned vaginal area after cleaning feces and cream was applied to buttocks and vaginal crease. Interview on 07/01/25 at 3:58 PM with CNA M revealed Resident #8 was last changed at 11:00 AM, Resident #8 then went to therapy and had lunch. I am responsible to check on residents every 2 hours, however Resident #8 will tell you she is not going to bed, so you cannot change her. Around 2:15 (after RN D told me), I tried to get her changed and she told me no. Twenty minutes later, I went again and told her that I would go get CNA N to get her changed. Interview on 07/02/25 at 3:51 PM with RN D, she revealed Resident #8 told her that she wanted to go back to therapy, but she needed to be changed. RN D stated she spoke to the CNA M, and he stated Resident #8 was last changed around 11:30 AM and he was waiting for another CNA to assist. RN D stated Resident #8 was a heavy wetter and was sure she needed to be changed. RN D stated the CNAs were responsible for rounding for incontinent care, and nurses were responsible for ensuring CNAs were rounding. RN D stated, not changing resident brief in a timely manner placed Resident #8 at risk of skin breakdown or irritation. Interview on 07/03/25 at 3:11 PM with the DON revealed he expected the CNAs and the Nurses to work together to complete incontinent care as needed. The DON stated CNAs were responsible for doing rounds every 2 hours on residents to ensure they were clean and dry. The DON stated nurses were also responsible for checking on their residents to ensure they were doing okay. The DON stated leaving Resident #8 wet placed her at risk of skin breakdown, infection, and pressure sores. Review of the facility's Perineal Care policy, last reviewed 04/22/24, reflected: Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection. Identify resident, assemble supplies, perform hand hygiene, follow procedure, document procedure, and notify charge nurse of any changes or abnormalities.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one of three residents (Residents #8) reviewed for oxygen. 1. The facility failed to ensure Residents #8's orders for oxygen administration were being accurately provided. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. Findings included: Record review of Resident #8's face sheet, dated 07/03/25, revealed Resident #8 was admitted to the facility on [DATE].Record review of Resident #8's Comprehensive MDS assessment, dated 05/25/25, revealed Resident #8 had cognition intact with a BIMS score of 15. Resident #8 was noted to have shortness of breath or trouble breathing when lying flat and required oxygen therapy. Active diagnoses included Stroke, Heart Failure, High Blood Pressure, High Blood Sugar, Hemiplegia or Hemiparesis (paralysis that affects only one side of the body), anxiety disorder and Chronic Obstructive Pulmonary Disease. Review of Resident #8's care plan, dated 07/03/25, revealed Resident #8 with breathing patterns related to diagnosis of Chronic Obstructive Pulmonary Disease [05/18/25: Onset] Evidenced by Oxygen 2 Liter per Minute Inhalation every shift. Goal: Resident will demonstrate an effective respiratory rate, depth, and pattern. Establish a normal/effective respiratory pattern with arterial blood gas within patient's normal range. Interventions included adjust head of bed and body positioning to assist ease of respirations. Administer medications, respiratory treatments, and oxygen as ordered. Monitor lung sounds, pallor, cough, and character of sputum. Monitor respiratory rate, depth, and effort. Notify physician and family of any change of condition. Record review of Resident #8's physician's orders revealed:Oxygen 2 liters per minute by nasal canula continuous Start dated 06/16/25 for Oxygen saturation, oxygen lung shortness of breath. Oxygen Saturation check for oxygen assistance, oxygen saturation, and respiration. Observation and interview on 07/01/25 at 2:57 PM with Resident #8 revealed she was sitting in a wheelchair with use of oxygen at 3 liters per minute. According to Resident #8, I have trouble with my esophagus and sometimes I feel like I'm suffocating, I am supposed to be on 2 liters of oxygen to assist with my breathing. Resident #8 stated staff usually checked it nightly when they come in to administer her bipap machine, no one had ever stated the oxygen level had increased to 3 liters. Observation on 07/03/25 at 12:10 PM of Resident #8 revealed she was at bedside resting with tubing in her nose, and the oxygen level was at 3 liters per minute. Observation and interview on 07/03/25 12:18 PM with LVN F revealed Resident #8 was sitting on the side of the bed with tubing in her nose, the oxygen level was at 3 liters per minute. According to LVN F the resident should be on an oxygen level of 2 liters per minute. LVN F reviewed Resident #8's orders and confirmed she should be on 2 liters per minute and stated Resident #8's oxygen was to be checked daily. LVN F stated he was new to the facility and working with Resident #8, he was not sure who provided an increase in oxygen or when it was increased to 3 liters per minute and stated he would contact the physician for clarification of the order. LVN F stated there should not have been an increase in Resident #8's oxygen level without a physician's order to do so. LVN F stated there was risk involved with having a higher level of oxygen. LVN F stated the nursing staff was responsible to inform the physician prior to making any changes in the order, and to monitor Resident #8's oxygen each shift daily. LVN F stated not following physician orders provided a risk to the resident breathing patterns. Interview with the DON on 07/03/25 at 3:11 PM revealed Resident #8 was on oxygen. The DON stated nursing staff should be checking Resident #8's water, tubing, and level of oxygen flow on each shift daily. According to DON Resident #8 or family members change it therefore staff had to provide education to on not increasing the oxygen level. The DON stated having an increase in oxygen could place the resident's body at risk of becoming used to needing a higher level of oxygen. The DON stated it was the nursing staff's responsibility to check the oxygen level daily and every shift, enter new orders from the physician and document as to why Resident #8's oxygen was increased. Record review of facility's Following Physician Orders policy, last reviewed November 27, 2023, reflected: .The licensed nursing staff will provide residents with medications and treatments as ordered by his/her physician.

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 on one of 4 medication carts (500 Halls cart) and 2 of 4 residents (Residents #50 and #63) reviewed for pharmacy services. The facility failed to ensure the 500 Hall nurses' medication cart had accurate narcotic counts for Residents #50 and #63.This failure could place residents at risk for medication errors, drug diversion, and delay in medication administration. Findings included:1.Record review of Resident #50's quarterly MDS Assessment, dated 06/25/25, reflected the Resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #50 had diagnoses which included Unspecified fracture of upper end of left humerus. The Resident's BIMS score was 12 indicating his cognition was moderately impaired. Section J-health conditions revealed she was on pain management. Record review of Resident #50's physician's orders, dated 06/19/25, reflected an order for Resident #50 to receive morphine sulfate 15mgs, 1 tablet by mouth twice daily for pain. 2.Record review of Resident #63's quarterly MDS Assessment, dated 05/06/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #63 had diagnoses which included other neurological conditions (wide range of disorders affecting the brain, spinal cord, and nerves) and hypertension (high blood pressure). The resident's BIMS score was 11 indicating his cognition was moderately impaired. Section J-health conditions reveal she was on pain management. Record review of Resident #63's physician's orders, dated 06/17/25, reflected an order for the resident to receive oxycodone hydrochloride 5mgs, 1 tablet by mouth every six hours at 01:00AM, 07:00AM, 01:00PM, 07:00PM for pain. Observation and record review on 07/02/25 at 11:20 AM of the 500 Hall nurses' medication cart and the Narcotic Administration Record with LVN C revealed Resident #50's Narcotic Administration Record for morphine sulfate 15mgs reflected a total of 10 pills remaining, while the blister pack count was 09 pills. It had last been administered on 07/01/25 at 08:00PM. Resident #63's Narcotic Administration Record for oxycodone 5mg reflected a total of 103 pills remaining, while the blister pack count was 102 pills. It had last been administered on 07/02 01:00AM. Interview with LVN C on 07/02/25 11:39 AM revealed she administered Resident #50's morphine sulfate Oral Tablet 15 mg 1 tablet twice and oxycodone 5 mg I tablet to Resident #63 every 6 hours, at 09:00AM and she had not signed off on the Narcotic Administration Record log. She said she gave the residents the medication, but she forgot to sign off on the Narcotic Administration Record. She stated she knew she was supposed to sign-out on the narcotic count sheet log after popping the pill from the blister and on the Medication Administration Record, but she did not. LVN C stated failure to sign off narcotics could lead to overdose since the person who came after her would not be able to tell when the narcotic was administered and could lead to medication error. She said she had done in-service on medication administration, but she could not recall when.Interview on 07/03/25 02:45 PM with the ADON B revealed her expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the MAR and to sign on the narcotic log. The ADON B said failure to document could lead to overdose and missing pills. She said it was her responsibility to audit the medication carts once a week and she could not tell when she last audited. She said the facility had completed in-services on medication administration and narcotic sign out and she could not recall when.Interview on 07/03/25 04:08 PM with DON revealed his expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the MAR and to sign on the narcotic log. DON said failure to document could lead to overdose and missing pills. He said it was his and the ADON's responsibility to audit the medication carts and perform random checks 2-3 times a week and he could not tell the last time they checked. He said the facility had completed in-services on medication administration and narcotic sign out.Record review of the training records on narcotic administration was requested on 07/03/25 and none were provided. Record review of the facility's Controlled Substances Administration policy, dated 01/23, reflected the following: .4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability when removing dose from controlled storage. a.Date and time of administrationb. Amount administeredc. Signature of the nurse administering the dose

Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 2 residents (Resident #8) observed for infection control. CAN M failed to perform proper hand hygiene while providing incontinence care to Resident #8.This failure could affect the resident by placing them at risk for worsening conditions and cross contamination. Findings included:Record review of Resident #8's face sheet, dated 07/03/25, revealed Resident #8 was admitted to the facility on [DATE].Record review of Resident #8's Comprehensive MDS assessment, dated 05/25/25, revealed Resident #8 had cognition intact with a BIMS score of 15. Resident #8 was noted to be dependent on staff for toileting, with substantial/max assistance with sit to stand, chair to bed transfer, and toilet transfer. Resident #8 was always incontinent of urinary and bowel. Active diagnosis included Stroke, Heart Failure, High Blood Pressure, High Blood Sugar, Hemiplegia or Hemiparesis (paralysis that affects only one side of the body), anxiety disorder and Chronic Obstructive Pulmonary Disease. Review of Resident #8's care plan, dated 07/03/25, revealed Resident #8 had Impaired Physical Mobility related to history of Paraplegia evidenced by general weakness. Goal: Maintain or improve physical function in Bed Mobility, Transfer, Ambulation, Locomotion, and Range of Motion. Intervention: Provide appropriate level of assistance to promote safety of resident. Resident #8 had Self Care Deficit related to limited joint mobility interfered with hygiene, and causing resident to have higher risk of skin breakdown. Goal: Maintain or improve self-care area of dress, grooming, hygiene, and bathing. Intervention: provide assistance with self-care as needed. Resident #8 at risk for problems with elimination evidenced by usual bowel pattern: daily. Goal: Resident's elimination status will be maintained or improved. Intervention: Assist to toilet as needed. Uses a brief. Resident #8 at risk of skin breakdown evidenced by Incontinent of bowel, always incontinent to bladder, confined to bed and chair most of the time, bed mobility and transfers: extensive. Goal: remain clean and intact skin. Interventions: apply protective or barrier lotion after incontinence. Keep skin clean, dry, and free of irritants. Resident #8 at risk of Infection Control evidenced by Enhanced Barrier Precautions every shift. Goal: Prevent spread of Multidrug-resistant Organisms. Intervention: Enhanced Barrier Precautions: gown and glove use during high-contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, wound care, and any skin opening requiring a dressing. Interview on 07/01/25 at 3:02 PM with Resident #8 revealed her saying I will not say I am good because no one comes to help me. Been here 2 months and it has been like this the whole time. I am paralyzed from my stroke on the right side and need help. I need to be changed right now so I can go therapy, and it has been a couple of hours since I was last changed. I think the last time I was changed was around 10:00 am before my therapy. My head nurse came in and I told her I need changed & they still have not come back in (over an hour ago). They do not check on me unless they are giving medications. I do have painful areas on butt from not being changed and laying/sitting all day. Was put in chair around 10 am and left there. This is what happens every day. Observation on 07/01/25 at 3:27 PM of incontinent care for Resident #8 revealed CNA M and CNA N completing hand hygiene and donning gown and gloves. As Resident #8 was transferred to her bed, it was revealed that her brief was soaked through onto a blanket placed on her wheelchair; stool was present. Resident #8 was rolled to her side then CNA M used Peri wash to clean resident starting at her buttocks cleaning the feces first. With dirty gloves CNA M reached into the wipes to pull more after cleaning feces. CNA M did not stop to remove the dirty gloves or wash his hands. CNA M then cleaned Resident #8's vaginal area while using the same gloves. CNA M continued with dirty gloves and applied cream to Resident #8's buttocks and vaginal crease, with same gloves and without washing his hands CNA M placed Resident #8 in a clean brief. CNA M then did not wash his hands but applied new gloves to dress Resident #8 with a new gown. CNA M grabbed a sheet off the bed and replaced the sheet on the wheelchair padding. Interview on 07/01/25 at 3:58 PM with CNA M revealed during peri care, I was supposed to get wipes out prior to beginning the incontinent care, peri wash, wipe from the front to the back. Today I started at the back. The reason that I did that for her, due to the protruding stomach so she can't lay back. After I did her back, then I did her front. I was supposed to change my gloves when I was done cleaning bowel movement and wash my hands before placing on new gloves however, I had 2 pairs of gloves on. You can wear 1 or 2 pairs of gloves, it's optional. I forgot to change my gloves after the bowel movement, I'm sorry. CNA M further stated not changing gloves or providing hand hygiene placed residents on contact precautions at risk of infections. Interview on 07/02/25 at 3:51 PM with RN D, RN D stated the CNAs were responsible for rounding for incontinent care and while doing so, using personal protective equipment and proper hand hygiene. RN D stated CNAs were to clean residents starting at the pelvic area before cleaning the buttocks. RN D stated nurses were responsible for ensuring CNAs were cleaning residents correctly during their incontinent care rounds. RN D stated, not using proper hand hygiene, personal protective equipment or cleaning residents properly placed Resident #8 at risk of skin breakdown or irritation.Interview on 07/03/25 at 3:11 PM with the DON revealed he expected the CNAs and the Nurses to work together to complete incontinent care as needed. The DON stated staff were expected to gather supplies and complete hand hygiene before, between and after providing incontinent care. The DON stated when doing incontinent care staff should begin at the front pelvic area and then move to the buttocks, this would prevent any cross contamination or infections. The DON stated after CNA M cleaned feces, he should have removed his gloves and washed his hands before applying new gloves to finish continence care, you never want to use contaminated gloves or dirty hands to get more wipes or cleaning a new area. The DON stated he would expect CNA M to used clean linen to place on the wheelchair, using sheet of the bed may have been contaminated placing Resident #8 at risk of further contamination. Review of the facility's Perineal Care policy, last reviewed 04/22/24, reflected: Staff will provide perineal care in accordance with the standard of practice to prevent skin breakdown and infection. Identify resident, assemble supplies, perform hand hygiene, follow procedure, document procedure, and notify charge nurse of any changes or abnormalities.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. The facility failed to keep a disinfectant cleaner containing four types of ammonium chloride out of Resident #1's reach to prevent the resident from drinking it. The resident was sent to the hospital after his lips began to swell and turn red. Resident #1 was diagnosed with acid burns to his oral mucosa (the mucous membrane that lines the inside of the mouth, including the cheeks, lips, floor of the mouth, and tongue) and had to be intubated for acute respiratory failure. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 01/12/25 and ended on 01/13/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life. Findings included: Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included progressive neurological condition, high blood pressure, diabetes, and Alzheimer's disease. The MDS reflected a BIMS was not conducted on the resident and his cognition was moderately impaired with inattention and disorganized thinking. The MDS further reflected Resident #1 wandered daily. Record review of Resident #1's care plan reviewed on 01/09/25 reflected the resident had cognitive deficit related to dementia and wandered in the evenings. Interventions included to assess for unmet needs such as pain, hunger, thirst, toileting, and to assist with finding location of room and items. Record review of the facility's Provider Investigation Report dated 01/20/25 reflected the following: .On 01.12.25, during routine rounding, [CNA A] observed [Resident #1] with emesis in his bed. As she approached, she noticed a bottle of cleaning spray in his hand. [CNA A] took the bottle of cleaning spray from Resident #1 and placed it on his bedside and then called [LVN B] into the room for assistance. When [LVN B] entered Resident #1's room, [CNA A] had begun to clean [Resident #1], as well as his bedding [Resident #1 was assessed on suspicion of ingestion of a cleaning spray the decision was made to send [Resident #1] to the ER as precaution. When EMT arrived, [Resident #1's] lips had become swollen and were dark pink Record review of Resident #1's progress noted dated 01/12/25 at 9:01 PM documented by [LVN B] reflected the following: This nurse was notified by CNA at 6:25 pm, that the resident is vomiting in his bedroom. Upon entering the room, and assessing resident, this nurse, noticed a bottle of cleaning supply sitting on the bed side table. When asked the CNA what the disinfectant was doing in resident room, CNA replied it was there when she entered the room to clean resident. When patient was asked if he drank the bottle of disinfectant, he denied it also denied vomiting. [Physician] notified of the situation via telehealth and stated to give the patient milk and water and monitor if lips had a coral pink tint Poison control called and stated to monitor for GI bleeding Vomit color was clear, no blood noted. Pt sent to [Hospital] Upon the EMT arrival the patients lips were swollen and were dark pink Record review of Resident #1's vital signs recorded following the incident on 01/12/25 reflected: blood pressure was 147/81; pulse 89; respirations 18; temperature 97.8, and oxygen saturation on room air was 96%. Record review of the disinfectant Safety Data Sheet reflected the following: .Product name: RoomSense 200 Disinfectant Cleaner . .Recommended Use: Neutral Disinfectant Cleaner . .2. Hazards Identification Hazard Statements Harmful if swallowed Harmful in contact with skin Causes severe skin burns and eye damage . .3. Composition/Information on Ingredients Hazardous Ingredients Alkyl dimethyl ammonium chloride Octyldecyl dimethyl ammonium chloride Dioctyl dimethyl ammonium chloride Didecyl dimethyl ammonium chloride . .Toxicology Information Ingestion: May cause burns to mouth, throat, and stomach Record review of Resident #1's hospital records dated 01/12/25 reflected the following: .Assessment: Principal Problem: Drug ingestion, accidental or unintentional, initial encounter. Active Problems: Acute respiratory failure . .Plan: Acute respiratory failure/airway edema/aspiration -d/t ingestion of cleaner, unknow amount -facial, lip, and tongue swelling . .Summary [AGE] year old Patient with dementia, memory care resident who presents with [sic]ccidental ingestion of cleaning liquid which caused acid burn to his oral mucosa with significant swelling of the face Patient got intubated and extubated and transferred out of ICU Interview on 02/21/25 at 10:54 AM with CNA A revealed she entered Resident #1's room, 01/12/25, and noticed the resident had a spray bottle of cleaning solution and noticed he was putting it on his bedside table. Resident #1 was noticed to be spitting on the floor, but she had been told that was a normal behavior for the resident. CNA A asked the resident if he had drank the cleaning solution and the resident said no but the CNA did know if Resident #1 understood what she was asking him. CNA A said she immediately stepped into the hall and called for the nurse, and she took over from there, but the CNA noticed the resident's face was turning red. CNA A further reflected Resident #1 was confused at times and would wander through the facility but normally stayed to himself. Interview on 02/21/25 at 11:08 AM with LVN B revealed she was called into Resident #1's room during the incident on 01/12/25, by CNA A, who said the resident was vomiting but when she entered the room the CNA had cleaned the resident up. LVN B saw the disinfectant spray bottle on the resident's bedside table and the cap was loosely on the bottle. LVN B asked Resident #1 if he had drank the disinfectant to which the resident responded he had not. The physician was contacted, and they were ordered to monitor the resident after they had called poison control who told them to monitor for any changes. After about 45 minutes of monitoring Resident #1, they noticed the resident's lips began to swell, and the sides of his lips had turned red, so he was sent to the hospital for further evaluation. LVN B described Resident #1 as one who wandered with his walker and was normally looking for something to eat or drink. The LVN said he would go into the dining room or the nurse's station looking for snacks, but she had never seen the resident pick up something that was not food related. LVN B further stated the nursing staff did not have access to the housekeeping cleaning products as they were usually kept on their carts or locked in their closets. Interview on 02/21/25 at 11:38 AM with Housekeeper C revealed she had cleaned Resident #1's room the day of the incident, 01/12/25, around 11:00 AM. She stated when she was done, she recalled putting the disinfectant spray back in her cart. Housekeeper C said that disinfectant was used daily to clean all room surfaces. She further stated all cleaning supplies were kept on their carts or locked in the closets. Housekeeper C stated Resident #1 would hoard items in his room like flower vases and napkins stating the items were his. Multiple attempts to contact the Weekend Supervisor, who worked the day of Resident #1's incident on 02/21/25, were unsuccessful. Interview on 02/21/25 at 11:47 AM with LVN D revealed he worked with Resident #1 and the resident would come out of his room with a walker and eat his meals in the dining room. LVN D said the resident was confused and would wander looking for and hoarding food but said he was easily redirected. Interview on 02/21/25 at 1:05 PM with Resident #1's family revealed the resident had indeed drank the cleaning solution because he had suffered chemical burn to his mouth, lips, and throat and had to be intubated when he was transferred to the hospital. The resident's family further stated the resident was at the hospital for a couple of weeks before he was transferred to another nursing home. Interview on 02/21/25 at 1:05 PM the Housekeeping Supervisor stated their policy was that all chemicals be stored at the bottom of the housekeeping cart where they could be locked while they cleaned the rooms. He said he was told about Resident #1's incident and looked at the schedule and noticed Housekeeper C had been assigned to the resident's room. When she was questioned, the Housekeeper said she indeed had cleaned the resident's room but had taken the disinfectant spray out of the room when she was done. The day after the incident (01/12/25), the Housekeeping Supervisor said he did an audit of all the housekeeping carts to see if the disinfectant bottle was missing from one of the carts and they were all accounted for. After the incident, the Housekeeping Supervisor also said they had changed all the lock and key doorknobs to the janitor closets and replaced them with keypad code locks that automatically lock when the door shuts. He also said he checked the closet doors every afternoon to ensure they were locked, and all housekeeping carts were audited daily to ensure all chemicals were properly stored and accounted for. Interview on 02/21/25 at 2:00 PM with the ADON revealed Resident #1 had dementia and ambulated with a walker. The resident would hoard napkins and saltshakers in his room. The ADON said she was told Resident #1 had drank some cleaning solution and had to be sent to the hospital for further evaluation. She further stated they were not able to determine how the resident got the disinfectant spray and thought he might have taken it from a housekeeper's cart . Interview on 02/21/25 at 2:53 PM with the DON revealed Resident #1 was alert and oriented to himself and would wander into other resident rooms but was easily redirected. The DON said he was told staff had found Resident #1 in his room with a bottle of disinfectant next to him and the staff were unsure if the resident had ingested the chemical. The doctor and poison control were immediately contacted, and they were told to monitor the resident for any changes. After a while staff noticed Resident #1's lips were turning blue, and he began to cough, the resident was sent to the hospital with the bottle of disinfectant spray, so the hospital staff knew what he had possibly ingested. The DON said Resident #1 mostly wandered looking for and picking up food and that was the first time the resident had been seen with anything that was not a food item. After the incident they conducted a widespread in-service to ensure all staff knew not to keep any type of harmful chemicals within the resident's reach. All staff were reminded to keep any chemicals locked away in the closets. All the housekeepers were re-educated to ensure their carts were always pushed against the walls, so no one had access to the cart doors. All janitor closets' lock and key were changed to a keypad code that only housekeeping had access to. The Weekend Supervisor did a walk-through on the day of the incident to ensure there were no harmful chemicals in the resident rooms and he did another walk-through the day after the incident. Interview on 02/21/25 at 2:18 PM with the Administrator revealed after Resident #1's incident, the Weekend Supervisor ensured there were no other harmful substances in the resident rooms. The Administrator stated cart audits were conducted after the incident (01/13/25) because the staff did not have access to the janitor closets at the time of the incidents to try and find out where the resident had obtained the disinfectant spray from and there were no issues as all the carts were appropriately stocked. He stated all staff were in-serviced to ensure there were no harmful chemicals left out within resident's reach. Record review of the facility's Resident Room Cleaning policy, effective November 2021, reflected the following: Purpose To provide a clean, attractive, and safe environment for residents, visitors, and staff. D. Leave your cleaning cart in the hallway, in sight. If you cannot see your cart, lock the cart. .17. .C. Ensure there are no housekeeping items left in the resident room. A Past Non-Compliance Immediate Jeopardy was identified on 02/21/25. The Administrator was notified of the Past Non-Compliance Immediate Jeopardy on 02/21/25 at 4:44 PM. The IJ template was provided to the facility on [DATE] at 4:59 PM. Observation on 02/21/25 starting at 10:00 AM revealed there were 4 janitor closets, and each door was locked and the there was a code keypad in place. Observation on 02/21/25 from 9:42 AM to 11:59 AM revealed there were no hazardous chemicals in resident rooms. Observation on 02/21/25 at 9:42 AM, 10:10 AM, 10:21 AM, and 1:51 PM revealed the housekeeping carts were locked and there were no chemicals within resident's reach when the housekeepers were cleaning the rooms. Record review of the cart audit dated 01/13/25 reflected all the cart cleaning supplies were accounted for and there were none missing for the 4 cleaning carts. Record review of the resident room audits dated 01/13/25 reflected all residents' rooms were checked to ensure that no hazardous chemicals were present in their rooms. Record review of the daily cleaning cart sign-off sheets reflected each housekeeping cart was being checked by the Housekeeping Supervisor to ensure all cleaning supplies were accounted for in each cart and to ensure the janitor closets were locked from 01/13/25 to 02/21/25. Record review of Housekeeper C's education/training record dated 01/13/25 reflected she had received a 1:1 in-service on securing chemicals and abuse and neglect. Record review of Disinfectant In-service dated 01/13/25 reflected all housekeepers, floor techs, and laundry aides were re-educated to ensure there were no housekeeping items left in the resident rooms after cleaning them or within their reach. Record review of a training in-service titled Don't leave cleaning supplies out. Put away after use. dated 02/21/25 reflected 56 staff has been in-serviced. Interview on 02/21/25 from 9:42 AM to 5:59 PM with CNA A, LVN B, Housekeeper C, LVN D, ADON, Housekeeping Supervisor, CNA E, LVN F, Housekeeper G, CNA H, RN I, RN J, MA K, CNA L, CNA M, CNA N, CNA O, MA P, and LVN Q revealed they were to check the resident rooms for hazardous chemicals when and if they enter. They all stated they were to ensure there were no hazardous chemicals in the resident rooms or within their reach. They were add educated to ensure they called poison control if they suspected a resident had ingested a hazardous chemical.

Based on interview and record review, the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Record review (PASRR) Level II determination and the PASRR evaluation report for 1 of 3 residents (Resident #2) reviewed for PASRR assessments. The facility failed to submit a NFSS form request by the specific deadline for Residents #2 for therapy services. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. Findings included: Record review of Resident #2's quarterly MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral palsy, anxiety disorder, and depression. Resident #2 was not able to complete a BIMS due to her severely impaired cognition. The MDS further reflected the resident was rarely/never understood or rarely/never understood. Record review of Resident #2's care plan reviewed on 01/06/25 reflected she had severe cognitive impairment and had speech deficit and rarely/never understood. Interventions included to monitor for any changes or decline in cognitive status. Record review of Resident #2's Local Intellectual and Developmental Disabilities Authority Habilitation Service Plan dated 01/06/25 reflected the following: .PASRR OT/ST Assessment and Treatment-NEW Observation on 02/21/25 at 10:35 AM of Resident #2 revealed she was in bed and appeared to be non-verbal as she did not respond when she was spoken to. The resident was able to make eye contact only and appeared to require total assistance with all ADLs. Interview on 02/21/25 at 10:42 AM with the PASRR Representative revealed they had a meeting on 01/06/25 with the facility and it was agreed that Resident #2 would be assessed for Occupational and Speech Therapy. The PASRR Representative said they met again on 02/14/25 with the facility staff and realized Resident #2 was not yet receiving the therapy services they had agreed upon. Interview on 02/21/25 at 3:06 PM with the Director of Rehab revealed she had not been involved in the PASRR meeting held on 01/06/25 so she was not aware Resident #2 required an occupational and speech therapy assessment. Another meeting was held on 02/14/25 where she did participate, and that was when the Director of Rehab said she had been made aware of the required therapy services. The PASRR Representative decided to drop speech therapy and only wanted the resident assessed for occupational therapy. After the meeting on 02/14/25 the required paperwork was completed and submitted, and Resident #2 was assessed for occupational therapy on 02/16/25. Record review of Resident #2's Occupational Therapy OT Evaluation and Plan of Treatment dated 02/16/25 reflected the resident had been evaluated for occupational therapy. Interview on 02/21/25 at 4:43 PM with the Administrator revealed the previous MDS Nurse was responsible for the PASRR meetings. The Administrator said he was not aware Resident #2 had been approved for new services through PASRR and that the required paperwork had not been submitted. Attempts to contact the previous MDS Nurse on 02/21/25 were unsuccessful. In an interview on 02/21/25 at 5:30 PM with the Administrator revealed the facility did not have a PASRR policy that covered PASRR positive policy, and procedures and they just followed the manual.

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents. CNA B failed to follow Resident #1's plan of care when she prepared to transfer the resident without assistance using a mechanical lift. This failure placed all residents, who required 2+ person assist with transfers/mobility, at risk for accidents and injuries. Findings included: Record review of Resident #1's face sheet, dated 09/13/24, reflected the resident was an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia (loss of thinking and memory), psychotic disturbance (mood disorder), Type II diabetes, unsteadiness of feet, lack of coordination, and above the knee amputation of right leg. Record review of Resident #1's Optional State Assessment (OSA) and Quarterly MDS assessment, both dated 08/01/24, reflected the resident required extensive assistance with two+ person assist for bed mobility and transfer. Record review of Resident #1's care plan, dated 05/10/24, revealed the resident was a fall risk related to a fall on 08/08/24, history of heart failure, history of hypertension, and evidenced by amputation, right lower extremity weakness, cognitive status, transfer (total dependence), mobility (immobile) and non-weight-bearing status. Interventions included: assessing and monitoring vital signs, assessing contributing factors related to fall history, assessing for potential fall-related injury prevention, assessing medications for contributing factors, assisting resident with ADLs and toileting as needed, keeping call light and frequently used items within reach, low bed, reminding the resident to call for assistance, and social services and therapy referral, and wheelchair. Further review of care plan reflected the resident also had impaired physical mobility related to history of cardiovascular disease and evidenced by assist rails, right lower extremity weakness, right knee joint pain, and left hip joint pain. Interventions included occupational/physical therapy, providing appropriate level of assistance to promote safety of resident, providing physical assistance to promote highest level of function, and restorative nursing assistance as needed. Record review of Resident #1's incident report dated 08/08/24 completed by LVN A, reflected in part the following: .At about 7:30 AM, an aid was trying to prepare resident to bring her to the dinning [sic] room. As she was trying to but [sic] the sling from the right side, resident roll few [sic] towards the right side of a very low bed, and almost falling. This nurse was in front of her door and ran to help the can [sic] to bush [sic] her back to the bed but very difficult and we lowered her to the grown [sic]. Resident's head accidentally hit the rail the resident stated. This nurse assessed resident and noted a node [sic] to left side of the head . Record review of Resident #1's neurological checks, dated 08/08/24-08/11/24, reflected no changes in the resident's neurological functions. Record review of a 1 to 1 in-service titled Hoyer transfer & Bed Mobility with CNA B, dated 08/08/24, reflected she was educated on proper Hoyer lift transfer and safety of patient and was able to return demonstration. Record review of Resident #1's progress note, dated 08/09/24 by LVN A, revealed the following: [Resident #1] is stable at this time. [Resident #1] in her room and family visiting. [Family] in the building this morning and informed this nurse that [Resident #1] is complaining of pain to the head where the nod [sic] is. This nurse already assessed [Resident #1] at this beginning of the shift and [Resident #1] verbalized pain to the nod [sic] on the head and tender when touch. Pain medication given and order for skull x-ray given. Order called in and awaiting tech. [Family] notified and will F/U with the result. Record review of an in-services titled Nurse Team Meeting Outline on 8/31/24, dated 08/31/24, reflected all staff were educated on multiple topics, including fall prevention. In an interview and observation on 09/12/24 at 4:00 PM, Resident #1 was observed in bed visiting with family. Resident #1 did not have any visible marks or bruises and was well-groomed with no odors. Resident #1 stated she was well and could not recall having any recent falls or injuries at the facility. Resident #1's family stated he was unhappy because last month the facility informed him that Resident #1 had an accident that resulted in a knot and bruise to her head, and it caused her pain a few days following the incident. The family stated CNA B, who was new, admitted to attempting to transfer Resident #1 alone when she fell halfway out of the bed and hit her head. The family stated Resident #1 required a two-person assist with transferring at all times and he did not believe this was being done. The family stated LVN A tried to convince him that CNA B was only preparing Resident #1 for the transfer and was not going to do the actual mechanical lift alone; however, the family stated he did not believe it. In an interview on 09/13/24 at 12:29 PM, LVN A stated she worked with Resident #1 on 08/08/24 when the incident occurred. LVN A stated she was standing near Resident #1's door at her cart while CNA B was preparing to transfer Resident #1 to her wheelchair. LVN A stated it was common for the aides to place the transfer sling underneath the residents and prepare them for a mechanical transfer alone, then call for help before performing the transfer. LVN A stated all mechanical transfers had to be completed with at least two staff. LVN A stated CNA B rolled Resident #1 over to slide the sling underneath her bottom and the resident rolled too fast due to having one leg. LVN A stated she rushed to the bedside to help get Resident #1 back in bed. LVN A stated Resident #1 sustained a node on her head after hitting it on the bed rail. LVN A stated she did a head-to-toe assessment, put a cold towel on Resident #1's head, and neurological checks were initiated with no concerns. LVN A stated she notified the MD, DON, and family. LVN A stated Resident #1 was not sent out to the hospital, the MD ordered close monitoring and neurological checks. An attempted interview on 09/13/24 at 12:50 PM with CNA B was unsuccessful due to no response to call. In an interview on 09/13/24 at 12:56 PM, the DON stated it was reported to him that on 08/08/24 CNA B was only preparing Resident #1 to be transferred and LVN A was standing near the door to help when it was time to place Resident #1 on the mechanical lift. The DON stated Resident #1 had lower body weakness due to amputation of her right leg, but she had strength in her upper extremities and was able to hold on to the bed rail to assist staff with bed mobility. The DON stated just as with incontinent care, it was okay for the staff to prepare residents for a mechanical lift by [placing the sling underneath without supervision/assistance; however, the mechanical lift procedure requires two people. The DON stated although Resident #1's MDS assessment indicated that she requires 2+ person assist with bed mobility and transfers, most times the resident only required one-person assist with bed mobility. The DON initially stated he was not sure why Resident #1's MDS assessment indicated that she needed 2+ person assistance with bed mobility. The DON stated immediately after the incident, padding was placed on Resident #1's bed rails and CNA B received 1 to 1 training on transfers and resident safety. The DON stated LVN A documented that Resident #1 was ordered a skull series x-ray; however, it was not completed because the physician decided she did not need one. The DON stated the risk of performing tasks that required bed mobility and transfers with a one-person assist if the resident required a two+ person assist was the resident could fall and/or be injured. In an interview on 09/13/24 at 2:24 PM with the DON and MDS Coordinator, the MDS Coordinator stated she worked at the facility since June 2024. The MDS Coordinator stated Resident #1's MDS assessment did indicate that she required extensive assistance and a 2+ person assist with bed mobility and transfers; however, the MDS was coded based on staff's documentation regarding ADL care. The MDS Coordinator stated if staff documented anywhere at anytime that two or more staff were required to complete a task, it would trigger the code for extensive assistance on the MDS assessment. The MDS Coordinator stated she was responsible for monitoring and updating the MDS Assessments for accuracy and could revise it if changes were needed. The MDS Coordinator stated the codes for assistance were a guide for care and did not mean the residents required that level of care at all times, so although Resident #1's MDS Assessment indicated she required extensive assistance and a 2+ person assist with bed mobility and transfers, it was okay for one staff to assist her when possible. The DON stated the MDS Assessment coding was measured over a 7-day period of performance, and the residents' ability could vary. The DON stated he worked with Resident #1 for many years and knew that she had the strength to assist staff with some tasks, and they encouraged this for Resident #1 to maintain her strength. The DON stated the incident that occurred on 08/08/24 was an accident and likely happened because Resident #1 moved too quickly and not because she was unable to assist with maintaining her balance due to lack of coordination from her amputated right leg. Review of the facility's policy titled Mechanical Lifts, revised 02/12/23, reflected in part the following: Policy: Residents will be assisted with their Activities of Daily living, utilizing lifts according to the manufacturer's guidelines. Procedure: .2. Mechanical Lift Operations a. Introduce self to Resident. b. Verify correct patient using two identifiers. c. Inform resident of procedure. d. Perform hand hygiene. e. Gather necessary equipment and second person to assist Review of CMS's Optional State Assessment (OSA) Manual, dated October 2023, reflected in part the following: Activities of Daily Living (ADL) Assistance 1. ADL Self-Performance: Code for resident's performance over all shifts-not including setup. If the ADL activity occurred 3 or more times at various levels of assistance, code the most dependent-except for total dependence, which requires full staff performance every time. 2. ADL Support Provided: Code for most support provided over all shifts; code regardless of resident's self-performance classification Definitions: ADL Self-Performance-measures what the resident actually did (not what they might be capable of doing) within each ADL category over the last 7 days according to a performance-based scale. ADL Support Provided-measures the most support provided by staff over the last 7 days, even if that level of support only occurred once

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 6 of 20 rooms (Rooms 330, 340, 602, 704, 707, and 710) and 3 of 6 carts (300 Hall, 500 Hall, and 700 Hall) reviewed for accidents and hazards. The facility failed to identify a process to ensure sharps containers for Rooms 330, 340, 602, 704, 707 and 710 and carts for 300 Hall, 500 Hall, and 700 Hall were monitored and changed before they became overfilled. This failure could place residents at risk of exposure to bloodborne pathogens. Findings included: Observations on 09/04/24 between 9:35 AM and 10:30 AM revealed Rooms 330, 340, 602, 704, 707 and 710 and nurse medication carts for 300 Hall, 500 Hall and 700 Hall were observed to have sharps containers (used to stored disposed syringes) that were filled past the Fill Line, which prevented the disposal flaps from closing properly. Interview on 09/04/24 at 10:50 AM, LVN A stated sharps containers in resident rooms were the responsibility of the ADONs, and sharps containers on the medication carts were the responsibility of the individual nurse assigned that cart. LVN A stated she did not know how long her cart's (500 Hall) sharps container had been over filled. She stated the risk of an overfilled sharps container was exposure to a used sharps. Interview on 09/04/24 at 11:00 AM, LVN B stated sharps containers on the nurse medication carts were the responsibility of the nurse. Sharps containers in the resident rooms were the responsibility of everyone. She stated the risk of an over filled sharps container was getting poked by a used needle. Interview on 09/04/24 at 11:05 AM, the ADON stated the nurses were responsible for all sharps containers and changing them out. The ADON stated anyone could identify a sharps container that needed to be changed and notify the nurse or herself. She stated the risk of an overfilled sharps container was exposure to used sharps. Interview on 09/04/23 at 11:20 AM, the DON stated changing out sharps containers was the responsibility of all nursing staff. He stated he was unaware of the fill line on the sharps container and would begin to educate staff immediately. He stated the risk of an overfilled sharps container was exposure to any used sharps they contained. Record review of the facility's Infection Control policy, dated January 2022, reflected: Sharps: 1. Used sharps, whether contaminated or not, are considered regulated medical waste and are discarded in hard sided, upright, leak-proof closable containers designated for that purpose. .4. Sharps containers are discarded when 3/4 or less filled.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident on two of four medication carts (100 and 300 Halls nurses' carts) and 2 of 3 staff (LVN E and LVN G) reviewed for pharmacy services. The facility failed to ensure 100 and 300 halls nurses medication cart contained accurate narcotic logs for Residents #35 and #75. LVN E and LVN G failed to document the administration of narcotic medications in a correct and timely manner. This failure could place residents at risk for drug diversion and delay in medication administration. Findings included: Observation on 06/05/24 at 11:29 AM of the nurses' medication cart for hall 100 and the narcotic administration record, with LVN E, revealed the following information: Resident #35's narcotic administration record sheet for Tramadol 50 mg was last signed off on 06/5/24 for a one-tablet dose given at 08:00 AM, for a total of 17 pills remaining while the blister pack count was 16 pills. Resident #75's narcotic administration record sheet for sheet for Hydrocodone-Acetaminophen 5/325 mg was last signed off on 06/5/24 for a one-tablet dose given 08:00 AM, for a total of 50 pills remaining while the blister pack count was 49 pills. Interview with LVN E on 06/05/24 at 12:00 PM, revealed she administered Tramadol 50 mg 1 tablet to Resident #35 and the Hydrocodone-Acetaminophen 5/325 mg 1 tablet to Resident #75 every 8 hours for pain and had not signed off on the NAR . She stated she gave the resident the medication, but she forgot to document it on the medication administration record and sign off on the narcotic administration log. She stated she knew she was to sign-out on the narcotic count sheet after administration, but she did not because she got busy. She stated failure to sign after administration could lead to medication error. Interview with LVN E on 06/06/24 at 09:59 AM, revealed she had given Resident#75 Hydrocodone-Acetaminophen 5/325 mg 1 tablet earlier than it was scheduled, and she documented she had administered at 01:00PM. She admitted she did not administer as scheduled and stated she accepted the error. She could not tell whether she had done any training on medication administration. Observation on 06/05/24 at 12:14 PM, of the nurses' medication cart for hall 300 and the narcotic administration record, with LVN G, revealed the following information: Resident #105's narcotic administration record sheet for Lorazepam 0.5mg was last signed off on 06/5/24 for a one-tablet dose given at 8:00 PM, for a total of 22 pills remaining while the blister pack count was 21 pills. Interview with LVN G on 06/05/24 at 12:27 PM, revealed he administered Lorazepam 0.5 mg 1 tablet to Resident #105 as needed for anxiety and he had not signed off on the NAR. He stated he gave the resident the medication, but he forgot to sign off on the narcotic administration log. He stated he knew he was to sign-out on the narcotic count sheet immediately after administration. He stated failure to do that could lead to a narcotics diversion, medication error, and forgetting to administer. He stated he had done an in-service on medication administration. Interview on 06/05/24 at 3:13 PM, the DON revealed his expectation was for staff administering narcotic medications to document the medications when they were given to the resident on the medication administration record and to sign on the narcotic log. He stated he had not done an in-service recently, but he had done the skills check off on medication administration and no documentation was provided. Interview on 06/06/24 at 10:30 AM, the DON revealed he had talked with LVN E and he notified her she could only administer medications when scheduled. He stated he would do an in-service with LVN E on the medication error.Reisdnet #75 was scheduled every 8 hours Interview with #75 on 06/06/24 at 03:45 PM, through interpreter revealed she got her pain pills when in pain. Interview with #35 on 06/06/24 at 03:59 PM, he would not tell whether he received a pain pill or not . Review of the facility current Medication-Controlled Substances policy requested and was not given

Based on observation, interview, and record review the facility failed to maintain infection control procedures designated to provide a safe environment to help prevent the development and transmission of disease and infection for two residents (Resident #46 and Resident #52) of ten residents and three (Cook A, MA B, and LA C) of ten staff reviewed for infection control. 1. The facility failed to ensure Cook A, MA B, and LA C were screened for signs and symptoms of COVID-19 before beginning their assigned work duties. Cook A was also not screened on 12/10/20 and later tested positive for COVID-19. 2. The facility failed to ensure MA B cleaned personal medical equipment between each resident (Resident #46 and Resident #52) while taking their blood pressure. 3. The facility failed to ensure Resident #46 did not enter a soiled utility room. An Immediate Jeopardy (IJ) was identified on 12/18/20. While the IJ was removed on 12/20/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate threat and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The IJ Template was provided to the Administrator and DON on 12/18/20 at 4:45 PM. These failures placed residents at risk of exposure to the COVID-19 virus which could result in serious illness, hospitalization , and/or death. Findings included: 1. An observation on 12/17/20 at 5:00 AM revealed LA C on the 500-hallway passing laundry to multiple resident rooms on the warm unit. An observation on 12/17/20 at 5:30 AM revealed LA C was at the front desk being screened by the Administrator. LA C was having her temperature checked and was asked about signs and symptoms of COVID-19, travel, and possible exposure. In an interview and record review on 12/17/20 at 5:30 AM with the Administrator revealed LA C was being screened for COVID-19. When asked why LA C was being screened after she had been working the Administrator stated she was not sure and thought LA C had just arrived for work. The Administrator confirmed through a record review of the employee screening tool sheet did not show evidence that LA C was screened before 5:30 AM. In an interview on 12/17/20 at 5:40 AM with LA C revealed she arrived for work at 4:45 AM and had been passing clothes to residents on the 500-hallway. LA C stated she could not find anyone to screen her when she arrived and went to work. LA C said she knew she had to be screened daily but she was worried about the residents not having clothes to wear when staff started to wake them up. LA C confirmed she was screened by the Administrator a few moments prior to this interview but had already been working on her assigned job duties before being screened, including entering resident rooms on the 500-hallway. Record review of the facility's COVID-19 Daily Employee Symptom Screening Tool sheets and LA C's time sheet for 12/16/20 revealed the following: On 12/16/20, LA C clocked in for work at 5:03 AM but was not screened until 6:00 AM. Record review of the facility's COVID-19 Daily Employee Symptom Screening Tool sheets and MA B's time sheets from 12/01/20 to 12/18/20 revealed the following: On 12/03/20, MA B clocked in for work at 5:40 AM but was not screened until 7:00 AM. On 12/04/20, MA B clocked in for work at 5:40 AM but was not screened until 7:10 AM. On 12/07/20, MA B clocked in for work at 5:39 AM but was not screened until 7:15 AM. On 12/08/20, MA B clocked in for work at 5:40 AM but was not screened until 7:00 AM. On 12/09/20, MA B clocked in for work at 5:42 AM, but was not screened until 7:00 AM. On 12/14/20, MA B clocked in for work at 5:36 AM, but was not screened until 7:00 AM. On 12/16/20, MA B clocked in for work at 5:48 AM, but was not screened until 6:05 AM. All screenings were conducted by Receptionist AA based on the provided COVID-19 Daily Employee Symtpom Screening Tool sheets. In an interview on 12/18/20 at 11:30 AM with MA B revealed she arrived to work around 5:45 AM each day. MA B stated she was screened every day but she would not provide any information related to what she did from the time she clocked in for work to when she was screened. MA B refused to answer further questions. In an interview and record review on 12/18/20 at 11:40 AM with Receptionist AA revealed she arrived to work between 5:00 AM and 6:00 AM each day, based on the screening needs. Receptionist AA revealed she used the COVID-19 Daily Employee Symptom Screening Tool sheets for all staff who come in for work or to the building. Receptionist AA stated she wrote the date, time, and name of the person being screened and then took their temperature. Receptionist AA said she asked the employee a list of designated questions related to symptoms of COVID-19, exposure, and travel. Receptionist AA said the staff who arrived to the facility before she did must go to the closest nurse's station to be screened which she identified as the memory care unit. Receptionist AA said if she noticed an employee not being screened when they came in it would be reported to management and disciplinary action would occur. In a record review of the screening tool sheets where it was noted a time and date, Receptionist AA confirmed that was when the employee was screened by her or to the best of her ability, about that time. Receptionist AA said she could not determine if MA B had come to be screened from the hallway or the front door each day. Receptionist AA said she had a lot of things to do and keep track of and did not always pay attention as to where the staff were coming from to be screened. Receptionist AA said most of time around shift change she had a line of people and was just trying to screen everyone so they could start their day. Receptionist AA said she had not noticed that MA B was coming in to be screened later than her shift started. Record review of the facility's COVID-19 Daily Employee Symptom Screening Tool sheets and Cook A's time sheet for 12/10/20 revealed there was no evidence to show she was screened after clocking in that day. In an interview on 12/18/20 at 4:42 PM with the Administrator revealed Cook A had tested positive earlier in the week. In an interview on 12/17/20 at 11:40 AM with ICP Nurse revealed all staff must be screened before beginning work. ICP Nurse said the memory care nurse was expected to screen staff between 10:00 PM and 6:00 AM since neither receptionist was at the front desk to do so. She said staff were not allowed to screen themselves, no matter how early they got to the facility. The ICP Nurse said if there was no one at the front, it was expected for staff to call someone to screen them and inform the DON or Administrator if there was no one to screen them at the front. The ICP Nurse said the concern of staff not being screened was that it was a normal infection control practice for the facility to prevent the spread of infection. In an interview on 12/17/20 at 12:30 PM with ADON E revealed all staff must be screened before beginning work. ADON E said someone was always at the front desk but could not identify who the night shift screener was. ADON E said if there was not someone at the front desk and staff arrived for work they would need to wait for a screener but were expected to check their own temperature with the thermometer. ADON E said staff could not complete the questionnaire on their own. ADON E stated an alternate screener would be a nurse but that there was not one designated for overnight. ADON E said the importance of being screened was due to COVID-19 and the pandemic and staff needed to be cleared for work. In an interview on 12/17/20 at 1:05 PM with ADON F revealed all staff must be screened by a qualified staff member which was usually the receptionist. ADON F said they did not have a receptionist overnight but the nurse on the memory care unit was expected to screen staff. ADON F said staff should call the nurse to be screened or go to the memory care unit to be screened before beginning work. ADON F said the importance of staff being screened before work was to check them for signs or symptoms of COVID-19 due to the vulnerable residents in the facility. In an interview on 12/17/20 at 1:24 PM with the DON revealed all staff must be screened before work. The DON said there were two receptionists during the day and a memory care nurse overnight to screen staff. The DON said staff must wait to be screened and were not allowed to go through the building in search of someone to screen them. It was expected for staff to wait until the screener returned to the front desk or for staff to contact the screener or contact the number posted on the front door. The DON said the importance of being screened before work was to not spread COVID-19 or something contagious through the building. The DON said staff had been educated multiple times not to start work until they had been screened first. In an interview on 12/17/20 at 1:38 PM with the Administrator revealed all staff were supposed to be screened by the receptionist or whoever was available. The Administrator said one receptionist arrived between 5:30 AM and 6:00 AM, but the staff who arrived prior to that were screened by the evening shift staff. The Administrator said the majority of evening shift staff were able to screen others except for a few new staff since the nighttime receptionist left at 10:00 PM and the morning receptionist did not arrive until the morning. The Administrator said it was the night shift floor staff's responsibility to make sure staff who come in late or early were screened. The Administrator said if staff were not at the front desk to screen them, they needed to flag someone down or call someone to the front desk. The Administrator said the importance of staff being screened before working was to ensure they were within the guidelines and expectations to not spread COVID-19 or other infectious diseases to residents or staff. In a follow-up interview on 12/18/20 at 1:25 PM with the DON revealed the time on the screening tool sheet was the time the receptionist screened that employee. The DON confirmed that MA B was being screened after clocking in for her shifts. The DON said the time clock for employees was through the lobby and around the corner through the double doors to another hallway near the Administrator's office. The DON did not say what MA B was doing between clocking in and being screened and refused to provide an answer due to not being there herself. The DON also refused to comment on LA C's 12/16/20 finding (referring to LA C clocking in an hour before it was documented that she had been screened) and made a comment that's what started all of this mess. The DON also replied with perfect when referring to Cook A not being screened on 12/10/20. In a follow-up interview on 12/18/20 at 4:42 PM with the Administrator revealed the time on the screening form was the time the employee was screened. The Administrator stated staff could clock in before being screened although it was not the preference. The Administrator confirmed MA B's, Cook A's, and LA C's timing of being screened did not match up to their clock in times. The Administrator did not comment on the gaps in time. Record review of the facility's undated policy, titled Coronavirus Management Plan Texas Phase 3 (Known Cases in Facility), revealed 2. Monitoring .Monitor Staff at beginning (prior to entering the facility) . 2. Record review of Resident #46's face sheet, dated 12/20/20, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #46's consolidated physician's orders [REDACTED]. Record review of Resident #52's face sheet, dated 12/20/20, revealed she was a [AGE] year-old female readmitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #52's consolidated physician's orders [REDACTED]. In a continuous observation on 12/17/20 at 6:40 AM revealed MA B took Resident #46's blood pressure using a blood pressure cuff. At 6:45 AM MA B took Resident #52's blood pressure using the same blood pressure cuff. The blood pressure cuff had not been sanitized or disinfected between uses. In an interview on 12/17/20 at 6:48 AM with MA B revealed she did not clean the blood pressure cuff between each resident. MA B said she only cleaned the blood pressure cuff when she went to the memory care unit after checking the general population resident's blood pressures. MA B stated she had wipes on her medication cart to use and would clean the blood pressure cuff if it touched non-intact skin. MA B explained that non-intact skin was if the resident had a tear or bruise. MA B confirmed she took the blood pressure for most residents since she also passed their medications. MA B said the reason she did not clean the blood pressure cuff between each resident was because it would damage the device. In an interview on 12/17/20 at 11:40 AM with the ICP Nurse revealed staff should use wipes to clean any medical equipment that touched a resident. ICP Nurse explained that medical equipment should be cleaned between each resident. ICP Nurse said the wipes provided to staff would not damage the medical equipment and the purpose of doing so was to not spread anything to other residents. In an interview on 12/17/20 at 12:30 PM with ADON E revealed medical equipment needed to be cleaned after each resident each time. ADON E said staff had access to wipes and could use those to clean a blood pressure cuff without damaging it. ADON E said the purpose of cleaning the device was to not spread infections to other residents. In an interview on 12/17/20 at 1:05 PM with ADON F revealed blood pressure cuffs should be wiped down between each resident to not spread infection to others. In an interview on 12/17/20 at 1:24 PM with the DON revealed staff should sanitize medical equipment between each use and make sure they were using clean equipment each time. The DON said staff had access to wipes and the purpose of cleaning the equipment was not spread an infection to other residents. In an interview on 12/17/20 at 1:38 PM with the Administrator revealed staff should use cleaning materials available to them to sterilize medical equipment in between residents. The Administrator said the facility used disinfectants that were confirmed to kill COVID-19 and was not aware that they would damage any equipment staff were using. The Administrator said the purpose of disinfecting the equipment was to not spread an infection to another resident. Record review of the facility's undated policy, titled Coronavirus Management Plan Texas Phase 3 (Known Cases in Facility), revealed 4. Infection Control .Clean and Disinfect facility .equipment (blood pressure cuffs) clean and disinfect after each use . 3. Record review of Resident #46's face sheet, dated 12/20/20, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #46's care plan, dated 12/20/20, revealed it did not address a behavior of wandering or entering the soiled linen closet. An observation on 12/17/20 at 4:40 AM revealed Resident #46 in a wheelchair in the 500-hallway soiled utility room across the hall from her room. Resident #46 had wheeled herself in the utility room and was attempting to throw trash away. Also observed were eleven bags of trash piled on top of two trash bins and the floor, including two biohazard red trash bags. An interview on 12/17/20 at 4:45 AM with CNA G revealed maintenance arrived later in the morning to take the trash out of the soiled linen/utility room. CNA G confirmed there were eleven bags of trash piled on top of trash bins and on the floor with two biohazard red trash bags as well in the utility room. CNA G said she was not sure who put the red biohazard trash bags in the room because she knew they were supposed to go around the corner in a different closet. CNA G said the soiled utility room looked like that every night shift she worked and had been that way for a few weeks now. CNA G confirmed the door was not locked and said the lock broke about a month ago. CNA G said it was the maintenance department's responsibility to replace the lock and ensure the trash was taken out. CNA G said she was only responsible for taking residents' trash to the soiled utility room and placing it in the trash bins but since they were already full, she had to place it on the floor. CNA G said Resident #46 wheeled herself into the closet daily and it was difficult to stop her from doing so. An interview on 12/17/20 at 4:55 AM with RN H revealed she knew the 500-hallway soiled utility room was full of trash that was overflowing, had trash bags on the floor and contained red biohazard trash bags as well. RN H said the red biohazard trash bags should have been placed in the biohazard room around the corner and not in the soiled linen room. RN H said her responsibility was to put the trash in the room and it was the maintenance department's responsibility to pick up the trash. RN H said she observed Resident #46 entering the soiled linen room often and had to redirect her. RN H said the lock was removed a while ago and could not provide a timeframe, but confirmed it was not locked. An interview on 12/17/20 at 6:35 AM with the Maintenance Director revealed he had two shifts for floor techs who picked up the trash from the soiled utility closets. The Maintenance Director said when the floor techs arrived to work that was the first duty they completed, was emptying out the rooms. The Maintenance Director said the floor techs also picked up the trash from the rooms during the day as it became full. The Maintenance Director said he knew the lock on the 500-hallway soiled linen room was broken and had been for about a month. The Maintenance Director said the facility looked at ordering another one, but it was too expensive. The Maintenance Director said he had not been informed about a resident going into the unlocked soiled linen room. An interview on 12/17/20 at 6:59 AM with Floor Tech I revealed he was responsible for picking up the trash in soiled linen closets. Floor Tech I said he arrived to work around 6:00 AM and went to each soiled linen closet to pick up the trash. Floor Tech I said he also went back to the closets at 11:00 AM and 2:00 PM to pull more trash because it filled up quickly. Floor Tech I stated the trash did pile up so it was difficult to open the door at times and confirmed this occurred every morning when he started his shift. Floor Tech I said this morning he noticed there was a few red biohazard trash bags in the 500-hallway soiled linen room and they should not have been there. Floor Tech I said he was not sure who put them in there, but all staff knew that red biohazard trash bags were supposed to go to the biohazard room and not the soiled linen closet. An interview on 12/17/20 at 10:08 AM with CNA J revealed she had to redirect Resident #46 multiple times a week because she was found in the soiled linen closet on the 500-hallway. CNA J stated Resident #46 was easily redirectable, but they had to watch her closely. An interview on 12/17/20 at 10:10 AM with LVN K revealed he had to redirect Resident #46 multiple times a week because she had a habit of going into the soiled linen closet on the 500-hallway. LVN K said it was hard to watch Resident #46 because she had this behavior so often and it was triggered by trash. LVN K explained if there was a piece of paper or trash on the floor in the hallway or in Resident #46's room, she would pick it up and wheel herself to the soiled linen closet to throw it away instead of using a trash can. An interview on 12/17/20 at 11:40 AM with ICP Nurse revealed the facility had a closet for red biohazard trash bags and none of them should be put in the soiled linen closet. The ICP Nurse said she saw the soiled linen closet earlier and noticed there was trash and boxes everywhere. The ICP Nurse said she sometimes saw the trash overfilling and told the floor tech about it. The ICP Nurse said the soiled linen closet did not have a lock on it and that residents should not be allowed to go into the room. ICP Nurse said that if a resident continued to enter the soiled linen closet a lock needed to be placed on it. ICP Nurse said it was an infection control concern if a resident was in the room because there were germs, feces, urine, and bodily fluids in there. ICP Nurse said she had not heard or seen residents in the soiled linen closet. An interview on 12/17/20 at 12:30 PM with ADON E revealed the maintenance department emptied the trash out of the soiled linen closets and the closet should be locked. ADON E said the reason it needed to be locked was because residents could wander in the closet and that was not a good thing because there was soiled linen and trash in the closet. ADON E said there should also not be any red biohazard trash bags in the soiled linen closet and that those belonged in the biohazard room around the corner. An interview on 12/17/20 at 1:05 PM with ADON F revealed red biohazard trash bags with bodily fluids were placed in the biohazard room and trash was placed in the soiled linen closet in the trash bins. ADON F said the soiled linen closet was supposed to be locked because there were residents with dementia and it was important to their safety to not let them in the closet. ADON F stated Resident #46 constantly went into the soiled linen closet and had to be redirected. ADON F could not provide a time frame for how long the soiled linen closet had been unlocked for. ADON F stated staff could not watch Resident #46 at all times to ensure compliance with not entering the soiled linen closet but they knew to watch her when she was out of her room. ADON F said the risk of a resident entering the soiled linen closet was that they could contract an infection or something like that. An interview on 12/17/20 at 1:24 PM with the DON revealed soiled linen closets have soiled linen and trash in them. The DON stated she was informed there was an unlocked soiled linen closet on the 500-hallway thirty seconds before being asked about it now. The DON said she was not sure why staff did not tell her about it beforehand and was not sure how long it had been going on. The DON confirmed that all soiled linen closets needed to be locked for safety purposes because they contained urine, bio, feces, etc. An interview on 12/17/20 at 1:38 PM with the Administrator revealed the floor techs were responsible for taking the trash out of the soiled linen closets. The Administrator confirmed the soiled linen closet on the 500 hallway was unlocked and was unaware that the previous lock on it had stopped working and was removed. The Administrator said she was not aware Resident #46 had a behavior of going into the soiled linen closet. The Administrator said it was important to have a lock on the soiled linen closet to prevent any potential contamination of infections. On 12/18/20 the Administrator and DON were notified an Immediate Jeopardy was identified and a Plan of Removal was requested. The IJ template was provided. The facility's Plan of Removal was accepted on 12/19/20 at 2:26 PM and reflected the following: (Facility Name) 12/18/2020 Plan of Removal: 1. In-serviced all staff starting 12/18/20 to be completed on 12/20/2020 and will continue until all staff are in-serviced before beginning work. (Administrator) or designee will be conducting the in-service about the following. a. Temp checks at the beginning of each shift b. No self-screening c. Don't clock in until screened a. All soiled Linen closets must stay locked b. Notify maintenance, (Maintenance Director), if the lock is malfunctioned or broken, immediately. The in-service will be followed up with a post-test to ensure adherence to the content of the in-service. A quick reference document regarding the proper protocol is provided to staff for reference and posted on the units. (Administrator) will also monitor the compliance of this education by checking all staff has completed the in-service. 2. Staff who is on leave of absence or PRN who are unable to come to the facility due personal reason by 12/20/2020 will be in-serviced and answer post questions upon return to facility. Each staff member that is not able to come to the building and is not on medical leave will be educated via phone and asked post test questions. (Administrator) will also monitor the compliance of this education. 3. Doors will be locked 24 hours a day. Staff, visitors, or residents will not be permitted without supervised access. The person that is providing supervised access to the facility will ensure that the staff, visitors or residents are screened by the designated screener, who is the receptionist or designee from 5am until 10pm. From 10pm to 5am the screener will be the nursing staff. 4. (LA C) was suspended pending investigation on 12/17/2020. Directed in-service was completed with the laundry aide about appropriate screening protocols. Please reference #1 in-service topics. (Administrator) completed in-service on 12/17/20 5. (MA B) received a directed in-service on 12/18/2020. In-service was completed about appropriate screening protocols. Please reference #1 in-service topics. (Administrator) completed in-service on 12/18/20 6.(Cook A) received a directed in-service. In-service was completed about appropriate screening protocols. Please reference #1 in-service topics. (Dietary Manager) completed in-service on 12/17/20 7. Soiled linen room locks were replaced 12/17/2020. Audit was done to ensure all soiled linen rooms had working locks by maintenance director on 12/17/2020 and completed on 12/17/2020 by (Maintenance Director). There were 3 doors that he changed the lock component on. 8. (Administrator) or designee will be conducting the in-service about the following for all staff. Started on 12/18/2020 and completed on 12/20/2020. 9. (MA B) received a directed in-service. In-service was completed about disinfecting medical equipment shared between residents. (Administrator) completed in-service on 12/18/20 10. In-serviced all clinical staff starting 12/18/20 and will continue until all clinical staff are in-serviced before beginning work on 12/20/2020. (Administrator) or designee will be conducting the in-service about the following. a. Medical equipment must be disinfected between each resident. This includes but is not limited to BP cuff, shower chairs, and glucometer The in-service will be followed up with a post-test to ensure adherence to the content of the in-service. A quick reference document is provided to staff for reference and posted on the unit. 11. Audits were completed to ensure all clinical staff are disinfecting medical equipment between residents. These audits were completed on 12/19/20 and will be done by the (DON) or designee, daily. 12. Audits were completed to ensure all staff are screened prior to clocking in. Team members clocking in times were pulled to compare to the time documented on the screening log. These audits were completed on 12/19/20. (Administrator) or designee completed the audits and will be conducted daily. 13. Medical Director notified by DON on 12/18/20. 14. (Regional Director of Operations) or designee will oversee the plan of removal compliance. Monitoring of the Plan of Removal included: Review of the facility's in-service records revealed the facility staff including CNAs, LVNs, RNs, MAs, dietary aides, housekeepers, laundry aides and so on, had completed in-services, covering all shifts, for the following topics from 12/18/20 to 12/20/20 (total of 88 staff) prior to working: -All soiled linen closets must stay locked. Notify maintenance if malfunctioned or broken -Disinfecting medical equipment between residents -Screening staff/visitors process, updated form, (temperature low and high), self-screening, designated screeners: 1. Normal ranges of (temperatures) for screening (greater or equal to) 96.0-99.5 (degrees Fahrenheit), when abnormal - re-check again, follow screening tool guidelines. 2.(Temperature) checks only at the beginning of each shift. 3.No self-screening 4.Fill out all sections of screening as indicated 5.Staff must be screened by a designated screener: 6 AM- 10 PM - screener, 10 PM - 6 AM - Nursing staff (screener) -Updated COVID-19 Screener Competency (which indicated completion of competency qualified staff to be screeners) -Post-test (which tested staff on being screened prior to clocking in, whether staff could work prior to getting screened, whether staff could self-screen or not, and if staff should notify the Administrator or Maintenance staff if the soiled/linen room doors were unlocked/malfunctioned) Review of the facility's audit regarding ensuring medical equipment was disinfected between use, dated December 2020, revealed the facility created a QAPI monitoring tool in order to ensure compliance, requiring signatures, date of compliance and indicating action was in compliance or not. Review of the facility's audit regarding screening revealed the facility created a Screening Audit tool, undated, in order to ensure compliance, which required the date of the audit, staff member being audited, their punch-in time, the time they were screened, and the auditor's initials. Interviews conducted on 12/19/20 from 4:50 AM to 11:00 PM with staff from all three shifts, including weekend staff, revealed staff were knowledgeable in the appropriate screening procedures, were aware who designated screeners were, ensuring soiled/linen doors were locked and the importance, and ensuring medical equipment were sanitized between each resident. The interviewed staff included: Maintenance Director, LVN L, Admissions Director, Staffing Coordinator, Receptionist M, Dietary Aide N, Housekeeper O, CNA P, LVN Q, LVN R, Cook S, RN T, Dietary Aide U, CNA V, CNA W, LVN X, LVN Y, and CNA Z. An IJ was identified on 12/18/20. While the IJ was removed on 12/20/20, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to ensure residents were free of significant medication errors for two (Residents # 1) of fifteen residents reviewed for significant medication errors. The facility failed to ensure Resident #1, who did not have a pancreas to produce insulin, received insulin and routine blood sugar checks as ordered for six days which resulted in a significant change in condition and required emergent intervention in the hospital. An Immediate Jeopardy (IJ) was identified to have occurred from 09/15/20 through 09/20/20. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. This failure placed residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician, change in condition, and death. Findings included: Review of Resident #1's face sheet dated 09/23/20, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with readmission on 09/14/20. He was discharged on [DATE]. He had a [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders for insulin revealed the following discontinued orders (including screen shots of previous orders ): Humalog Kwik Pen 100 unit/ml Sub-Q Pen (Insulin [MEDICATION NAME]) units per sliding scale subcutaneous before meals Site location 0-60 = 0 units, 61-149 = 0 units, 150-199 = 2 units 200-249 = 4 units 250 -299 = 6 units, 300- 349 = 8 units 350 or greater than 10 units MD Call. Diagnosis: [REDACTED]. Start Date: 09/14/20 Entered by LVN B on 09/14/2020 at 3:53 PM D/C by DON on 09/15/2020 at 2:04 PM. Humalog Kwik Pen 100 unit/ml Sub-Q Pen (Insulin [MEDICATION NAME]) units per sliding scale subcutaneous before meals Site location 0-60 = 0 units, 61-149 = 0 units, 150-199 = 2 units 200-249 = 4 units 250 -299 = 6 units, 300- 349 = 8 units 350 or greater than 10 units MD Call. Diagnosis: [REDACTED]. Start Date: 09/14/20 Entered by DON on 09/15/20 at 2:04 PM D/C by DON on 09/15/20 at 2:05 PM. Review of Resident #1's physician's orders for blood sugar checks revealed the following orders (including screen shots of previous orders): Finger stick blood sugar/Accu-Chek 1 stick as needed Hyper/Hypoglycemic can complete if high blood sugar or symptomatic if < 60 or > 350 call MD. Blood glucose check. Start Date: 09/14/20 Finger Stick Blood sugar/Accu-Chek 1 stick before meals and at bedtime can complete if high blood sugar or symptomatic if less than < 60 or greater than > 350 call MD. Blood glucose check. Start Date : 09/20/20 Review of Resident #1's electronic clinical record revealed there were no active orders for insulin and routine blood sugar checks from 09/15/20-09/20/20. Review of Resident #1's electronic Medication Administration Record [REDACTED]< (less than) 60 or > (greater than) 350 call MD. Blood glucose check Diagnosis: [REDACTED]. Humalog Kwik Pen 100 unit/ml Sub-Q Pen (Insulin [MEDICATION NAME]) units per sliding scale subcutaneous before meals Site location 0-60 = 0 units, 61-149 = 0 units, 150-199 = 2 units 200-249 = 4 units 250 -299 = 6 units, 300- 349 = 8 units 350 or greater than 10 units MD Call. Diagnosis: [REDACTED]. Record review of Resident #1's electronic MAR for September 2020 revealed there was no documentation of Resident #1's blood sugar levels being tested or insulin being administered on 09/15/20, 09/16/20, 09/17/20, 09/18/20, 09/19/20, and 09/20/20. Review of Resident #1's progress notes revealed: 09/14/2020 (Resident #1) arrived at 2:45 pm via Wheelchair Transport from Acute Care hospital. (Resident #1) escorted via wife. (Resident #1) to be followed by (Doctor). Dx of : [DIAGNOSES REDACTED], DM2, . BSFS checked and noted at 141 mmhg. No noted acute distress at this time. Completed By (LVN K ) 09/14/2020 04:19 PM. Review of Resident #1's progress notes revealed: 09/20/2020 at 2:30pm (Resident #1) in bed, resting and able to open eyes to voice stimuli. V/S 132/72 (blood pressure), 74 (pulse), 97.1 (temperature), 94% (oxygen saturation) at room air. 3:30 pm, (Resident #1) family visiting and at the resident room window. Assisted (Resident #1) to a sitting position on a w/c. (Resident #1) not responding to family per making eye contact. Blood sugar check done per his wife request. Blood sugar reading was (High) after 2nd check. Called and informed (Doctor) , new order for AC and HS Acc check per sliding scale and to give 10 units of [MEDICATION NAME]now. (Resident #1) wife aware of of new order.4:50 pm, ( Resident #1) blood check done and reads (High). (Doctor) informed and new order to administer another 10 units now and call after 1 hrs. Draw lab for Hg A1c in am noted, and MAR updated. (Resident #1) wife called on phone and notified of reading and new order. 5:30 PM, (Doctor) called with blood sugar reading of (High) and in the processing of speaking with (Doctor) on phone, Ambulance came in to pick (Resident #1) to the ER per Resident wife request. (Doctor) aware of this at this time and said its ok to transfer resident to the ER per Resident family request. (Resident #1) wife was called at 5:40 pm, and she states she did called in the Ambulance to transfer the resident to (hospital) ER. Completed By (LVN M) 09/20/2020 09:23 PM. Review of Resident #1's hospital records revealed: date of service 09/22/20 assessment plan (Resident #1 is a [AGE] year-old male . He was recently discharged from this facility to (SNF) after being treated for [REDACTED]. The patient was unresponsive and brought to ED. Septic shock unknown of the source, UA negative, may have aspirated . DM2 (Diabetes Mellitus Type 2) no pancreas. Acute Metabolic [MEDICAL CONDITION] (altered mental state cause by other health conditions such as diabetes)- baseline fully mentated with slowness due to previous [MEDICAL CONDITION]-CT head negative for acute process, MRI may be beneficial but this is likely metabolic given above Ammonia and UDS negative, following simple commands. Data Review recent labs dated 09/20/20 GLU- 586, BUN 110. In an interview on 09/22/20 at 2:26 PM the Administrator and DON revealed Resident #1 was sent out on 09/20/20 to the hospital due to a change in condition. They stated Resident #1's wife was visiting with the resident through the window and he was not oriented. DON stated that the nurse took Resident #1's blood sugar and it read high on the glucometer. The nurse notified Resident # 1's physician and received an order to give Resident # 1 [MEDICATION NAME] 10 units. The nurse waited one hour to see if there was any impact and when Resident #1's blood sugar was still high she contacted the physician. She received an order to give another 10 units of insulin, but Resident #1's blood sugar remained elevated so he was sent out to the emergency room . In an interview on 09/22/20 at 2:56 PM the Administrator stated when Resident #1 admitted to the facility he had an order for [REDACTED]. Administrator stated the facility conducted an investigation to determine why Resident #1's order for insulin and blood sugar checks were discontinued. She stated the facility determined that there was glitch in their computer system. Resident #'1's order for insulin was modified and during the modification the computer system put an end date to Resident #1's order for insulin and discontinued it. She stated that this was the first time the facility noticed there was an issue. She stated the facility had conducted several in-services due to this incident. She also stated they had reached out to the computer system administrator to have them complete an investigation. The facility created a new process for modification of orders, new process for nursing communication in regards to diabetics/residents with insulin and involved the regional leadership to ensure that type of glitch did not occur in the future. She stated the DON had made the modification to Resident #1's insulin order that was already entered. She stated Resident #'1's initial order for insulin did not include the parameters. In an interview on 09/22/20 at 3:13 PM the DON revealed after Resident #1 went to the hospital she started an investigation. She stated she knew Resident #1 had an order for [REDACTED].#1's insulin medication was modified and determined the same day the computer system entered an end date to the order and it discontinued the medication. She stated she clicked the edit button on the insulin order and entered the parameters, and when to notify the MD. She then clicked save mortify. She stated she entered the modification on 09/15/20 the day after Resident #1 admitted to the facility at 2:04 PM and at 2:05 PM the computer system discontinued the medication. She stated she reviewed Resident #1 admissions orders the next day 09/15/20 in the clinical morning meeting. She stated she reported the error immediately after she reviewed Resident #1's medication after he was transferred from the hospital. She stated the facility's corporate office started working with the computer system to break down each click that was made after she reported that Resident #1 medication order for insulin had been discontinued. She stated that facility had completed a 100 percent audit on all the residents receiving insulin/blood sugar checks and determined that Resident #2's order for insulin was discontinued. She stated the ADON made a modification to Resident #2's insulin order . She stated Resident #2 had not had any adverse effects from missing his insulin. DON did not stated when Resident #2 insulin order was modified. Interview on 09/22/20 at 5:15 PM with the DON revealed she was responsible for ensuring that orders were entered correctly. She stated when Resident #1 had admitted on [DATE] it was in the evening time. She stated the next day, 09/15/20, she reviewed Resident #1's admission paperwork and that was when she made modifications to Resident #1's order at 2:04 PM. She stated the system somehow discontinued Resident #1's order for insulin. She stated the order contained both the blood sugar check and the insulin order and when the modification was made it deleted the both. She stated Resident #1 had PRN order to check blood sugar. She stated unless the resident was showing symptoms, staff did not have to check residents' blood sugar. She stated LVN K was the nurse who had admitted Resident #1 on 9/14/20. Interview on 09/23/20 at 10:20 AM with Resident #1's family member revealed Resident #1 went to the hospital on Sunday 09/20/20. Family member stated that Resident #1 had problems with blood sugar dropping and blood pressure, the prior night, but made it through the night. Family member stated they had spoken with Resident #1 throughout the week prior to him being admitted to the hospital and on Thursday Resident #1 informed them that he was not feeling well. He told them that the facility was not giving him any insulin. Family member stated at the time they thought Resident #1 may had been confused. Family member stated they called the Resident #1 Friday and never got an answer, so they drove up to the facility and told the facility they wanted to have Resident #1 discharged . They stated they were informed by a staff member that they could not remove Resident #1 unless they paid out of pocket for the week Resident #1 had been living at the facility. Family member stated on Saturday they called Resident #1 and were unable to reach him. Family member stated on Sunday 09/20/20 they had a family meeting outside Resident #1's room. They stated that Resident #1's blinds were pulled and they could see the resident laying down in his bed, one leg was touching the floor. Family member stated they asked Resident #1's nurse to put him in the wheelchair, and they noticed that the resident was unconscious, sagging in his wheelchair, looking down at the floor, and his right hand was shaking. Family member stated they asked the nurse that brought Resident #1 to the window what his blood sugar was. Family member stated the nurse asked why they were asking about Resident #1's blood sugar since he was not diabetic. Family member stated they asked the nurse to bring the medication Humalog, the resident's insulin that he was to take with each meal. Family member stated the nurse informed them the he would call the doctor. Family member stated Resident #1 had not had a pancreas for [AGE] years, he was extremely diabetic, and was unable to make any insulin. Family member stated the nurse called the doctor and received an order to give Resident #1 ten units of insulin. Family stated that the nurse waited another hour, retested Resident #1 blood sugar, but the blood sugar still read high on the [MEDICATION NAME] meter. The family member stated the nurse called the physician back and was told to administer another 10 units of insulin. Family member stated they called the paramedics and informed them they wanted a welfare check completed on Resident #1. Family member stated paramedics arrived at the facility and Resident #1's blood sugar was still reading high, they stated Resident #1 was transferred to the hospital. Family member stated Resident #1 had been in critical condition ever since he left the facility, and was non-responsive. Family member stated the hospital was completing an MRI to determine if there had been any damage done. Family member stated the nurse in the ER told the paramedics that Resident #1 had not had insulin the whole week and his blood sugar could have been as high as 900 based on the insulin given while he was in the hospital and his blood sugar level sill reading high. Family member stated that it was hard to imagine that Resident #1 could change within a week. Family member stated when Resident #1 arrived at the nursing facility he was able to shave himself and walk to and from the bathroom. Family member stated they did not remember the name of the nurse that was working with Resident #1 on 09/20/20. An interview on 09/23/20 at 11:54 AM with the Medical Director revealed Resident #1 still in ICU. He stated Resident #1's blood pressure and hemodynamics were good as of 09/22/20. He stated Resident #1 mentally waxed/waned and was confused at times. He stated that this was not off from Resident #1's baseline. He stated tube feeding was started for blood sugar regulation. The Medical Director revealed an MRI showed the resident had an acute stroke or recent small stroke of the left parietal lobe, but that it was unclear when it occurred. The Medical Director stated Resident #1's highest blood sugar was 586 and blood draw was 578. The Medical Director was asked would the lack of insulin contribute to a stroke. He stated it would not from a volume deficient aspect, the high blood sugar would have caused dehydration. Medical Director stated when he spoke with the staff he expressed the concern of the dehydration. The Medical Director stated he did not believe any long-term harm had occurred due to lack of insulin. The Medical Director did not indicate there was a correlation between the stroke and the insulin not being received by Resident #1. Medical Director stated Resident #1 was answering to his name. He was noted to be alert to self but confused to place, following simple commands. He stated there was concern of possible aspiration from stroke or mental status change. He stated the hospital had started broad spectrum antibiotics. The Medical Director stated when orders were being modified in the computer system, the orders were falling off. He stated that the facility was making sure the nursing staff reconciled the orders. He stated the orders should not be modified but discontinued and reentered. He stated the facility would be reconciling the orders going forward. Review of the facility policy titled, Medication Guidelines and clinical practice dated 02/12/20 revealed: Staff will provide medication in accordance with standard practice and guidelines. Review of the facility policy titled, Physician orders Electronic dated 02/12/20 revealed: 1. The licensed nurse will receive and transcribe the physicians' orders according to practice guidelines. 2. The licensed nurse staff will prove resident s with medication and treatment as ordered The Administrator, and DON were notified on 09/24/20 at 1:43 PM, that an Immediate Jeopardy existed from 09/01/20 to 09/21/20. The Administrator was provided with the IJ template at this time. The facility took the following corrective actions prior to entrance on 09/22/20: The DON and ADON were provided one to one in-service on 09/22/20 regarding change of order, 24 hour report, pull orders daily, review, print place in binder daily including Saturday and Sunday. The in-service was provided by RN A. The DON and ADON were provided one to one in-service on 09/22/20 regarding change of shift report. The in-service was provide by RN A. The DON and ADON completed an audit on 09/21/20 of all the residents that were diabetic and received insulin and no other medication issues were noted. All nursing staff were provided nurse competencies assessment On 09/21/20 staff were provided in-service by the DON regarding Diabetes Toolkit-treatment of [REDACTED]. On 09/21/20 all nurses and CMA's was provided in-service by the DON titled, Effective immediately nurses are not to edit/modify any order if any corrections needs to be done, you must discontinue the order re-enter the order and the corrections. On 09/21/20 staff were provided in-service by ADON C titled change of shift report policy and procedures. On 09/21/20 staff were provided inservice by ADON C titled, Clinical operations. On 09/21/20 staff were provided in-service by ADON C titled, Daily clinical start up meeting. On 09/21/20 staff were provided in-service by DON titled, [DIAGNOSES REDACTED] and [MEDICAL CONDITION] signs and symptoms. On 09/21/20 staff were provided in-service by DON titled Change of Condition Care Path Symptoms of Acute Mental Status Change. On 09/21/20 staff were provided in-service by DON titled, Nurses to make sure they are receiving the change of order column on the dashboard under the 24 hour report. On 09/21/20 staff were provided in-service by DON titled, Effective immediately nurse must document and make known on 24 hour report of diabetics On 09/21/20 staff were provided in-service by Don titled, Medication Error: Reporting and management. In an interview on 09/22/20 at 6:07 PM the ADON revealed the facility had placed on the 24-hour report an asterisk mark by the resident name once a resident medication had been discontinued. The staff were able to look to see if there were any changes on the 24-hour report, staff had the option of asking more question about why medication has been discontinued. In an interview on 09/23/20 at 9:06 AM, DON revealed on 09/22/20 the facility reached out to the Corporate clinical nurse regarding They have escalated it up to programing team so they and fix this problem when modifications are made. She stated the option to edit orders had been removed. She stated staff would need to discontinue an order and re-enter it. She stated when a nurse would discontinue an order, they would have to put in their pin number. She stated the facility could check every click that staff made. She stated she knew she did not discontinue Resident #1's insulin order. She stated to prevent that from happening again the staff would discontinue the medications and reenter She stated everything from 09/20/20 would be addressed in a QAPI plan. She stated it was a computer error, not a human error. She stated no other meds with parameters were affected and the facility had completed a system wide check of all the residents receiving insulin . She stated the facility Corporate was working with the computer programming company. They were taking the option of discontinuing or modifying away . She stated the change would be a corporate wide change. The DON stated the facility in-serviced the staff to cancel and re-enter orders instead of modifying them. She stated staff were to document on the 24-hour report every patient that was diabetic . In an interview with the Administrator on 09/23/20 at 9:53 AM, she revealed a Plan of Action had been developed during the QAPI meeting on 9/22/20 . The facility discussed the issue and ways to rectify the situation. She stated staff had been instructed to delete and make new orders instead of making modifications. She stated the Medical director was concerned for Resident #1 due to him not receiving the insulin. She stated the Medical Director was on the same page as the facility clinical leaders, Where's the glitch, how do we mitigate it. It can't happen again. Administrator stated that the issues was with the computer program. She stated the computer company and Corporate nurse were trying to find a solution immediately corporate wide. The Administrator stated the update that was provided from the Medical Director was that Resident #1's blood sugar had reached 598 in the hospital. Observation on 09/23/20 at 11:26 AM of medication pass revealed, a blood sugar check was done for Resident #3 by LVN L. She knocked, explained procedure to resident, washed her hands, gloved, and performed the blood sugar check with the alcohol pad, a new lancet, and a glucometer which was clean. The resident's blood sugar was 125. No insulin given. Interview with Resident #3 on 09/23/20 11:29 AM revealed the facility staff checked her blood sugar 4 or 5 times a day, before meals and at night. They give her insulin if she needed it, and they do it right. In an interview on 09/23/20 at 2:27 PM the ADON stated he had been trained not to modify orders in the computer because the facility had a computer problem. He stated if staff modified an order it would just disappear. He stated staff had been instructed after the incident occurred with Resident #1 to delete the orders and re-enter it but never modify. He stated that the facility's corporate office was trying to figure out what happened on the computer that caused it to discontinue the orders. The ADON stated Resident #2 was receiving 6 units of insulin every day, but then the order for insulin disappeared on 09/01/20. He stated the reason that the nurses did not notice that Resident #2's order was missing was because Hallway 500, where the resident resided, had not had a constant nurse assigned to the hallway that was administering insulin to Resident #2. In an interview with LVN H on 09/23/20 at 3:43 PM she stated the facility's procedures for modification to current orders was to discontinue the current order and input new order. Interview with LVN J on 09/23/20 at 4:01 PM revealed if there were modifications to an order that needed to be made staff had been instructed to discontinue the order and enter a new order.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure accurate acquiring, receiving, dispensing and administering of all drugs to meet the needs for two (Resident #1 and Resident #2) of 15 residents reviewed for pharmacy services. 1. The facility failed to have oversight procedures in place to verify the accuracy of orders after modifications of the residents' electronic medical record (EMR) which resulted in Residents #1 and #2 not receiving insulin or blood sugar checks after attempts to modify their insulin parameters resulted in the undetected deletion of related orders. 2. The facility failed to ensure Resident #1, who did not have a pancreas to produce insulin, received insulin and routine blood sugar checks as ordered for six days after related orders were unintentionally deleted from the Medication Administration Record [REDACTED]. 3. The facility failed to ensure Resident #2 received routine blood sugar checks and insulin if needed as ordered for 20 days which placed him at risk for [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified to have occurred from 09/01/20 through 09/21/20. This was determined to be a Past Noncompliance IJ due to the facility having implemented actions that corrected the noncompliance prior to the investigation. These failures placed residents at risk for serious illness, hospitalization and/or death. Findings included: 1. Review of Resident #1's face sheet dated 09/23/20, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with readmission on 09/14/20. He was discharged on [DATE]. He had a [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders for insulin revealed the following orders (including screen shots of previous orders): Humalog Kwik Pen 100 unit/ml Sub-Q Pen (Insulin [MEDICATION NAME]) units per sliding scale subcutaneous before meals Site location 0-60 = 0 units, 61-149 = 0 units, 150-199 = 2 units 200-249 = 4 units 250 -299 = 6 units, 300- 349 = 8 units 350 or greater than 10 units MD Call. Diagnosis: [REDACTED]. Start Date: 09/14/20 Entered by LVN B on 09/14/2020 at 3:53 PM D/C by DON on 09/15/2020 at 2:04 PM Humalog Kwik Pen 100 unit/ml Sub-Q Pen (Insulin [MEDICATION NAME]) units per sliding scale subcutaneous before meals Site location 0-60 = 0 units, 61-149 = 0 units, 150-199 = 2 units 200-249 = 4 units 250 -299 = 6 units, 300- 349 = 8 units 350 or greater than 10 units MD Call. Diagnosis: [REDACTED]. Start Date: 09/14/20 Entered by DON on 09/15/20 at 2:04 PM D/C by DON on 09/15/20 at 2:05 PM Review of Resident #1's physician's orders for blood sugar checks revealed the following orders (including screen shots of previous orders): Finger stick blood sugar/Accu-Chek 1 stick as needed Hyper/Hypoglycemic can complete if high blood sugar or symptomatic if < 60 or > 350 call MD. Blood glucose check. Start Date: 09/14/20 Finger Stick Blood sugar/Accu-Chek 1 stick before meals and at bedtime can complete if high blood sugar or symptomatic if less than < 60 or greater than > 350 call MD. Blood glucose check. Start Date : 09/20/20 Review of Order group report date from 09/22/20 through 09/22/20 revealed: (Resident #1) Finger stick blood sugar/Accuchek 1 stick, before meals and at bedtime. Can complete if high blood sugar or symptomatic if < 60 or > 350 call MD. Dx Type 2 diabetes mellitus without complications. admitted [DATE] start date 09/14/20 Review of Resident #1's electronic Medication Administration Record [REDACTED]< (less than) 60 or > (greater than) 350 call MD. Blood glucose check Diagnosis: [REDACTED]. Humalog Kwik Pen 100 unit/ml Sub-Q Pen (Insulin [MEDICATION NAME]) units per sliding scale subcutaneous before meals Site location 0-60 = 0 units, 61-149 = 0 units, 150-199 = 2 units 200-249 = 4 units 250 -299 = 6 units, 300- 349 = 8 units 350 or greater than 10 units MD Call. Diagnosis: [REDACTED]. Record review of Resident #1's electronic MAR for September 2020 revealed there was no documentation of Resident #1's blood sugar levels being tested or insulin being administered on 09/15/20, 09/16/20, 09/17/20, 09/18/20, 09/19/20, and 09/20/20. Review of Resident #1's hospital records revealed: date of service 09/22/20 assessment plan (Resident #1 is a [AGE] year-old male . He was recently discharged from this facility to (SNF) after being treated for [REDACTED]. The patient was unresponsive and brought to ED. Septic shock unknown of the source, UA negative, may have aspirated . DM2 (Diabetes Mellitus Type 2) no pancreas. Acute Metabolic [MEDICAL CONDITION] (altered mental state cause by other health conditions such as diabetes)- baseline fully mentated with slowness due to previous [MEDICAL CONDITION]-CT head negative for acute process, MRI may be beneficial but this is likely metabolic given above Ammonia and UDS negative, following simple commands. Data Review recent labs dated 09/20/20 GLU- 586, BUN 110. Review of Resident #1's progress notes revealed: 09/20/2020 at 2:30pm (Resident #1) in bed, resting and able to open eyes to voice stimuli. V/S 132/72, 74, 97.1, 94% at room air. 3:30 pm, (Resident #1) family visiting and at the resident room window. Assisted (Resident #1) to a sitting position on a w/c. (Resident #1) not responding to family per making eye contact. Blood sugar check done per his wife request. Blood sugar reading was Hi after 2nd check. Called and informed (Doctor) , new order for AC and HS Acc check per sliding scale and to give 10 units of [MEDICATION NAME]now. (Resident #1) wife aware of aware of new order.4:50 pm, ( Resident #1) blood check done and reads Hi. (Doctor) informed and new order to administer another 10 units now and call after 1 hrs. Draw lab for Hg A1c in am noted, and MAR updated. ( Resident #1) wife called on phone and notified of reading and new order. 5;30 PM, (Doctor) called with blood sugar reading of HI and in the processing of speaking with (Doctor) on phone, Ambulance came in to pick (Resident #1) to the ER per Resident wife request. (Doctor) aware of this at this time and said its ok to transfer resident to the ER per Resident family request. (Resident #1) wife was called at 5:40 pm, and she states she did called in the Ambulance to transfer the resident to (hospital) ER. Completed By (LVN M) 09/20/2020 09:23 PM. Review of Resident #1's progress notes revealed: 09/14/2020 (Resident #1) arrived at 2:45 pm via Wheelchair Transport from Acute Care hospital. (Resident #1) escorted via wife. (Resident #1) to be followed by (Doctor). Dx of : DM2, .and Pancreatic Ca (cancer). Denies any pain or discomfort at present Height checked and noted at 6 Foot/0 inches. Weight checked and noted at 210 lbs. BSFS checked and noted at 141 mmhg. 147/79 - 97.3 - 71 -18. (Medical Director) notified of new admission and orders verified .Completed By (LVN K ) 09/14/2020 04:19 PM. In an interview on 09/22/20 at 2:26 PM the Administrator and DON revealed Resident #1 was sent out on 09/20/20 to the hospital due to change in condition. They stated Resident #1's wife was visiting with the resident through the window and he was not oriented. DON stated that the nurse took Resident #1's blood sugar and it read high on the glucometer . The nurse notified Resident # 1's physician and received an order to give Resident # 1 [MEDICATION NAME] 10 units. The nurse waited one hour to see if there was any impact and when Resident #1's blood sugar was still high she contacted the physician. She received an order to give another 10 units of insulin, but Resident #1's blood sugar remained elevated so he was sent out to the emergency room . In an interview on 09/22/20 at 2:56 PM the Administrator stated when Resident #1 admitted to the facility he had an order for [REDACTED]. Administrator stated the facility conducted an investigation to determine why Resident #1's order for insulin and blood sugar checks were discontinued. She stated the facility determined that there was glitch in their computer system. Resident #'1's order for insulin was modified and during the modification the computer system put an end date to Resident #1's order for insulin and discontinued it. She stated that this was the first time the facility noticed there was an issue. She stated the facility had conducted several in-services due to this incident. She also stated they had reached out to the computer system administrator to have them complete an investigation. The facility created a new process for modification of orders, new process for nursing communication in regards to diabetics/residents with insulin and involved the regional leadership to ensure that type of glitch did not occur in the future. She stated the DON had made the modification to Resident #1's insulin order that was already entered. She stated Resident #'1's initial order for insulin did not include the parameters. The Administrator stated the facility determined that Resident #2's order for insulin was also discontinued during medication modification. She stated that Resident #2 was stable, and had not had any adverse effects from not receiving his insulin for 20 days. She stated she did not know how many dosages Resident #2 had missed. In an interview on 09/22/20 at 3:13 PM the DON revealed after Resident #1 went to the hospital she started an investigation . She stated she knew Resident #1 had an order for [REDACTED].#1's insulin medication was modified and determined the same day the computer system entered an end date to the order and it discontinued the medication. She stated she clicked the edit button on the insulin order and entered the parameters, and when to notify the MD. She then clicked save mortify. She stated she entered the modification on 09/15/20 the day after Resident #1 admitted to the facility at 2:04 PM and at 2:05 PM the computer system discontinued the medication. She stated she reviewed Resident #1 admissions orders the next day 09/15/20 in the clinical morning meeting. She stated she reported the error immediately after she reviewed Resident #1 medication after he was transferred from the hospital. She stated the facility's corporate office started working with the computer system to break down each click that was made after she reported that Resident #1 medication order for insulin had been discontinued. Interview on 09/22/20 at 5:15 PM with the DON revealed she was responsible for ensuring that orders were entered correctly. She stated when Resident #1 had admitted on [DATE] it was in the evening time. She stated the next day, 09/15/20, she reviewed Resident #1's admission paperwork and that was when she made modifications to Resident #1's order at 2:04 PM. She stated the system somehow discontinued Resident #1's order for insulin. She stated the order contained both the blood sugar check and the insulin order and when the modifications was made it deleted the both. She stated Resident #1 had PRN order to check blood sugar . She stated unless the resident was showing symptoms, staff did not have to check resident blood sugar. She stated LVN K was the nurse who had admitted Resident #1 on 9/14/20. Interview on 09/23/20 at 10:20 AM with Resident #1's family member revealed Resident #1 was having an MRI, he went to the hospital on Sunday 09/20/20. Family member stated that Resident #1 had problems with blood sugar dropping and blood pressure, the prior night, but made throughout the night. Family member stated they had spoken with Resident #1 throughout the week, and on Thursday Resident #1 informed them that he was not feeling well. He told them that the facility was not giving him any insulin. Family member stated at the time they thought Resident #1 may had been confused. Family member stated they called the Resident #1 Friday and never got an answer, so they drove up to the facility and told the facility they wanted to have Resident #1 discharged . They stated they were informed by a staff member that they could not remove Resident #1 unless they paid out of pocket for the week Resident #1 had been living at the facility. Family member stated on Saturday they called Resident #1 and were unable to reach him. On Sunday 09/20/20 family member stated they had a family meeting outside Resident #1's room. They stated that Resident #1's blinds were pulled and they could see the resident laying down in his bed, one leg was touching the floor. Family member stated they asked Resident #1's nurse to put him in the wheelchair, and they notice that resident was unconscious sagging in his wheelchair, looking down at the floor, and his right hand shaking. Family member stated they asked the nurse that brought Resident #1 to the window what his blood sugar was. Family member stated the nurse stated to them why are you asking about Resident #1's blood sugar, he is not diabetic. Family member stated they asked the nurse to bring the medication Humalog, the resident's insulin that he was to take with each meal. Family member stated the nurse informed them the he would call the doctor. Family member stated Resident #1 had not had a pancreas for [AGE] years, he was extremely diabetic, and was unable to make any insulin. Family member stated the nurse called the doctor and received an order to give Resident #1 ten units of insulin. Family stated that the nurse waited another hour, retested Resident #1 blood sugar, but the blood sugar still read high on the [MEDICATION NAME] meter. The family member stated the nurse called the physician back and was told to administer another 10 units of insulin . Family member stated they called the paramedics and informed them they wanted a welfare check completed on Resident #1. Family member stated paramedics arrived at the facility and Resident #1's blood sugar was still reading high, they stated Resident #1 was transferred to the hospital. Family member stated Resident #1 had been in critical condition ever since he left the facility, and was non-responsive. Family member stated the hospital was completing an MRI to determine if there had been any damage done. Family member stated the nurse in the ER told the paramedics that Resident #1 had not had insulin the whole week and his blood sugar could have been as high as 900 based on the insulin given while he was in the hospital and his blood sugar level sill reading high. Family member stated that it was hard to imagine that Resident #1 could change within a week. Family member stated when Resident #1 arrived at the nursing facility he was able to shave himself and walk to and from the bathroom. Family member stated they did not remember the name of the nurse that was working with Resident #1 on 09/20/20. An interview on 09/23/20 at 11:54 AM with the Medical Director revealed Resident #1 was still in ICU. He stated the issue was with Resident #1's health medical record and assumed the surveyor had spoken with the facility. He stated Resident #1's blood pressure and hemodynamics were good 09/22/20. He stated Resident #1's mental capacity waxed/waned and he was confused at times. He stated that this was not off from Resident #1's baseline. He stated tube feeding was started for blood sugar regulation. The Medical Director revealed an MRI showed the resident had an acute stroke or recent small stroke of the left parietal lobe, but that it was unclear when it occurred. The Medical Director stated Resident #1's highest blood sugar was 586 and blood draw was 578. The Medical Director was asked would the lack of insulin contribute to a stroke. He stated it would not from a volume deficient aspect, the high blood sugar would have caused dehydration. Medical Director stated when he spoke with the staff he expressed the concern of the dehydration. The Medical Director stated he did not believe any long-term harm had occurred due to lack of insulin. He stated he was not able to determine any direct correlation and short term-mental change or dehydration. Medical Director stated Resident #1 was answering to his name. He was noted to be alert to self but confused to place, following simple commands. He stated there was concern of possible aspiration from stroke or mental status change. He stated the hospital had started broad spectrum antibiotics. The Medical Director stated when orders were being modified in the computer system, the orders were falling off. He stated that the facility was making sure the nursing staff reconciled the orders. He stated the orders should not be modified but discontinued and reentered. He stated the facility would be reconciling the orders going forward . 2. Review of Resident #2's face sheet dated 09/23/20 revealed a 73-old-year male admitted to the facility 06/04/20. His [DIAGNOSES REDACTED]. Review of Resident # 2's Consolidated Orders revealed the following were the only active orders related to insulin and blood sugar checks: Start date 06/05/020: Finger stick blood sugar/Accu-chek 1 stick as needed Hyper/Hypoglycemic and complete if high blood sugar or symptomatic if <60 or > 350 call. MD Blood Glucose check. Start date 06/05/20: [MEDICATION NAME] 1mg solution for injection [MEDICATION NAME] 1 recon soln inject as needed low bs (blood sugar) if blood sugar is < 60 and unresponsive give [MEDICATION NAME] and call MD. Re-check in 15 minutes. Blood Glucose check, administer if BS is less than 60 and resident is unresponsive MD call. Start date 06/05/20: Glucose 15 40 % Oral Gel ([MEDICATION NAME]) 1 Gel by mouth as needed low bs (blood sugar) if FSBS <60 and responsive, recheck FSBS in 15 min and call MD. If blood sugar is <60 and responsive give glucose 15 gm call MD. Re check in 15 minutes. Review of Resident # 2's Medication Administration Record [REDACTED]<60 or > 350 call MD Blood Glucose check Diagnosis: [REDACTED]. Modification date: 08/05/20 End date: 09/01/20. [MEDICATION NAME] N [MEDICATION NAME] 100 unit/ml Sub Q Cartridge Human insulin [MEDICATION NAME] 6 units/units subcutaneous 2 times daily before meals site location Diagnosis: [REDACTED]. Start Date: 08/05/20 End date modification: 09/01/20. Review of Resident #2's MAR for September 2020 revealed there was no documentation Resident #2's blood sugar levels were checked or insulin was administered from 09/01/20 through 09/20/20. In an interview on 09/22/20 at 3:13 PM the DON revealed the facility had completed a 100 percent audit on all the residents receiving insulin/blood sugar checks and determined that Resident #2's order for insulin was discontinued. She stated the ADON made a modification to Resident #2's insulin order . She stated Resident #2 had not had any adverse effects from missing his insulin. DON did not indicate when Resident #2 insulin order was modified. In an interview on 09/23/20 at 2:27 PM the ADON stated Resident #2 was receiving 6 units of insulin every day, but then the order for insulin disappeared on 09/01/20. He stated the reason that the nurses did not notice that Resident #2's order was missing was because Hallway 500, where the resident resided, had not had a constant nurse assigned to the hallway that was administering insulin to Resident #2. Interview on 09/22/20 at 4:08 PM with Resident #2 revealed he was not receiving insulin anymore. He stated it had been awhile since he received it. He stated that he had been feeling okay. He stated the staff had not been checking his blood sugar for some reason. He stated he may not have diabetes anymore. He stated that he had not had a diabetic spell during his stay in the facility. Review of the facility policy titled, Physician orders Electronic dated 02/12/20 revealed: 1. The licensed nurse will receive and transcribe the physicians' orders according to practice guidelines. 2. The licensed nurse staff will prove resident s with medication and treatment as ordered Review of the facility policy titled, Nursing 24 hour report dated 02/12/20 revealed: The qualified licensed nursing staff will review and complete the 24 hour report in the EHR- for their assignment each shift, seven 7 days per week. Review of facility policy titled, Medication Error: Reporting and Management dated 02/12/20 revealed: Community staff and prescribing practitioner will mitigate the occurrence of medication errors and attempt to identify and mange them appropriately when they occur in accordance with standard practice guidelines. The Administrator, and DON were notified on 09/24/20 at 1:43 PM, that an Immediate Jeopardy existed from 09/01/20 to 09/21/20. The Administrator was provided with the IJ template at this time. The facility took the following corrective actions prior to entrance on 09/22/20: The DON and ADON was provided one to one in-service on 09/22/20 regarding change of order, 24 hour report, pull orders daily, review, print place in binder daily including Saturday and Sunday. The in-service was provided by RN A. The DON and ADON was provided one to one in-service on 09/22/20 regarding change of shift report. The in-service was provided by RN A. The DON and ADON completed audit on 09/21/20 of all the residents that were diabetic, receive insulin and one other medication issues were noted. It has been corrected with no adverse effects to Resident #2. No other residents were found with issues. On 09/21/20 staff were provided in-service by the DON regarding Diabetes Toolkit-treatment of [REDACTED]. On 09/21/20 all nurses and CMA's was provided in-service by the DON titled, Effective immediately nurses are not to edit/modify any order if any corrections needs to be done, you must discontinue the order re-enter the order and the corrections. On 09/21/20 staff were provided in-service by ADON C titled change of shift report policy and procedures. On 09/21/20 staff were provided in-service by ADON C titled, Clinical operations. On 09/21/20 staff were provided in-service by ADON C titled, Daily clinical start up meeting. On 09/21/20 staff were provided in-service by DON titled, [DIAGNOSES REDACTED] and [MEDICAL CONDITION] signs and symptoms. On 09/21/20 staff were provided in-service by DON titled Change of Condition Care Path Symptoms of Acute Mental Status Change. On 09/21/20 staff were provided in-service by DON titled, Nurses to make sure they are receiving the change of order column on the dashboard under the 24 hour report. On 09/21/20 staff were provided in-service by DON titled, Effective immediately nurse must document and make known on 24 hour report of diabetics On 09/21/20 staff were provided in-service by DON titled, Medication Error: Reporting and management. In an interview on 09/22/20 at 5:59 PM, the DON revealed the facility corporate had contacted the computer system administrator, so they could investigate the system. She stated that it was not a user error, but a computer glitch. She stated corporate had discussed with the computer system administrator taking the option of clicking to modify away. She stated that facility would have to discontinue the medications and enter new orders going forward. In an interview on 09/22/20 at 6:07 PM the ADON revealed the facility had placed an asterisk mark on the 24-hour report by the resident name once a resident medication had been discontinued. The staff were able to look to see if there were any changes on the 24-hour report, staff had the option of asking more question about why medication has been discontinued. In an interview on 09/23/20 at 9:06 AM, DON revealed on 09/22/20 the facility reached out to the Corporate clinical nurse regarding the computer program. They had escalated it up to the programing team so they could fix the problem when modifications were made. She stated the option to edit orders had been removed. She stated staff would need to discontinue an order and re-enter it. She stated when a nurse would discontinue an order, they would have to put in their pin number. She stated the facility could check every click that staff made. She stated she knew she did not discontinue Resident #1's insulin order. She stated to prevent that from happening again the staff would discontinue the medications and reenter She stated everything from 09/20/20 would be addressed in a QAPI plan. She stated it was a computer error, not a human error. She ADON had modified Resident #2's order and it did the same thing . She stated they were doing checks but there was no insulin order. The DON stated she had not investigated if Resident # 2 needed his blood sugar checked. She stated Corporate was looking into that as well. She stated Resident #'2's orders had been corrected. Resident # 2 had been placed on scheduled blood sugar checks. She stated they were running 144. She stated Resident #2 would tell you anything that he believed was wrong with his care. She stated no other meds with parameters were affected and the facility had completed a system wide check of all the residents receiving insulin . She stated the facility Corporate was working with the computer programming company. They were taking the option of discontinuing or modifying away . She stated the change would be a corporate wide change. The DON stated the facility in-serviced the staff to cancel and re-enter orders instead of modifying them. She stated staff were to document on the 24-hour report every resident that was diabetic . In an interview with the Administrator on 09/23/20 at 9:53 AM, she revealed a Plan of Action had been developed during the QAPI meeting on 9/22/20 . The facility discussed the issue and ways to rectify the situation. She stated staff had been instructed to delete and make new orders instead of making modifications. The ADON and DON had made the checks of Resident #2's blood sugar during morning clinical stand up meeting. She stated Resident # 2's blood sugars were never out of whack. She stated the Medical director was concerned for Resident #1 due to him not receiving the insulin. She stated the Medical Director was on the same page as the facility clinical leaders, Where's the glitch, how do we mitigate it. It can't happen again. Administrator stated that the issues was with the computer program. She stated the computer company and Corporate nurse were trying to find a solution immediately corporate wide. The Administrator stated the update that was provided from the Medical Director was that Resident #1's blood sugar had reached 598 in the hospital. Observation on 09/23/20 at 11:26 AM of medication pass revealed, a blood sugar check was done for Resident #3 by LVN L. She knocked, explained procedure to resident, washed her hands, gloved, and performed the blood sugar check with the alcohol pad, a new lancet, and a glucometer which was clean. The resident's blood sugar was 125. No insulin given. Interview with Resident #3 on 09/23/20 11:29 AM revealed the facility staff checked her blood sugar 4 or 5 times a day, before meals and at night. They give her insulin if she needed it, and they do it right. In an interview on 09/23/20 at 2:27 PM the ADON stated he had been trained not to modify orders in the computer because the facility had a computer problem. He stated if staff modified an order it would just disappear. He stated staff had been instructed after the incident occurred with Resident #1 and Resident #2 to delete the orders and re-enter it but never modify. He stated that the facility's corporate office was trying to figure out what happened on the computer that caused it to discontinue the orders. In an interview with LVN H on 09/23/20 at 3:43 PM she stated the facility's procedures for modification to current orders was to discontinue the current order and input new order. Interview with LVN J on 09/23/20 at 4:01 PM revealed if there were modifications to an order that needed to be made staff had been instructed to discontinue the order and enter a new order.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 28 residents reviewed for care plans. (Resident #3) The facility did not provide Resident #3 with blood sugar checks, insulin (a medication used to treat diabetes) and [MEDICATION NAME] (a medication used to prevent [MEDICAL CONDITION] and [MEDICAL CONDITION]) for 5 days. The resident was found nonverbal and unable to follow commands and was sent to the hospital where he was diagnosed with [REDACTED]. This was determined to be past non-compliance that existed from 9/18/19 through 9/25/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for harm and death. Findings included: The face sheet dated 10/31/19 indicated Resident #3 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated resident was readmitted on [DATE]. A physician order [REDACTED].#3 was to receive [MEDICATION NAME] 75 mg tablet 1 time per day and was on a mechanical soft diet and nectar thick liquids. A physician order [REDACTED].#3 was to receive [MEDICATION NAME] 100 unit/ml 5 units subcutaneously 1 time daily and [MEDICATION NAME] 100 unit/ml subcutaneously 3 times a day with meals per sliding scale as follows: 0 - 149 = 0 units 150 - 199 = 2 units 200 - 249 = 4 units 250 - 299 = 6 units 300 - 349 = 8 units 350 and higher 10 units and call the physician. Physician orders [REDACTED]. A physician order [REDACTED].#3 was to receive a pureed diet and nectar thick liquids. The MDS dated [DATE] indicated Resident #3 had clear speech, could make himself understood and had moderate cognitive impairment. The MDS indicated Resident #3 required extensive assistance with bed mobility, transfers, locomotion in wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #3 received insulin injections for all days of the lookback period. The care plan dated 9/26/19 indicated Resident #3 experienced elevated blood sugar levels and the facility would administer medications as ordered. During an interview on 10/31/19 at 9:46 a.m., LVN F said he sent Resident #3 to the hospital on [DATE] after a fall with injury and the resident was bleeding. He said Resident #3 came back to the facility on [DATE] at 1:00 a.m. LVN F said RN H did not put the re-admission orders [REDACTED]. LVN F said blood sugar checks were dependent on the insulin orders. LVN F said when he cared for Resident #3 between 9/18/18 and 9/23/19 he checked his blood sugars and they were within normal limits. He said he wrote the blood sugars down on his notepad, but he was unable to produce the notepad. The nursing notes dated 9/18/19 through 9/23/19 did not indicate nursing staff were monitoring or checking blood glucose levels for Resident #3. The Medication Administration Record [REDACTED]. A nursing note dated 9/23/19 at 8:41 a.m., indicated Resident #3 was nonverbal and not able to follow simple commands. The note indicated Resident #3's blood sugar was 486 and he was transported to the hospital. During an interview on 10/30/19 at 4:35 p.m., LVN [NAME] said Resident #3 was usually smiling and communicating with her when she cared for him in the past. LVN [NAME] said on 9/23/19 on the day shift, she took over care for Resident #1 and found him lethargic and unable to follow commands. She said she checked his blood sugar and it was 486. She said she immediately contacted 911 and notified the physician of Resident #3's status and obtained an order to transport him to the hospital. LVN [NAME] said the night nurse did not check Resident #3's blood sugar at 7:30 a.m. She said the night nurse reported to her that Resident #3 had another fall but was stable. LVN [NAME] said the nurse that readmitted Resident #3 from his 9/17/19 hospital visit left his blood sugar checks, insulin and [MEDICATION NAME] orders on hold so Resident #3 had not received insulin or [MEDICATION NAME] between 9/18/19 and 9/23/19. A hospital assessment and plan dated 9/23/19 indicated Resident #3 had a [MEDICAL CONDITION] month ago. The note indicated the resident came to the emergency room with altered mental status and slurred speech for 2 days. The note indicated the MRI of the brain showed a hyperacute right paramedian pontine infarct (a type of stroke that occurs when a blood clot within a vessel disrupts blood flow to the brain and affects a region of the [DIAGNOSES REDACTED]) and the resident's new onset of worsening of dysarthria (slurred or slow speech) and difficulty with eye movements could be attributed to his hyperacute right paramedian pontine infarct. The noted indicated Resident #'3's diabetes was not well controlled as evidenced by his hemoglobin A1c (estimates a person's average blood sugar levels over a 2 to 3-month span) of 12.8 (normal below 5.7) and his blood sugar continued to be elevated. The note indicated speech therapy assessed Resident #3's dysphagia (a condition that makes it difficult to swallow) and recommendation was to initiate a puree/liquid diet with one-on-one assist with all meals. A stroke neurology progress note dated 9/24/19 indicated Resident #3 had severe dysarthria, worse than prior to stroke, and an MRI completed on 9/23/19 indicated a new infarct (a localized area of dead tissue resulting from failure of blood supply) in the right paramedian pons. The note indicated Resident #3 had multiple risk factors for stroke, including uncontrolled diabetes and hypertension. The note indicated the resident had left myoclonic (quick, involuntary muscle jerks) jerks on admission that could have been a manifestation of [MEDICAL CONDITION]. The note indicated the plan was to treat the acute stroke with aspirin, [MEDICATION NAME], atorvastatin (medication to lower cholesterol), PT, OT and ST, inpatient rehabilitation and a pureed diet with medications in pureed foods. An after visit summary hospital record dated 9/30/19 indicated Resident #3 was admitted to the hospital on [DATE] and was discharged on [DATE]. The record indicated Resident #3 was treated for [REDACTED]. The record indicated the speech therapist recommended nectar thick liquids/puree textures with 1:1 assist. During an interview on 10/31/19 at 11:59 a.m., ADON D said if a resident left the facility and returned, orders should be checked and reconciled. He said any changes should be noted in the nursing notes. ADON D said he was not sure if Resident #3's blood sugars were checked during the period he did not have insulin orders. During an interview on 10/31/19 at 4:21 p.m., the DON said when Resident #3 was re-admitted to the facility on [DATE] and RN H did not click on each medication as required. She said Resident #3's [MEDICATION NAME] 75 mg daily, blood sugar checks and routine and sliding scale insulin was not restarted on 9/18/19. She said the facility did not monitor Resident #3's blood sugars, administer insulin or [MEDICATION NAME] from 9/18/19 until 9/23/19. The DON said the nurses should have questioned why Resident #3 came back from the hospital with no blood sugar checks and insulin. The DON said since the incident with Resident #3, she was now doing a complete audit of orders every time a resident returned to the facility. She said they no longer allowed the nurses to place orders on hold in the computer system. The DON said after the incident she ran a report of hold orders every morning. The DON said the facility had not been monitoring the resident's orders or the held orders prior to this incident. The DON said the [MEDICATION NAME], blood sugar checks and insulin were on hold due to a computer error by the admitting nurse. The DON said nurses were trained on medication administration competency and medication reconciliation on admit and return from hospital after the incident with Resident #3. During an interview on 10/31/19 at 5:09 p.m., the administrator said when they realized Resident #3's insulin and [MEDICATION NAME] were left off when he returned from the hospital on [DATE], they wrote the nurse up and put a procedure in place to correct the medication error from happening again. He said the procedure was a complete order audit of the physician orders [REDACTED]. The physician orders [REDACTED]. The website https://www.health.harvard.edu/newsletter_article/[MEDICATION NAME] accessed on 11/6/19 accessed on 11/7/19 indicated [MEDICATION NAME] (brand name for [MEDICATION NAME]) is used for people at high risk for [MEDICAL CONDITION] or stroke. The medication works by preventing platelet activation and significantly decreasing the risk of a blood clot. The website https://www.saebo.com/pontine-stroke-causes-symptoms-treatments/ accessed on 11/7/19 indicated .A pontine stroke is a type of ischemic stroke that affects the pons region of the [DIAGNOSES REDACTED]. A pontine stroke can be particularly devastating and may to lead to paralysis .An ischemic stroke occurs when a blood clot within a blood vessel disrupts or blocks blood flow to the brain .A stroke affecting the brainstem can result in loss of motor function or other deficits . It was determined these failures placed Resident #3 in an Immediate Jeopardy (IJ) situation from 9/18/19 through 9/25/19. The facility took the following actions to correct the non-compliance from 9/23/19 through 9/25/19: *A notice of warning dated 9/24/19 indicated RN H received an investigatory suspension related to unsatisfactory performance. The notice indicated RN H failed to initiate all the physician orders. RN H refused to sign the document. *Completed a training in-service dated 9/23/19, titled Do not hold orders for residents sent to the E.R./Appt for nurses. *Completed a training in-service titled 9/24/19, titled [MEDICATION NAME] ([MEDICATION NAME]) and stroke/[MEDICAL CONDITION] for nurses. *Completed an undated training in-service titled Order reconciliation from ER returns and doctor visit returns for nurses. *Completed a training-in-service dated 9/24/19, titled Hold Orders for nurses. *Completed a training in-service form dated 9/25/19, titles Diabetes for nurses. *A review of the QAAPI records dated 9/23/19 indicated the facility identified a problem with placing medications on hold and reconciliation of medications upon return from the hospital. The facility planned to address the providing training in-servicing on medication reconciliation, medication holds, and hold orders. The record indicated nurses would no longer be allowed to put medications on hold and the DON would run a daily report indicating any holds on medications. During an interview on 10/30/19 at 4:35 p.m., LVN [NAME] said she was in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital. She said she would not place orders on hold for residents being sent to the ER or appointments. She said nurses were no longer supposed to put orders on hold for any reason. She said when a resident returned from the hospital or physician visit, she would do a complete reconciliation of medications and make sure any changes were updated in the computer and on the EMAR. During an interview on 10/31/19 at 9:46 a.m., LVN F said was she was in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital. She said she would not place orders on hold for residents being sent to the ER or appointments. She said when a resident returned from the hospital or physician visit, she would do a complete reconciliation of medications and make sure any changes were updated in the computer and on the EMAR. During an interview on 10/31/19 at 11:59 a.m., ADON D said all nurses were in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital. She said nurses were not to place orders on hold for residents being sent to the ER or appointments or any other reason. She said when a resident returned from the hospital or physician visit, nurses were to do a would do a complete reconciliation of medications and make sure any changes were updated in the computer and on the EMAR. She staff nurses were to contact herself or the DON if a medication was ordered to be held by the physician. During an interview on 10/31/19 at 5:09 p.m., the administrator said he was in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital.

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 28 residents reviewed for quality of care. (Resident #3) The facility did not follow physician orders [REDACTED]. Resident #3 did not receive blood sugar checks, insulin and [MEDICATION NAME] for 5 days after returning to the facility from an emergency room visit. The resident was found nonverbal and unable to follow commands and was sent to the hospital where he was diagnosed with [REDACTED]. This was determined to be past non-compliance that existed from 9/18/19 through 9/25/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for harm and death. Findings included: The face sheet dated 10/31/19 indicated Resident #3 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated resident was readmitted on [DATE]. A physician order [REDACTED].#3 was to receive [MEDICATION NAME] 75 mg tablet 1 time per day and was on a mechanical soft diet and nectar thick liquids. A physician order [REDACTED].#3 was to receive [MEDICATION NAME] 100 unit/ml 5 units subcutaneously 1 time daily and [MEDICATION NAME] 100 unit/ml subcutaneously 3 times a day with meals per sliding scale as follows: 0 - 149 = 0 units 150 - 199 = 2 units 200 - 249 = 4 units 250 - 299 = 6 units 300 - 349 = 8 units 350 and higher 10 units and call the physician. Physician orders [REDACTED]. A physician order [REDACTED].#3 was to receive a pureed diet and nectar thick liquids. The MDS dated [DATE] indicated Resident #3 had clear speech, could make himself understood and had moderate cognitive impairment. The MDS indicated Resident #3 required extensive assistance with bed mobility, transfers, locomotion in wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #3 received insulin injections for all days of the lookback period. The care plan dated 9/26/19 indicated Resident #3 experienced elevated blood sugar levels and the facility would administer medications as ordered. During an interview on 10/31/19 at 9:46 a.m., LVN F said he sent Resident #3 to the hospital on [DATE] after a fall with injury and the resident was bleeding. He said Resident #3 came back to the facility on [DATE] at 1:00 a.m. LVN F said RN H did not put the re-admission orders [REDACTED]. LVN F said blood sugar checks were dependent on the insulin orders. LVN F said when he cared for Resident #3 between 9/18/18 and 9/23/19 he checked his blood sugars and they were within normal limits. He said he wrote the blood sugars down on his notepad, but he was unable to produce the notepad. The nursing notes dated 9/18/19 through 9/23/19 did not indicate nursing staff were monitoring or checking blood glucose levels for Resident #3. The Medication Administration Record [REDACTED]. A nursing note dated 9/23/19 at 8:41 a.m., indicated Resident #3 was nonverbal and not able to follow simple commands. The note indicated Resident #3's blood sugar was 486 and he was transported to the hospital. During an interview on 10/30/19 at 4:35 p.m., LVN [NAME] said Resident #3 was usually smiling and communicating with her when she cared for him in the past. LVN [NAME] said on 9/23/19 on the day shift, she took over care for Resident #1 and found him lethargic and unable to follow commands. She said she checked his blood sugar and it was 486. She said she immediately contacted 911 and notified the physician of Resident #3's status and obtained an order to transport him to the hospital. LVN [NAME] said the night nurse did not check Resident #3's blood sugar at 7:30 a.m. She said the night nurse reported to her that Resident #3 had another fall but was stable. LVN [NAME] said the nurse that readmitted Resident #3 from his 9/17/19 hospital visit left his blood sugar checks, insulin and [MEDICATION NAME] orders on hold so Resident #3 had not received insulin or [MEDICATION NAME] between 9/18/19 and 9/23/19. A hospital assessment and plan dated 9/23/19 indicated Resident #3 had a [MEDICAL CONDITION] month ago. The note indicated the resident came to the emergency room with altered mental status and slurred speech for 2 days. The note indicated the MRI of the brain showed a hyperacute right paramedian pontine infarct (a type of stroke that occurs when a blood clot within a vessel disrupts blood flow to the brain and affects a region of the [DIAGNOSES REDACTED]) and the resident's new onset of worsening of dysarthria (slurred or slow speech) and difficulty with eye movements could be attributed to his hyperacute right paramedian pontine infarct. The noted indicated Resident #'3's diabetes was not well controlled as evidenced by his hemoglobin A1c (estimates a person's average blood sugar levels over a 2 to 3-month span) of 12.8 (normal below 5.7) and his blood sugar continued to be elevated. The note indicated speech therapy assessed Resident #3's dysphagia (a condition that makes it difficult to swallow) and recommendation was to initiate a puree/liquid diet with one-on-one assist with all meals. A stroke neurology progress note dated 9/24/19 indicated Resident #3 had severe dysarthria, worse than prior to stroke, and an MRI completed on 9/23/19 indicated a new infarct (a localized area of dead tissue resulting from failure of blood supply) in the right paramedian pons. The note indicated Resident #3 had multiple risk factors for stroke, including uncontrolled diabetes and hypertension. The note indicated the resident had left myoclonic (quick, involuntary muscle jerks) jerks on admission that could have been a manifestation of [MEDICAL CONDITION]. The note indicated the plan was to treat the acute stroke with aspirin, [MEDICATION NAME], atorvastatin (medication to lower cholesterol), PT, OT and ST, inpatient rehabilitation and a pureed diet with medications in pureed foods. An after visit summary hospital record dated 9/30/19 indicated Resident #3 was admitted to the hospital on [DATE] and was discharged on [DATE]. The record indicated Resident #3 was treated for [REDACTED]. The record indicated the speech therapist recommended nectar thick liquids/puree textures with 1:1 assist. During an interview on 10/31/19 at 11:59 a.m., ADON D said if a resident left the facility and returned, orders should be checked and reconciled. He said any changes should be noted in the nursing notes. ADON D said he was not sure if Resident #3's blood sugars were checked during the period he did not have insulin orders. During an interview on 10/31/19 at 4:21 p.m., the DON said when Resident #3 was re-admitted to the facility on [DATE] and RN H did not click on each medication as required. She said Resident #3's [MEDICATION NAME] 75 mg daily, blood sugar checks and routine and sliding scale insulin was not restarted on 9/18/19. She said the facility did not monitor Resident #3's blood sugars, administer insulin or [MEDICATION NAME] from 9/18/19 until 9/23/19. The DON said the nurses should have questioned why Resident #3 came back from the hospital with no blood sugar checks and insulin. The DON said since the incident with Resident #3, she was now doing a complete audit of orders every time a resident returned to the facility. She said they no longer allowed the nurses to place orders on hold in the computer system. The DON said after the incident she ran a report of hold orders every morning. The DON said the facility had not been monitoring the resident's orders or the held orders prior to this incident. The DON said the [MEDICATION NAME], blood sugar checks and insulin were on hold due to a computer error by RN H. The DON said nurses were trained on medication administration competency and medication reconciliation on admit and return from hospital after the incident with Resident #3. During an interview on 10/31/19 at 5:09 p.m., the administrator said when they realized Resident #3's insulin and [MEDICATION NAME] were left off when he returned from the hospital on [DATE], they wrote the nurse up and put a procedure in place to correct the medication error from happening again. He said the procedure was a complete order audit of the physician orders [REDACTED]. The physician orders [REDACTED]. The website https://www.health.harvard.edu/newsletter_article/[MEDICATION NAME] accessed on 11/6/19 accessed on 11/7/19 indicated [MEDICATION NAME] (brand name for [MEDICATION NAME]) is used for people at high risk for [MEDICAL CONDITION] or stroke. The medication works by preventing platelet activation and significantly decreasing the risk of a blood clot. The website https://www.saebo.com/pontine-stroke-causes-symptoms-treatments/ accessed on 11/7/19 indicated .A pontine stroke is a type of ischemic stroke that affects the pons region of the [DIAGNOSES REDACTED]. A pontine stroke can be particularly devastating and may to lead to paralysis .An ischemic stroke occurs when a blood clot within a blood vessel disrupts or blocks blood flow to the brain .A stroke affecting the brainstem can result in loss of motor function or other deficits . It was determined these failures placed Resident #3 in an Immediate Jeopardy (IJ) situation from 9/18/19 through 9/25/19. The facility took the following actions to correct the non-compliance from 9/23/19 through 9/25/19: *A notice of warning dated 9/24/19 indicated RN H received an investigatory suspension related to unsatisfactory performance. The notice indicated RN H failed to initiate all the physician orders. RN H refused to sign the document. *Completed a training in-service dated 9/23/19, titled Do not hold orders for residents sent to the E.R./Appt for nurses. *Completed a training in-service titled 9/24/19, titled [MEDICATION NAME] ([MEDICATION NAME]) and stroke/[MEDICAL CONDITION] for nurses. *Completed an undated training in-service titled Order reconciliation from ER returns and doctor visit returns for nurses. *Completed a training-in-service dated 9/24/19, titled Hold Orders for nurses. *Completed a training in-service form dated 9/25/19, titles Diabetes for nurses. *A review of the QAAPI records dated 9/23/19 indicated the facility identified a problem with placing medications on hold and reconciliation of medications upon return from the hospital. The facility planned to address the providing training in-servicing on medication reconciliation, medication holds, and hold orders. The record indicated nurses would no longer be allowed to put medications on hold and the DON would run a daily report indicating any holds on medications. During an interview on 10/30/19 at 4:35 p.m., LVN [NAME] said she was in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital. She said she would not place orders on hold for residents being sent to the ER or appointments. She said nurses were no longer supposed to put orders on hold for any reason. She said when a resident returned from the hospital or physician visit, she would do a complete reconciliation of medications and make sure any changes were updated in the computer and on the EMAR. During an interview on 10/31/19 at 9:46 a.m., LVN F said was she was in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital. She said she would not place orders on hold for residents being sent to the ER or appointments. She said when a resident returned from the hospital or physician visit, she would do a complete reconciliation of medications and make sure any changes were updated in the computer and on the EMAR. During an interview on 10/31/19 at 11:59 a.m., ADON D said all nurses were in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital. She said nurses were not to place orders on hold for residents being sent to the ER or appointments or any other reason. She said when a resident returned from the hospital or physician visit, nurses were to do a would do a complete reconciliation of medications and make sure any changes were updated in the computer and on the EMAR. She staff nurses were to contact herself or the DON if a medication was ordered to be held by the physician. During an interview on 10/31/19 at 5:09 p.m., the administrator said he was in serviced on re-admitting residents, medication administration competency and medication reconciliation on admission/return from hospital.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 2 of 5 residents reviewed for pressure injuries. (Resident #s 1 and 2) The facility did not provide Resident #1 with weekly head to toe skin assessments as indicated by his comprehensive care plan. The facility did not accurately identify pressure injuries and provide interventions to treat and prevent pressure injuries. Resident #1 was admitted to the hospital on [DATE] with 6 DTI's and a Stage 1 pressure injury that had not been identified by the facility. The facility did not provide accurate skin assessments, assessment of catheter tube placement and catheter care for Resident #2 to prevent the development of a Stage 3 pressure injury on his penis. The facility did not ensure Resident #2's air mattress was on the correct setting for his weight. This failure could place residents at risk for new development of pressure injuries or worsening of existing pressure injuries, wound infections and or death. Findings included: 1. A physician order [REDACTED].#1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].# 1 was to have a secure protective ointment applied to the perineal area twice a day. The physician order [REDACTED].#1 was to have the wound to his buttock cleansed every 3 days with normal saline and patted dry, collagen gel and [MEDICATION NAME] gel applied to area, then covered with [MEDICATION NAME] dressing. The summary indicated the resident was discharged to the hospital on [DATE]. A resident patient transfer form dated [DATE] indicated Resident #1 was sent to the hospital on [DATE] for decreased sensorium (in ability to think clearly) and an elevated potassium of 7.8 (normal 3.5 to 5.0). The weekly wound log for [DATE] to [DATE] indicated Resident #1 had been treated for [REDACTED]. A physician wound progress note dated [DATE] indicated the wound to the right buttock of Resident #1 was resolved. The MDS dated [DATE] indicated Resident #1 was understood and usually understood others. The MDS indicated Resident #1 had severely impaired cognitive function and required extensive assistance with bed mobility, transfers, walking with his cane, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #1 required supervision with eating. The MDS indicated Resident #1 was totally dependent on staff for bathing and was always incontinent of bladder and had occasional incontinence of bowel. The MDS indicated Resident #1 was at risk for pressure injury development and had no unhealed pressure injuries. The MDS dated [DATE] indicated Resident #1 required limited assistance with bed mobility and extensive assistance with transfers, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated the resident only walked once or twice during the 7 day look back period. The MDS indicated Resident #1 had no unhealed pressure injuries. The care plan updated on [DATE] indicated Resident #1 was at risk for skin breakdown and interventions included to inspect skin, complete body head to toe assessment every week and document results. The skin assessments for Resident #1 between [DATE] and [DATE] indicated the following: *week of [DATE] - [DATE] there was no skin assessment completed; *week of [DATE] - [DATE] there was no skin assessment completed; *week of [DATE]-[DATE] there was no skin assessment completed; *week of [DATE]-[DATE] there was no skin assessment completed; * [DATE] indicated Resident #1 had no skin issues; *week of [DATE]- [DATE] there was no skin assessment completed; * [DATE] indicated Resident #1 had no skin issues; * [DATE] indicated Resident #1 had redness to his buttock/coccyx and bruising to his right leg, left leg, right foot and left foot, and did not have pressure wounds, abrasions, heel discoloration or open [MEDICAL CONDITION]. The assessment did not contain any measurements or descriptions and did not indicate the physician was notified. *[DATE] indicated Resident #1 had a Stage I pressure injury to his genital/perineal area. The assessment did not contain any measurements or descriptions and did not indicate the physician was notified. *week of [DATE]-[DATE] there was no skin assessment completed *[DATE] indicated Resident #1 had open areas to his buttock. The assessment did not contain any measurements of descriptions and did not indicate the physician was notified. *[DATE] indicated Resident #1 had no skin issues; and *[DATE] indicated Resident #1 had redness to his sacrum, buttock, coccyx, groin, and did not have pressure wounds, bruises, abrasions, heel discoloration or open [MEDICAL CONDITION]. The assessment did not contain any measurements or description and did not indicate the physician was notified. A wound care physician note dated [DATE] indicated Resident #1 had a Stage II pressure injury to his left buttock measuring 8.2 cm (centimeters) in length, 8 cm in width and 0.2 cm in depth. The note indicated Resident #1 had a wound to his right shin, described as a scab measuring 12.5 cm in length, 1 cm in width, and had an unmeasurable depth. The note indicated Resident #1 had a wound to the left shin, described as a scab, measuring 18 cm in length, 1.5 cm in width and had an unmeasurable depth. The note indicated Resident # 1 had a wound to the back of his right hand described as a scab, measuring 5 cm in length, 4 cm in width and had an unmeasurable depth. The note indicated Resident #1 had a wound to the back of his left hand described as a scab measuring 0.8 cm in length, 0.8 cm in width and had an unmeasurable depth. The wound care nurse's skin assessment and note on [DATE] indicated Resident #1 had redness to his upper back, groin and both legs. The skin assessment indicated Resident #1 had wounds to his sacrum, buttock and coccyx. The skin assessment indicated Resident #1 had bruising to his right hip, a skin tear to his right hand, scabbed areas to his left leg and right leg. The skin assessment indicated Resident #1 had blanchable redness to both of his heels. The note indicated Resident #1 had several new open areas to the sacrum since the assessment performed with the wound care physician on [DATE]. The assessment did not contain measurements or descriptions of the wounds and did not indicate the physician was notified. The hospital records dated [DATE] indicated Resident #1 was identified with the following pressure injuries: *Stage II pressure injury to the right buttock; *DTI to the right iliac crest; *DTI to left medial ankle; *DTI to the left medial heel; *DTI to the left foot metatarsal; * DTI to the left foot lateral; * Stage I pressure injury to the left heel; and * DTI to the sacrum. During an interview on [DATE] at 6:45 p.m., a family member for Resident #1 said they were only notified by the facility of a wound on the resident's bottom that would come and go. The family member said they were never notified of any of the other wounds. The family said they were shocked when they got to the hospital and was told of all the wounds. The family member said Resident #1 was discharged from the hospital on [DATE] to a hospice facility and died on [DATE]. During an interview on [DATE] at 11:50 a.m., LVN A said nurses performed skin assessments weekly on all residents. LVN A said if there were any skin issues identified during the assessment it would be reported to the wound care nurse. LVN A said he would not report bruising to the wound care nurse if he knew the reason or had an explanation for the bruising. LVN A said he had taken care of Resident #1 many times and Resident #1 seemed to have a decline the end of (MONTH) 2019. LVN A said on the weekends the nurses performed wound care. LVN A said on the weekends leading up to Resident #1's discharge to the hospital he performed wound care on Resident #1. LVN A said on [DATE] he found areas of redness to Resident #1's buttock and notified the wound care nurse. LVN A said Resident #1 had three areas to his buttock which were being treated before he went to the hospital. LVN A said Resident #1 was also being treated with a cream to his legs for dryness prior to his hospitalization . LVN A said there were not any open wounds or bruises on Resident #1's legs before he went to the hospital. LVN A said the wound care nurse told him they would have to keep an eye on Resident #1's wounds because he was not eating well. During an interview on [DATE] at 11:10 a.m., the wound care nurse said the nurses completed the weekly skin assessments on all residents. She said she performed her own skin assessments on residents upon admission to the facility. She said she performed random skin assessments to ensure accuracy of skin assessments. The wound care nurse said she started wound care in (MONTH) of 2019 and identified a Stage II pressure injury to Resident #1's buttock. She said the pressure injury was healed out in (MONTH) 2019. She said she had not assessed Resident #1 between [DATE] and the week of his hospitalization on [DATE]. She said nurses were responsible for weekly skin assesments and she would be notified if there was a skin issue. She said if a resident had a skin issue, she would assess and start providing care at that time. She said Resident #1 had a very quick decline in his health 2 weeks prior to his hospitalization . The wound care nurse said LVN A notified her of an area on the buttock of Resident #1 the week Resident #1 was hospitalized . LVN A said the area on the buttock looked like a DTI (deep tissue injury). She said Resident #1 also had a large bruise on his right hip, but she was not sure if it was a DTI. She said Resident #1 had a skin tear to his right hand and his heels did not look good. She said if she would have been notified of the observed bruising to Resident #1's feet on [DATE] she would have assessed the resident herself because she would have suspected DTI. During an interview on [DATE] CNA G said that he took care of Resident #1 while he was at the facility. CNA G said Resident #1 did not have any wounds or pressure injuries. During an interview on [DATE] at 4:00 p.m., the DON said nurses performed skin assessments every week on all residents. The DON said she was not aware a nurse had identified bruising to the legs and feet of Resident #1 on [DATE]. The DON said she was not aware Resident #1 had not received weekly skin assessments. The DON said she and the ADON's now performed spot check skin assessments to double check the skin assessments. She said residents chosen for spot checks were randomly selected. The DON said the system of spot checks was implemented because of Resident #1's hospitalization . The facility policy titled, Skin Data Collection: Licensed Nurses, revised (MONTH) (YEAR), stated, A licensed nurse will collect data during weekly skin evaluations. Weekly, the Licensed Nurse performs a head to toe check of the patient's/ resident's skin, paying attention to: (A) The surfaces of the skin that come in contact with the bed and chair. (B) Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head, etc.) .The licensed nurse should pay attention to: (A) Redness (check for blanching and document blanchable, or non-blanchable redness); (B) Rashes; (C) Discolorations; (D) Open areas; (E) Blisters; (F) Dry/Flaking skin; (G) [MEDICAL CONDITION]. Any significant abnormal findings are reported to the patient's/resident's physician and resident or responsible party. Documentation that the check was performed is denoted on the EMR/medical record. Abnormal findings are to be documented in the EMR/medical record, along with summary of all notified with their responses. The facility policy titled, Prevention of Pressure ulcers/Injuries, dated (MONTH) (YEAR), stated, It is important that each existing PU/PI (pressure ulcer/pressure injury) be identified, whether present on admission or developed after admission, and that factors that influenced it's development, the potential for development of additional PU/PI or the deterioration of the PU/PI be recognized, assessed and addressed. Any new PU/PI suggests a need to reevaluate the adequacy of prevention measures in the resident's care plan. When assessing the PU/PI itself, it is important that the documentation address: The type of injury; a description of the PU/PI's characteristics; the progress toward wound healing; if infection is present; the presence of pain, what has been done to address it, and the effectiveness of the intervention; and a description of dressings and treatments. 2. The face sheet dated [DATE] indicated Resident #2 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].#2 had a urinary catheter and staff would check privacy bag, placement of leg strap and provide catheter care every shift starting on [DATE]. The order starting [DATE] indicated the facility would change the urinary catheter every month on the 18th day. An order starting [DATE] indicated wound care orders for Resident #3's penis were to cleanse the wound to the tip of Resident #3's penis with normal saline pat dry and apply xeroform gauze. The MDS dated [DATE] indicated Resident #2 had clear speech, made himself understood and was cognitively intact. The MDS indicated Resident #2 did not have a behavior of rejection of care and required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. He was dependent on staff for locomotion in a wheelchair. The MDS indicated Resident #2 had an indwelling urinary catheter and was at risk for pressure injuries and did not have any pressure injuries during the seven-day lookback period. The MDS indicated the resident weighed 190 pounds. The care plan dated [DATE] indicated Resident #2 had decreased mobility and paralysis and staff would inspect his skin with daily care. The care plan indicated Resident #2 required total assistance with ADLs. The care plan indicated Resident #2 had an indwelling urinary catheter and staff would care for and change as ordered. The care plan indicated Resident #2 was at risk for skin breakdown and staff would perform a complete body, head to toe inspection every week and document results. The care plan indicated Resident #2 had a pressure relieving mattress and staff would position resident properly. The daily skilled nursing notes from [DATE] to [DATE] indicated Resident #2 did not have a pressure injury or wound on his penis. The weekly wound assessment dated [DATE] indicated Resident #2 had a pressure injury to his genitalia that was facility acquired and was a stage 3 measuring 1 cm x 1 cm with a small amount of yellow exudate. The daily skilled nursing note dated [DATE] indicated Resident #2 had a pressure injury to his coccyx. The note did not indicate a wound on his penis. The daily skilled nursing note dated [DATE] indicated Resident #2 had no wounds and no open [MEDICAL CONDITION]. The note did not indicate a wound on his penis. The daily skilled nursing notes dated [DATE] and [DATE] indicated Resident #2 had a pressure injury to his coccyx. The note did not indicate a wound on his penis. The daily skilled nursing note dated [DATE] indicated Resident #2 had a pressure injury to his coccyx. The note indicated a wound was on his penis. The weekly wound assessment dated [DATE] indicated Resident #2 had a stage 3 pressure injury to his genitalia that had deteriorated and measured 1.5 cm x 1.5 cm with no depth. The daily skilled nursing note dated [DATE] indicated Resident #2 had rash/redness to his buttocks and a wound on his penis. The weekly wound assessment dated [DATE] indicated Resident #2 had a stage 3 pressure injury to his genitalia was unchanged and measured 1.5 cm x 1.5 cm with no depth. The daily skilled nursing note dated [DATE] indicated Resident #2 had no wounds and no open [MEDICAL CONDITION]. The note did not indicate a wound on his penis. The weekly wound assessment dated [DATE] indicated Resident #2 had a stage 3 pressure injury to his genitalia was unchanged and measured 1.5 cm x 1.5 cm with no depth. The weekly wound document dated [DATE] indicated Resident #2 had a wound first identified on his penis on [DATE] that was facility acquired. The wound was documented as Stage 3 and the measurements were 1 cm by 1 cm and had a small amount of yellow exudate. The document indicated the sacral wound from admission had healed on [DATE]. During an observation and interview on [DATE] at 2:00 p.m., Resident #2 was lying on his back in his bed. Resident #2 said he had a wound on his penis because his urinary catheter put pressure on the end of his penis. Resident #2 said he did not have the wound to his penis when he admitted to the facility on [DATE]. Resident #2 said he had a urinary catheter since [DATE]. Resident #2 said staff had not been regularly cleaning or checking the catheter until the wound was discovered. Resident #2 said prior to the discovery of the wound, staff did not assess his penis or provide catheter care daily or weekly. Resident #2 said he could not be sure if staff assessed or provided catheter care at least every two weeks. Resident #2 had a pressure relieving mattress. The pressure reliving mattress was set at 400 pounds. Resident #2 said he weighed approximately 200 pounds. During an observation on [DATE] at 5:00 p.m., Resident #2 was lying on his back in his bed. The pressure setting on his bed was set on 400 pounds. During an observation on [DATE] at 9:00 a.m., Resident #2 was not in his room. The pressure setting on his bed was set at 400 pounds. During an observation on [DATE] at 4:00 p.m., Resident #2 was lying in bed, his penis had a 2-centimeter wound to the head where the urinary catheter came out of his penis. During an observation and interview on [DATE] at 11:15 a.m., the treatment nurse said Resident #2 admitted with a urinary catheter and a stage 2 on his coccyx but there was not a wound on his penis at the time of admission. The treatment nurse said about a week after he was at the facility, she was called to assess his penis and it looked eroded and there was a split at the tip of his penis. She said the wound was probably caused by pressure from the catheter tubing. She said the catheter tubing was most likely pulled too tight against his penis and caused the pressure injury. Resident #2's air mattress setting was set at 400 pounds. The treatment nurse said the air mattress should be set according to his weight. She said he weighed 195 pounds. The treatment nurse said the bed setting should not be set to 400 pounds. During an interview on [DATE] at 10:37 a.m., LVN A said the CNAs were responsible for catheter care, but nurses were responsible to ensure CNAs performed this care. During an interview on [DATE] at 9:58 a.m., CNA B said she worked there for 3 years and had been a CNA for [AGE] years. She said CNAs were supposed to do incontinent care at least once per shift. She said she performed catheter care during bathing and when she emptied urine from the catheter bag. She said she would report any changes in the skin around the catheter such as redness, swelling or tearing. During an interview on [DATE] at 12:00 p.m., the ADON D said that nurses were responsible for catheter care for residents with a urinary catheter. During an interview on [DATE] at 4:21 p.m., the DON said that nurses monitored catheter cleaning and the task comes up on the nurse treatment administration record. She said that CNAs performed catheter care during incontinent care. The DON said she expected nurses to monitor male residents with urinary catheters for penile erosion. She said nurses were responsible for weekly skin assessments. The DON said she performed random skin audits since they identified a failure. The DON said the nurses should monitor the air mattress settings and they should be set according to the resident's weight. During an interview on [DATE] at 5:00 p.m., the administrator said he expected staff to prevent pressure injuries and perform timely and accurate assessments. The prevention of pressure ulcer/injuries policy dated (MONTH) (YEAR) indicated residents would receive care to maintain skin integrity and prevent pressure ulcers/injuries. The urinary catheter care policy dated (MONTH) 2007 indicated the facility would provide perineal care to prevent skin rash and breakdown. The policy indicated the facility would ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. The website https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 53/ accessed on [DATE] indicated urethral erosion is a long-term complication of indwelling catheter that can be prevented by educating caregivers. Awareness of catheter tubing placement on the inner thigh and allowing it free mobility can prevent it from cutting through the skin and urethra. Free mobility of the catheter tubing can be achieved by securing the bag leg drainage tube to the thigh with a strap, allowing free movement and avoiding any tension or pull on the catheter and penis. The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed [DATE] indicated the following . Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions .

Based on observation, interview, and record review, the facility failed to provide care that would ensure acceptable parameters of nutritional status for 1 of 28 resident reviewed for nutritional status. (Resident #1) The facility did not obtain daily weights for Resident #1 as indicated by his care plan. The facility did not assess the resident, notify the physician and implement interventions when it was reported Resident #1 had a decreased appetite and oral intake. Resident #1 had a 7.6% weight loss in a 3-week time frame that went unnoticed by the facility. Resident #1 was hospitalized with severe dehydration and electrolyte imbalance. He was discharged from the hospital to hospice and died . This failure could place residents at risk for altered nutritional status, illness and death. Findings included: The physician order [REDACTED].#1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. The summary indicated the resident was discharged to the hospital on [DATE]. The orders indicated Resident #1 received a multi-vitamin with minerals starting [DATE]. Resident #1 received vitamin C 500 mg daily starting [DATE]. The summary indicated Resident #1 was to receive skilled ST services for the treatment difficulty swallowing starting [DATE]. The summary indicated the resident was to be administered sodium chloride 0.9% intravenously at 75 ml/hr starting [DATE]. A resident patient transfer form dated [DATE] indicated Resident #1 was sent to the hospital on [DATE] for decreased sensorium (inability to think clearly) and an elevated potassium of 7.8 (normal 3.5 to 5.0). Resident #1 was discharged from the hospital on [DATE] to a hospice facility and died on [DATE]. The MDS dated [DATE] indicated Resident #1 was understood and usually understood others and had severely impaired cognitive function. The MDS indicated Resident #1 required extensive assistance with bed mobility, transfers, walking with his cane, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #1 required supervision with eating and was totally dependent on staff for bathing. The MDS indicated Resident #1 was always incontinent of bladder and had occasional incontinence of bowel. The MDS indicated Resident #1 had a [DIAGNOSES REDACTED].#1 was 73 inches tall and weighed 185 lbs. and had a significant weight gain and was not on physician prescribed weight-gain regimen. The MDS indicated Resident #1 was on a therapeutic diet and was not receiving nutrition or hydration by an artificial route. The MDS indicated Resident #1 was at risk for pressure injury development and had no unhealed pressure injuries. The MDS dated [DATE] indicated Resident #1 required limited assistance with bed mobility. The MDS indicated Resident #1 required extensive assistance with transfers, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated the resident required supervision with eating. The MDS indicated the resident only walked once or twice during the 7 day look back period. The MDS indicated Resident #1 weighed 179 pounds, was on a therapeutic diet and was not receiving nutrition or hydration by an artificial route. The MDS indicated Resident #1 was at risk for pressure injury development and had no unhealed pressure injuries. The registered dietician nutrition progress note dated [DATE] indicated Resident #1 was eating independently, consuming ,[DATE]% of oral intake. The nutrition progress note indicated Resident #1 had a stage II pressure injury and was at risk for dehydration due to the presence of wounds, use of diuretics, laxatives and cardiovascular medications. The nutrition progress note indicated Resident #1 would be monitored for significant weight changes, skin issues, oral intake of food/ fluid and labs would be monitored when available. The physician progress notes [REDACTED]. *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; and *[DATE]. The care plan updated on [DATE] indicated Resident #1 was on diuretic therapy with interventions including monitoring for [MEDICAL CONDITION] daily, monitoring for fluid over load by measuring intake and output and obtaining daily weights. The care plan indicated Resident #1 had altered nutritional status and included interventions to monitor oral intake of food and fluid, provide snacks between meals and monitor weight. The Resident Weight Record for Resident #1 dated [DATE] to [DATE] indicated the following: *[DATE] 181 lbs.; *[DATE]-184.8lbs.; * there was no weight for (MONTH) *[DATE]-184.8 lbs.; *[DATE]-185 lbs.; *[DATE]-182.6 lbs.; *[DATE] -182.4 lbs.; *[DATE] - 179.4lbs; The hospital admission records dated [DATE] indicated Resident #1's admission weight was165.5 lbs. which indicated a 7.75% weight loss since the facility last weighed Resident #1 on [DATE] (approximately 3 weeks). A comprehensive metabolic laboratory result obtained at the facility dated [DATE] indicated Resident #1 had an [MEDICATION NAME] (a protein in the blood, which when low, may indicate problems with the liver, heart or malnutrition) of 3.4 g/dL (normal range 3.4 to 5.4). A comprehensive metabolic laboratory result obtained by the facility dated [DATE] indicated Resident #1 had an [MEDICATION NAME] of 3.0 g/dL. The hospital discharge summary dated [DATE] indicated Resident #1 had an [MEDICATION NAME] level of 1.7 g/dL when admitted on [DATE]. The summary indicated Resident #1 had a potassium level of 8.2 (normal 3.5 to 5.0) and a sodium level of 165 (normal 135 to 145). The discharge summary indicated Resident # 1 had acute kidney injury due to severe volume depletion and a creatinine (an indicator of kidney function) of 12.7 (normal 0.7 to 1.2) on admission to the hospital. The discharge summary indicated Resident #1 had acute metabolic [MEDICAL CONDITION] (an alteration of brain function or consciousness due to the failure of other internal organs causing metabolic disturbances) due to dehydration and possible aspiration pneumonia. During an interview on [DATE] at 9:53 a.m., LVN [NAME] said most residents were weighed monthly. LVN [NAME] said residents were weighed more often if there was a concern about weight loss. LVN [NAME] said residents with [MEDICAL CONDITION] are weighed daily. She said nurses did not have to have an order to weigh a resident daily with [DIAGNOSES REDACTED]. LVN [NAME] said she did not know of any other place weights would be documented. LVN [NAME] said she did not recall Resident #1. During an interview on [DATE] at 9:57 a.m., CNA B said she took care of Resident #1 often while he was at the facility. CNA B said the few weeks before Resident #1 went to the hospital he was fed in his room. CNA B said as far as she could remember Resident #1 was fed at the assisted dining table before that. CNA B said the nurse aides documented the percentages of meals residents ate and their fluid intake. She said about 2 weeks prior to Resident #1 going to the hospital she reported to LVN A on 2 occasions she was concerned how little Resident #1 was eating and drinking. During an interview on [DATE] at 11:00 a.m., LVN A said he had taken care of Resident #1 many times and routinely took care of him. LVN A said residents got monthly weights unless there was a concern a resident's nutrition was declining and then the resident would be weighed weekly. He said if a resident had a [DIAGNOSES REDACTED]. LVN A said he did not think Resident #1 had a [DIAGNOSES REDACTED]. LVN A said an order was not required to weigh a resident weekly or daily. LVN A said Resident #1 seemed to be having a decline during the end of (MONTH) 2019. LVN A said he was told by CNAs that Resident #1 was not eating or drinking well. LVN A said he had the restorative aide weigh the resident when it was reported to him the resident was not eating well. He said he was not sure if the resident had lost weight at that time. He said he reported to the physician Resident #1 had a decreased appetite, but there was no documentation of the notification. LVN A said he thought Resident #1 was getting weighed more often than monthly. He said the resident weight logs was the only place Resident #1's weights would be documented. He said he thought he had asked the restorative aide to weigh the resident more often. LVN A said the wound care nurse had told him they would have to keep an eye on the residents' wounds because he was not eating well. During an interview on [DATE] at 12:00 p.m., ADON D said all residents were weighed monthly. ADON D said if a resident was having a gain or a lose the resident would be weighed weekly. ADON D said a resident with [MEDICAL CONDITION] would be weighed daily. During an interview on [DATE] the DON said all residents were weighed monthly. The DON said a resident who was not eating well would be weighed weekly. The DON said a resident with [MEDICAL CONDITION] would be weighed daily. The DON said she ensured residents were being weighed by running a weekly report that was reviewed in their weekly meeting. The DON said she did not know how it was missed that Resident #1 was not weighed daily. The DON said they attempted to start an IV on Resident #1 for hydration when it was ordered on [DATE], but were unable to get it started. A policy titled Prevention of Pressure Ulcers/Injury revised (MONTH) (YEAR), stated, .adequate nutrition and hydration are essential for overall functioning. Nutrition provides vital energy building blocks for all the body's structures and processes. Any organ or body system may require additional energy or structural materials for repair or function. Residents at high risk for nutritional needs or have the presence of a pressure ulcer should be referred to a Registered Dietitian and/or physician .weight stability (in the absence of fluid excess or loss) is a useful indicator of overall caloric balance. A policy titled Acceptable Parameters of Nutrition Status, dated [DATE], stated Residents with unplanned weight loss will be identified. Significant Weight Loss-5% weight loss in 1 month, 7.5% weight loss in 3 months, 10% weight loss in 6 months. Severe Weight Loss->5% weight loss in 1 month,>7.5% weight loss in 3 months,>10% weight loss in 6 months. Resident hydration needs will be identified within the comprehensive nutrition assessment. Nutrition risk factors and recommended nutritional interventions will be based on each resident's medical condition, needs, preferences and goals. A policy titled Hydration dated [DATE], stated, Residents at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to encourage adequate hydration. Risk factors for dehydration will be identified through the comprehensive nutrition therapy assessment process. General fluid needs will be determined as follows (or as determined by clinician): (a) Resident/patient without renal or cardiac distress (i). 30 cc/kg body weight (2.2 pounds = 1 kg)(b) Residents / patients diagnosed with [REDACTED]. Approaches will be individualized as needed through the assessment/reassessment and care planning process . If fluids by mouth are not tolerated, an alternative intervention will be pursued. The facility policy titled, Obtaining Accurate Height/Weight, dated [DATE], stated, .Each resident's height and weight will be obtained and documented on admission. Weights will be obtained monthly, unless physician's orders [REDACTED]. Nursing services will be responsible for the initial determination and documentation of each resident's height and weight. Subsequent weights will be documented in the medical record .Residents who are unable to be weighed will be measured at abdomen, mid-arm, thigh and calf. Measurements will be monitored for change . According to the website https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/electrolyte-balance/[MEDICAL CONDITION]-high-level-of-sodium-in-the-blood accessed on [DATE] .[MEDICAL CONDITION] is when the level of sodium in the blood is too high. It involves dehydration. Severe [MEDICAL CONDITION] can lead to [MEDICAL CONDITION] including confusion, muscle twitches and [MEDICAL CONDITION], coma and death. According to the website https://www.sciencedirect.com/topics/medicine-and-dentistry/metabolic-[MEDICAL CONDITION] accessed on [DATE]: .Metabolic [MEDICAL CONDITION] is defined as an alteration in consciousness caused by diffuse [MEDICAL CONDITION]. Common contributing factors are the use of are electrolyte disturbance, endocrine disease and severe nutritional deficiency .

Based on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and maintain the highest practicable physical, mental and psychosocial well-being for 3 of 28 residents reviewed for nursing services. (Residents #'s 1, 2 and 3) The facility did not follow physician orders [REDACTED].#3. Resident #3 did not receive blood sugar checks, insulin and [MEDICATION NAME] for 5 days after returning to the facility from an emergency room visit. The resident was found nonverbal and unable to follow commands and was sent to the hospital where he was diagnosed with [REDACTED]. The facility did not provide Resident #1 with weekly head to toe skin assessments as indicated by his comprehensive care plan, with accurate findings and interventions to prevent pressure injury development. Resident #1 was admitted to the hospital on [DATE] with 6 DTI's and a Stage 1 pressure injury that had not been identified by the facility. The facility did not obtain daily weights for Resident #1 as indicated by his care plan. The facility did not assess the resident, notify the physician and implement interventions when it was reported Resident #1 had a decreased appetite and oral intake. Resident #1 had a 7.6% weight loss in a 3-week time frame that went unnoticed by the facility. Resident #1 was hospitalized with severe dehydration and electrolyte imbalance. He was discharged from the hospital to hospice and died The facility did not provide accurate skin assessments, assessment of catheter tube placement and catheter care for Resident #2 to prevent the development of a Stage 3 pressure injury on his penis. The facility did not ensure Resident #2's air mattress was on the correct setting for his weight. This failure could place residents and at risk for serious illness, injury and death. Findings included: 1. The face sheet dated [DATE] indicated Resident #3 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated the resident was readmitted on [DATE]. A physician order [REDACTED].#3 was to receive [MEDICATION NAME] 75 mg tablet 1 time per day and was on a mechanical soft diet and nectar thick liquids. A physician order [REDACTED].#3 was to receive [MEDICATION NAME] 100 unit/ml 5 units subcutaneously 1 time daily and [MEDICATION NAME] 100 unit/ml subcutaneously 3 times a day with meals per sliding scale as follows: 0 - 149 = 0 units 150 - 199 = 2 units 200 - 249 = 4 units 250 - 299 = 6 units 300 - 349 = 8 units 350 and higher 10 units and call the physician. A physician order [REDACTED].#3 was to receive a puree diet and nectar thick liquids. The MDS dated [DATE] indicated Resident #3 had clear speech, could make himself understood and had moderate cognitive impairment. The MDS indicated Resident #3 required extensive assistance with bed mobility, transfers, locomotion in wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #3 received insulin injections for all days of the lookback period. The care plan dated [DATE] indicated Resident #3 experienced elevated blood sugar levels and the facility would administer medications as ordered. During an interview on [DATE] at 9:46 a.m., LVN F said he sent Resident #3 to the hospital on [DATE] after a fall with injury and the resident was bleeding. He said Resident #3 came back to the facility on [DATE] at 1:00 a.m. LVN F said the admitting nurse did not put the re-admission orders [REDACTED]. LVN F said blood sugar checks were dependent on the insulin orders. LVN F said when he cared for Resident #3 between [DATE] and [DATE] he checked his blood sugars and they were within normal limits. He said he wrote the blood sugars down on his notepad, but he was unable to produce the notepad. A nursing note dated [DATE] at 8:41 a.m., indicated Resident #3 was nonverbal and not able to follow simple commands. The note indicated Resident #3's blood sugar was 486 and he was transported to the hospital. During an interview on [DATE] at 4:35 p.m., LVN [NAME] said Resident #3 was usually smiling and communicating with her when she cared for him in the past. LVN [NAME] said on [DATE] on the day shift, she took over care for Resident #1 and found him lethargic and unable to follow commands. She said she checked his blood sugar and it was 486. She said she immediately contacted 911 and notified the physician of Resident #3's status and obtained an order to transport him to the hospital. LVN [NAME] said the night nurse did not check Resident #3's blood sugar at 7:30 a.m. She said the night nurse reported to her that Resident #3 had another fall but was stable. LVN [NAME] said the nurse that readmitted Resident #3 from his [DATE] hospital visit left his blood sugar checks, insulin and [MEDICATION NAME] orders on hold so Resident #3 had not received insulin or [MEDICATION NAME] between [DATE] and [DATE]. A hospital assessment and plan dated [DATE] indicated Resident #3 had a [MEDICAL CONDITION] month ago. The note indicated the resident came to the emergency room with altered mental status and slurred speech for 2 days. The note indicated the MRI of the brain showed a hyperacute right paramedian pontine infarct (a type of stroke that occurs when a blood clot within a vessel disrupts blood flow to the brain and affects a region of the [DIAGNOSES REDACTED]) and the resident's new onset of worsening of dysarthria (slurred or slow speech) and difficulty with eye movements could be attributed to his hyperacute right paramedian pontine infarct. The noted indicated Resident #'3's diabetes was not well controlled as evidenced by his hemoglobin A1c (estimates a person's average blood sugar levels over a 2 to 3-month span) of 12.8 (normal below 5.7) and his blood sugar continued to be elevated. The note indicated speech therapy assessed Resident #3's dysphagia (a condition that makes it difficult to swallow) and recommendation was to initiate a puree/liquid diet with one-on-one assist with all meals. A stroke neurology progress note dated [DATE] indicated Resident #3 had severe dysarthria, worse than prior to stroke, and an MRI completed on [DATE] indicated a new infarct (a localized area of dead tissue resulting from failure of blood supply) in the right paramedian pons. The note indicated Resident #3 had multiple risk factors for stroke, including uncontrolled diabetes and hypertension. The note indicated the resident had left myoclonic (quick, involuntary muscle jerks) jerks on admission that could have been a manifestation of [MEDICAL CONDITION]. The note indicated the plan was to treat the acute stroke with aspirin, [MEDICATION NAME], atorvastatin (medication to lower cholesterol), PT, OT and ST, inpatient rehabilitation and a pureed diet with medications in pureed foods. An after visit summary hospital record dated [DATE] indicated Resident #3 was admitted to the hospital on [DATE] and was discharged on [DATE]. The record indicated Resident #3 was treated for [REDACTED]. The record indicated the speech therapist recommended nectar thick liquids/puree textures with 1:1 assist. During an interview on [DATE] at 11:59 a.m., ADON D said if a resident left the facility and returned, orders should be checked and reconciled. He said any changes should be noted in the nursing notes. ADON D said he was not sure if Resident #3's blood sugars were checked during the period he did not have insulin orders. During an interview on [DATE] at 4:21 p.m., the DON said when Resident #3 was re-admitted to the facility on [DATE] and the admitting nurse did not click on each medication as required. She said Resident #3's [MEDICATION NAME] 75 mg daily, blood sugar checks and sliding scale insulin was not restarted on [DATE]. She said the facility did not monitor Resident #3's blood sugars, administer insulin or [MEDICATION NAME] from [DATE] until [DATE]. The DON said the nurses should have questioned why Resident #3 came back from the hospital with no blood sugar checks and insulin. The DON said since the incident with Resident #3, she was now doing a complete audit of orders every time a resident returned to the facility. She said they no longer allowed the nurses to place orders on hold in the computer system. The DON said after the incident she ran a report of hold orders every morning. The DON said the facility had not been monitoring the resident's orders or the held orders prior to this incident. The DON said that the [MEDICATION NAME], blood sugar checks and insulin were on hold due to a computer error by the admitting nurse. The DON said nurses were trained on medication administration competency and medication reconciliation on admit and return from hospital after the incident with Resident #3. During an interview on [DATE] at 5:09 p.m., the administrator said when they realized Resident #3's insulin and [MEDICATION NAME] were left off when he returned from the hospital on [DATE], they wrote the nurse up and put a procedure in place to correct the medication error from happening again. He said the procedure was a complete order audit of the physician orders [REDACTED]. The physician orders [REDACTED]. The website https://www.health.harvard.edu/newsletter_article/[MEDICATION NAME] accessed on [DATE] accessed on [DATE] indicated [MEDICATION NAME] (brand name for [MEDICATION NAME]) is used for people at high risk for [MEDICAL CONDITION] or stroke. The medication works by preventing platelet activation and significantly decreasing the risk of a blood clot. The website https://www.saebo.com/pontine-stroke-causes-symptoms-treatments/ accessed on [DATE] indicated .A pontine stroke is a type of ischemic stroke that affects the pons region of the [DIAGNOSES REDACTED]. A pontine stroke can be particularly devastating and may to lead to paralysis .An ischemic stroke occurs when a blood clot within a blood vessel disrupts or blocks blood flow to the brain .A stroke affecting the brainstem can result in loss of motor function or other deficits . 2. A physician order [REDACTED].#1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED].# 1 was to have a secure protective ointment applied to the perineal area twice a day. The physician order [REDACTED].#1 was to have the wound to his buttock cleansed every 3 days with normal saline and patted dry, collagen gel and [MEDICATION NAME] gel applied to area, then covered with [MEDICATION NAME] dressing. The orders indicated Resident #1 received a multi-vitamin with minerals starting [DATE]. Resident #1 received vitamin C 500 mg daily starting [DATE]. The summary indicated Resident #1 was to receive skilled ST services for the treatment difficulty swallowing starting [DATE]. The summary indicated the resident was to be administered sodium chloride 0.9% intravenously (through a vein) at 75 ml/hr starting [DATE].The summary indicated the resident was discharged to the hospital on [DATE]. A resident patient transfer form dated [DATE] indicated Resident #1 was sent to the hospital on [DATE] for decreased sensorium (in ability to think clearly) and an elevated potassium of 7.8 (normal 3.5 to 5.0). The MDS dated [DATE] indicated Resident #1 was understood and usually understood others. The MDS indicated Resident #1 had severely impaired cognitive function and required extensive assistance with bed mobility, transfers, walking with his cane, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated Resident #1 required supervision with eating and was totally dependent on staff for bathing and was always incontinent of bladder and had occasional incontinence of bowel. The MDS indicated Resident #1 had a [DIAGNOSES REDACTED].#1 was 73 inches tall and weighed 185 lbs. and had a significant weight gain and was not on physician prescribed weight-gain regimen. The MDS indicated Resident #1 was on a therapeutic diet and was not receiving nutrition or hydration by an artificial route. The MDS indicated Resident #1 was at risk for pressure injury development and had no unhealed pressure injuries. The MDS dated [DATE] indicated Resident #1 required limited assistance with bed mobility and extensive assistance with transfers, locomotion in his wheelchair, dressing, toilet use and personal hygiene. The MDS indicated the resident only walked once or twice during the 7 day look back period. The MDS indicated the resident required supervision with eating and weighed 179 pounds, was on a therapeutic diet and was not receiving nutrition or hydration by an artificial route. The MDS indicated Resident #1 was at risk for pressure injury development and had no unhealed pressure injuries. The care plan updated on [DATE] indicated Resident #1 was at risk for skin breakdown and interventions included to inspect skin, complete body head to toe assessment every week and document results. The care plan indicated Resident #1 was on diuretic therapy with interventions including monitoring for [MEDICAL CONDITION] daily, monitoring for fluid over load by measuring intake and output and obtaining daily weights. The care plan indicated Resident #1 had altered nutritional status and included interventions to monitor oral intake of food and fluid, provide snacks between meals and monitor weight. A physician wound progress note dated [DATE] indicated a wound to the right buttock of Resident #1 was resolved. The weekly wound log for [DATE] to [DATE] indicated Resident #1 had been treated for [REDACTED]. The skin assessments for Resident #1 between [DATE] and [DATE] indicated the following: *week of [DATE] - [DATE] there was no skin assessment completed; *week of [DATE] - [DATE] there was no skin assessment completed; *week of [DATE]-[DATE] there was no skin assessment completed; *week of [DATE]-[DATE] there was no skin assessment completed; * [DATE] indicated Resident #1 had no skin issues; *week of [DATE]- [DATE] there was no skin assessment completed; * [DATE] indicated Resident #1 had no skin issues; * [DATE] indicated Resident #1 had redness to his buttock/coccyx and bruising to his right leg, left leg, right foot and left foot, and did not have pressure wounds, abrasions, heel discoloration or open [MEDICAL CONDITION]. The assessment did not contain any measurements or descriptions and did not indicate the physician was notified. *[DATE] indicated Resident #1 had a Stage I pressure injury to his genital/perineal area. The assessment did not contain any measurements or descriptions and did not indicate the physician was notified. *week of [DATE]-[DATE] there was no skin assessment completed *[DATE] indicated Resident #1 had open areas to his buttock. The assessment did not contain any measurements of descriptions and did not indicate the physician was notified. *[DATE] indicated Resident #1 had no skin issues; and *[DATE] indicated Resident #1 had redness to his sacrum, buttock, coccyx, groin, and did not have pressure wounds, bruises, abrasions, heel discoloration or open [MEDICAL CONDITION]. The assessment did not contain any measurements or description and did not indicate the physician was notified. A wound care physician note dated [DATE] indicated Resident #1 had a Stage II pressure injury to his left buttock measuring 8.2 cm (centimeters) in length, 8 cm in width and 0.2 cm in depth. The note indicated Resident #1 had a wound to his right shin, described as a scab measuring 12.5 cm in length, 1 cm in width, and had an unmeasurable depth. The note indicated Resident #1 had a wound to the left shin, described as a scab, measuring 18 cm in length, 1.5 cm in width and had an unmeasurable depth. The note indicated Resident # 1 had a wound to the back of his right hand described as a scab, measuring 5 cm in length, 4 cm in width and had an unmeasurable depth. The note indicated Resident #1 had a wound to the back of his left hand described as a scab measuring 0.8 cm in length, 0.8 cm in width and had an unmeasurable depth. The wound care nurse's skin assessment and note on [DATE] indicated Resident #1 had redness to his upper back, groin and both legs. The skin assessment indicated Resident #1 had wounds to his sacrum, buttock and coccyx. The skin assessment indicated Resident #1 had bruising to his right hip, a skin tear to his right hand, scabbed areas to his left leg and right leg. The skin assessment indicated Resident #1 had blanchable redness to both of his heels. The note indicated Resident #1 had several new open areas to the sacrum since the assessment performed with the wound care physician on [DATE]. The assessment did not contain measurements or descriptions of the wounds and did not indicate the physician was notified. The hospital records dated [DATE] indicated Resident #1 was identified with the following pressure injuries: *Stage II pressure injury to the right buttock; *DTI to the right iliac crest; *DTI to left medial ankle; *DTI to the left medial heel; *DTI to the left foot metatarsal; * DTI to the left foot lateral; * Stage I pressure injury to the left heel; and * DTI to the sacrum. During an interview on [DATE] at 6:45 p.m., a family member for Resident #1 said they were only notified by the facility of a wound on the resident's bottom that would come and go. The family member said they were never notified of any of the other wounds. The family said they were shocked when they got to the hospital and was told of all the wounds. The family member said Resident #1 was discharged from the hospital on [DATE] to a hospice facility and died on [DATE]. During an interview on [DATE] at 11:10 a.m., the wound care nurse said the nurses completed the weekly skin assessments on all residents. The wound care nurse said she performed her own skin assessments on residents upon admission to the facility. The wound care nurse said she performed random skin assessments to ensure accuracy of skin assessments. The wound care nurse said she started wound care in (MONTH) of 2019 and identified a Stage II pressure injury to Resident #1's buttock. The wound care nurse said the pressure injury was healed out in (MONTH) 2019. She said she had not assessed Resident #1 between [DATE] and the week of his hospitalization on [DATE]. She said Resident #1 had a very quick decline in his health 2 weeks prior to his hospitalization . The wound care nurse said LVN A notified her of an area on the buttock of Resident #1 the week Resident #1 was hospitalized . LVN A said the area on the buttock looked like a DTI (deep tissue injury). She said Resident #1 also had a large bruise on his right hip, but she was not sure if it was a DTI. The wound care nurse said Resident #1 had a skin tear to his right hand and his heels did not look good. The wound care nurse said if she would have been notified of the observed bruising to Resident #1's feet on [DATE] she would have assessed the resident herself because she would have suspected DTI. During an interview on [DATE] at 11:15 a.m., LVN A said nurses performed skin assessments weekly on all residents. LVN A said if there were any skin issues identified during the assessment it would be reported to the wound care nurse. LVN A said he would not report bruising to the wound care nurse if he knew the reason or had an explanation for the bruising. LVN said he had taken care of Resident #1 many times and Resident #1 seemed to have a decline the end of (MONTH) 2019. LVN A said on the weekends the nurses performed wound care. LVN A said on the weekends leading up to Resident #1's discharge to the hospital he performed wound care on Resident #1. LVN A said on [DATE] he found areas of redness to Resident #1's buttock and notified the wound care nurse. LVN A said Resident #1 had three areas to his buttock which were being treated before he went to the hospital. LVN A said Resident #1 was also being treated with a cream to his legs for dryness prior to his hospitalization . LVN A said there were not any open wounds or bruises on Resident #1's legs before he went to the hospital. LVN A said the wound care nurse told him they would have to keep an eye on Resident #1's wounds because he was not eating well. During an interview on [DATE] at 9:53 am, LVN [NAME] said all residents received a weekly skin assessment. LVN [NAME] said any identified skin issues were reported to the wound care nurse. During an interview on [DATE] CNA G said that he took care of Resident #1 while he was at the facility. CNA G said Resident #1 did not have any wounds or pressure injuries. During an interview on [DATE] at 4:00 p.m., the DON said nurses performed skin assessments every week on all residents. The DON said she was not aware a nurse had identified bruising to the legs and feet of Resident #1 on [DATE]. The DON said she was not aware Resident #1 had not received weekly skin assessments. The DON said she and the ADON's now performed spot check skin assessments to double check the skin assessments. She said residents chosen for spot checks were randomly selected. The DON said the system of spot checks was implemented because of Resident #1's hospitalization . The registered dietician nutrition progress note dated [DATE] indicated Resident #1 was eating independently, consuming ,[DATE]% of oral intake. The nutrition progress note indicated Resident #1 had a stage II pressure injury and was at risk for dehydration due to the presence of wounds, use of diuretics, laxatives and cardiovascular medications. The nutrition progress note indicated Resident #1 would be monitored for significant weight changes, skin issues, oral intake of food/ fluid and labs would be monitored when available. The physician progress notes [REDACTED]. *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; *[DATE]; and *[DATE]. The Resident Weight Record for Resident #1 dated [DATE] to [DATE] indicated the following: *[DATE] 181 lbs.; *[DATE]-184.8lbs.; * there was no weight for (MONTH) *[DATE]-184.8 lbs.; *[DATE]-185 lbs.; *[DATE]-182.6 lbs.; *[DATE] -182.4 lbs.; *[DATE] - 179.4lbs; The hospital admission records dated [DATE] indicated Resident #1's admission weight was165.5 lbs. which indicated a 7.75% weight loss since the facility last weighed Resident #1 on [DATE] (approximately 3 weeks). A comprehensive metabolic laboratory result obtained at the facility dated [DATE] indicated Resident #1 had an [MEDICATION NAME] (a protein in the blood, which when low, may indicate problems with the liver, heart or malnutrition) of 3.4 g/dL (normal range 3.4 to 5.4). A comprehensive metabolic laboratory result obtained by the facility dated [DATE] indicated Resident #1 had an [MEDICATION NAME] of 3.0 g/dL. The hospital discharge summary dated [DATE] indicated Resident #1 had an [MEDICATION NAME] level of 1.7 g/dL when admitted on [DATE]. The summary indicated Resident #1 had a potassium level of 8.2 (normal 3.5 to 5.0) and a sodium level of 165 (normal 135 to 145). The discharge summary indicated Resident # 1 had acute kidney injury due to severe volume depletion and a creatinine (an indicator of kidney function) of 12.7 (normal 0.7 to 1.2) on admission to the hospital. The discharge summary indicated Resident #1 had acute metabolic [MEDICAL CONDITION] (an alteration of brain function or consciousness due to the failure of other internal organs causing metabolic disturbances) due to dehydration and possible aspiration pneumonia. During an interview on [DATE] at 9:53 a.m., LVN [NAME] said most residents were weighed monthly. LVN [NAME] said residents were weighed more often if there was a concern about weight loss. LVN [NAME] said residents with [MEDICAL CONDITION] are weighed daily. She said nurses did not have to have an order to weigh a resident daily with [DIAGNOSES REDACTED]. LVN [NAME] said she did not know of any other place weights would be documented. LVN [NAME] said she did not recall Resident #1. During an interview on [DATE] at 9:57 a.m., CNA B said she took care of Resident #1 often while he was at the facility. CNA B said the few weeks before Resident #1 went to the hospital he was fed in his room. CNA B said as far as she could remember Resident #1 was fed at the assisted dining table before that. CNA B said the nurse aides documented the percentages of meals residents ate and their fluid intake. She said about 2 weeks prior to Resident #1 going to the hospital she reported to LVN A on 2 occasions she was concerned how little Resident #1 was eating and drinking. During an interview on [DATE] at 11:00 a.m., LVN A said he had taken care of Resident #1 many times and routinely took care of him. LVN A said residents got monthly weights unless there was a concern a resident's nutrition was declining and then the resident would be weighed weekly. He said if a resident had a [DIAGNOSES REDACTED]. LVN A said he did not think Resident #1 had a [DIAGNOSES REDACTED]. LVN A said an order was not required to weigh a resident weekly or daily. LVN A said Resident #1 seemed to be having a decline during the end of (MONTH) 2019. LVN A said he was told by CNAs that Resident #1 was not eating or drinking well. LVN A said he had the restorative aide weigh the resident when it was reported to him the resident was not eating well. He said he was not sure if the resident had lost weight at that time. He said he reported to the physician Resident #1 had a decreased appetite, but there was no documentation of the notification. LVN A said he thought Resident #1 was getting weighed more often than monthly. He said the resident weight logs was the only place Resident #1's weights would be documented. He said he thought he had asked the restorative aide to weigh the resident more often. LVN A said the wound care nurse had told him they would have to keep an eye on the residents' wounds because he was not eating well. During an interview on [DATE] at 12:00 p.m., ADON D said all residents were weighed monthly. ADON D said if a resident was having a gain or a lose the resident would be weighed weekly. ADON D said a resident with [MEDICAL CONDITION] would be weighed daily. During an interview on [DATE] the DON said all residents were weighed monthly. The DON said a resident who was not eating well would be weighed weekly. The DON said a resident with [MEDICAL CONDITION] would be weighed daily. The DON said she ensured residents were being weighed by running a weekly report that was reviewed in their weekly meeting. The DON said she did not know how it was missed that Resident #1 was not weighed daily. The DON said they attempted to start an IV on Resident #1 for hydration when it was ordered on [DATE], but were unable to get it started. The facility policy titled, Skin Data Collection: Licensed Nurses, revised (MONTH) (YEAR), stated, A licensed nurse will collect data during weekly skin evaluations. Weekly, the Licensed Nurse performs a head to toe check of the patient's/ resident's skin, paying attention to: (A) The surfaces of the skin that come in contact with the bed and chair. (B) Bony prominences (heels, tailbone, shoulder blades, elbows, back of the head, etc.) .The licensed nurse should pay attention to: (A) Redness (check for blanching and document blanchable, or non-blanchable redness); (B) Rashes; (C) Discolorations; (D) Open areas; (E) Blisters; (F) Dry/Flaking skin; (G) [MEDICAL CONDITION]. Any significant abnormal findings are reported to the patient's/resident's physician and resident or responsible party. Documentation that the check was performed is denoted on the EMR/medical record. Abnormal findings are to be documented in the EMR/medical record, along with summary of all notified with their responses. The facility policy titled, Prevention of Pressure ulcers/Injuries, dated (MONTH) (YEAR), stated, It is important that each existing PU/PI (pressure ulcer/pressure injury) be identified, whether present on admission or developed after admission, and that factors that influenced it's development, the potential for development of additional PU/PI or the deterioration of the PU/PI be recognized, assessed and addressed. Any new PU/PI suggests a need to reevaluate the adequacy of prevention measures in the resident's care plan. When assessing the PU/PI itself, it is important that the documentation address: The type of injury; a description of the PU/PI's characteristics; the progress toward wound healing; if infection is present; the presence of pain, what has been done to address it, and the effectiveness of the intervention; and a description of dressings and treatments. A policy titled Prevention of Pressure Ulcers/Injury revised (MONTH) (YEAR), stated, .adequate nutrition and hydration are essential for overall functioning. Nutrition provides vital energy building blocks for all the body's structures and processes. Any organ or body system may require additional energy or structural materials for repair or function. Residents at high risk for nutritional needs or have the presence of a pressure ulcer should be referred to a Registered Dietitian and/or physician .weight stability (in the absence of fluid excess or loss) is a useful indicator of overall caloric balance. A policy titled Acceptable Parameters of Nutrition Status, dated [DATE], stated Residents with unplanned weight loss will be identified. Significant Weight Loss-5% weight loss in 1 month, 7.5% weight loss in 3 months, 10% weight loss in 6 months. Severe Weight Loss->5% weight loss in 1 month,>7.5% weight loss in 3 months,>10% weight loss in 6 months. Resident hydration needs will be identified within the comprehensive nutrition assessment. Nutrition risk factors and recommended nutritional interventions will be based on each resident's medical condition, needs, preferences and goals. A policy titled Hydration dated [DATE], stated, Residents at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to encourage adequate hydration. Risk factors for dehydration will be identified through the comprehensive nutrition therapy assessment process. General fluid needs will be determined as follows (or as determined by clinician): (a) Resident/patient without renal or cardiac distress (i). 30 cc/kg body weight (2.2 pounds = 1 kg)(b) Residents / patients diagnosed with [REDACTED]. Approaches will be individualized as needed through the assessment/reassessment and care planning process . If fluids by mouth are not tolerated, an alternative intervention will be pursued. The facility policy titled, Obtaining Accurate Height/Weight, dated [DATE], stated, .Each resident's height and weight will be obtained and documented on admission. Weights will be obtained monthly, unless physician's orders [REDACTED].

Based on record review and interviews, the facility failed to ensure residents are free of any significant medication errors for one (Resident #1) of four residents reviewed for pharmacy services. The facility failed to clarify a prescription written by an outside neurologist for Resident #1, resulting in a medication intended to reduce the likelihood of stroke ([MEDICATION NAME]) not being administered for five days beginning [DATE] through [DATE]. This failure resulted in Resident #1 being hospitalized and treated for [REDACTED]. Findings included: Resident #1's electronic facility clinical record reviewed on [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged on [DATE] following symptoms consistent with a urinary tract infection first noted on [DATE] and symptoms consistent with a possible stroke first noticed on [DATE]. Resident #1's electronic facility clinical record revealed a scan of a prescription signed by Neurologist A, dated [DATE], for [MEDICATION NAME] ,[DATE] (antiplatelet/antiaggregant) to be given one capsule by mouth every morning for five days, then one capsule by mouth BID (twice daily) stroke prevention. The prescription also included #180 for 90 days and indicated three refills. Resident #1's facility electronic MAR for the months of September through [DATE] revealed an order reading [MEDICATION NAME] 200mg-25mg capsule, extended release (Aspirin/[MEDICATION NAME]) 1 capsule, ER multiphase 12 hr by mouth 1 time per day 5 days. The order noted a start date of [DATE] and an end date of [DATE]. The order was entered by Licensed Vocational Nurse (LVN) A. All ordered doses were documented as being administered. Record review of Resident #1's electronic MAR for the months of September through [DATE] revealed an order reading [MEDICATION NAME] 200mg-25mg capsule, extended release (Aspirin/[MEDICATION NAME]) 1 capsule, ER multiphase 12 hr by mouth 2 times per day 90 days. The order noted a start date of [DATE] and an end date of [DATE]. The order was entered by LVN A. All ordered doses were documented as being administered through [DATE]. No doses were documented as being administered after [DATE]. The facility Admission/Discharge log for [DATE] revealed Resident #1 had been discharged on [DATE] to short-term general hospital for inpatient care. Documentation from Hospital #1 revealed Resident #1 had been admitted on [DATE] and discharged on [DATE]. A Discharge Summary note dated [DATE] and signed by Registered Nurse (RN) A indicated Resident #1 was treated for [REDACTED]. It indicated the reason for visit was [MEDICAL CONDITION] ([MEDICAL CONDITION]). The Physician's Discharge Summary, signed by Physician C, also reflected Resident #1 was, started on aspirin and [MEDICATION NAME] for better antiplatelet management. A Consultation Report, signed and dated by Physician B on [DATE] from Hospital #1, revealed she called the facility, and spoke to a nurse who had been caring for (Resident #1) approximately 24 hours prior and asked her about the antiplatelet agent (Resident #1) was on. She was reported to have been on [MEDICATION NAME]. The nurse whose name is (LVN B) reported to me that the patient had initially been started on [MEDICATION NAME] on [DATE], but it had been held for more than 24 to 48 hours. She noted she needed to investigate the MAR indicated [REDACTED]. I did report this to (Physician C) and (Physician C) will be calling (the facility) back to follow up on the reasoning why. A progress note by Physician C from Hospital #1, dated [DATE], reflected, discussed with (the facility) myself on ,[DATE] and patient's [MEDICATION NAME] rx was for 90 days only and expired last week. A telephone interview on [DATE] at 11:56 a.m. with the Former Director of Nursing (DON) revealed she felt the doctor's orders were clear to give the meds for 90 days. She stated there had been no mention from Resident #1's family or her doctor to make a follow-up appointment. She stated it is not standard protocol to follow-up at the end of the 90 days. We are not at liberty to determine what the doctor means. A telephone interview on [DATE] at 11:56 a.m. with LVN A revealed she did not remember the specific order for [MEDICATION NAME] for Resident #1, but said that if a stop date was included in the order, general nursing practice would be to contact the prescribing physician to inform of any problems or adverse reactions at the end of the 90 days and to see if it would be renewed. She said that was standard nursing procedure and I learned that in nursing school. A telephone interview on [DATE] at 12:22 p.m. with Resident #1's facility attending Physician A revealed Resident #1 had been added to his caseload at the end of [DATE]. Regarding the [MEDICATION NAME] order, he stated, Usually those kinds of medications should be continuing. That's not how I would have written the order. The facility may have their own policy and procedure on this. Generally, with medications like this, or with blood pressure medications, folks know to check back, but it depends on the facility. A telephone interview on [DATE] at 2:08 p.m. with Medical Assistant A revealed she worked with Neurologist A who had prescribed Resident #1's [MEDICATION NAME]. Regarding Resident #1's prescription for [MEDICATION NAME], she said This is not a temporary medication. She explained the prescription was intended to be a one-year supply, with the original 180 capsules for a 90-day supply, and three refills of 180 capsules, each to cover 90 days. She said Resident #1's family was given the actual prescription. A copy of a letter from Neurologist A, provided by Resident #1's grand-daughter, dated [DATE], indicated It was my recommendation that (Resident #1) remain on [MEDICATION NAME] indefinitely unless she had significant side effect that precluded its continued use and I was not aware that [MEDICATION NAME] had been discontinued and substituted with aspirin until I was informed of this change by her daughters. The letter also noted that Resident #1 had not been seen by Neurologist A since their initial encounter, and Neurologist A had not had contact with any care provider responsible for (Resident #1's) medications. Interview on [DATE] at 4:02 p.m. with the current facility DON revealed she did not work at the facility when Resident #1 was a resident. She reviewed Resident #1's [MEDICATION NAME] prescription and said she would interpret it to mean there were three, 90-day refills. She said she would have called the prescribing physician for clarification. On [DATE] at 8:45 a.m., the DON stated Resident #1's [MEDICATION NAME] was not care-planned by the facility. She said that because it was an antiplatelet and not an anticoagulant, it would not have triggered a change to a care plan. She said she did not see that the facility addressed TIAs on care plans, and that she felt they should be. Interview on [DATE] at 10:15 a.m. with LVN B revealed she had only worked with Resident #1 a few times. She said someone from Hospital #1 had called her at the facility and asked why Resident #1's [MEDICATION NAME] had been discontinued. She said she found an order for [REDACTED]. She said the family and the facility should have followed up. She said the family wanted an outside doctor, so they should have made an appointment for Resident #1 and taken her. The facility should have followed up to make sure the [MEDICATION NAME] order was correct before stopping the medication. She said the order was not clear form her perspective. Interview on [DATE] at 4:20 p.m. with the Pharmacist revealed Resident #1's prescription for [MEDICATION NAME] was, good for a year. She confirmed that Resident #1's family picked up the medication. Interview on [DATE] at 12:24 p.m. with current facility DON revealed the facility had revised its procedures to add antiplatelet medications to its list of care plan triggers, and those would be discussed in weekly Quality Assurance meetings. In addition, she said that she or her designate would see all new orders during the 24-hour report meetings, and prescriptions from outside the facility would be approved by the facility physician after the DON or ADON reviewed the actual prescription as a final check. She said that final step was not being done back then. According to product information at <https://www.[MEDICATION NAME].com/taking-[MEDICATION NAME]>, reviewed on [DATE], You should never stop taking your medication without talking to your doctor first. Once you've had a TIA or stroke caused by a blood clot, your risk of another stroke is increased. The facility's Anticoagulant Report, dated [DATE], revealed a total of nine residents with current physician orders [REDACTED]. None of the orders contained an end date. The facility census on [DATE], provided by the facility Administrator, was 99.