Every finding on record at Vintage Faire Nursing & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to protect residents' health information when the Rehabilitation (rehab) Department downloaded and used WhatsApp (a messaging application that allows users to send text messages, photos, videos, documents, and other information through the internet) on staff members' personal phones to communicate PHI (Protected Health Information, health information that can identify a resident) among rehab staff members for four of four sampled residents (Residents 1, Resident 2, Resident 3, and Resident 4).This failure placed Resident 1, Resident 2, Resident 3, and Resident 4 at risk for unauthorized access, use, or disclosure of their PHI and compromised the confidentiality and security of their health information using WhatsApp, an unapproved messaging system on staff members' personal phones.Findings:During a concurrent observation and interview on 8/20/26 at 2:05 PM with Speech Therapy (ST) 1, ST 1 shared her personal smart phone containing WhatsApp messages from approximately 18 rehab staff members in a group under the name of Vintage Faire Rehab. Review of the WhatsApp messages indicated that on 7/29/26 at 8:39 AM, a message contained Resident 1's first and last name, room number, and information that Resident 1 was found on the floor. On 8/5/26 at 12:53 PM, the Director of Rehab (DOR) sent a picture of a physician's note for Resident 2 that included Resident 2's first and last name, the physician's first and last name, and an order indicating Resident 2 was okay to bear weight. On 8/18/26 at 3:46 PM, another picture of a physician's note was sent to the Vintage Faire Rehab group that included Resident 3's first and last name, the physician's first and last name, and information regarding Resident 3's follow-up for a left shoulder fracture. On 8/20/26 at 9:19 AM, the DOR sent a message to the Vintage Faire Rehab group containing Resident 4's first and last name and weight-bearing information. ST 1 stated that the rehab department staff used WhatsApp on their personal phones to communicate residents' medical information. ST 1 stated that she was uncomfortable because residents' private health information was being shared and disclosed through a system that was not approved by the facility for sharing residents' private health information, which violated residents' rights to privacy and confidentiality. ST 1 further stated that the WhatsApp group was not secure, some rehab staff members in the group were not involved in the care of every resident whose information was shared, and residents' information should not be shared with staff members who were not involved in their care.During an interview on 8/20/26 at 3:16 PM with Physical Therapy Aide (PTA), the PTA stated that the rehab department used personal phones where they downloaded the WhatsApp text messaging system to share residents' health information with rehab staff members who were members of the WhatsApp group text. The PTA stated that he believed WhatsApp was encrypted (protected so unauthorized people could not read the information) and safe to use to share residents' health information. The PTA further stated that sharing residents' health information through a system that was not encrypted violated HIPAA (Health Insurance Portability and Accountability Act - a federal law that protects the privacy and security of a person's health information).During an interview on 8/20/26 at 3:40 PM with the DOR, the DOR stated that the rehab department used WhatsApp for text messaging but did not include any residents' information. The DOR further stated that the text messages between the rehab staff members were only used to share staff schedules.During an interview on 8/20/26 at 3:42 PM with the Administrator (Adm), the Adm stated that the facility's approved communication system for staff members was secure messaging through PCC (Point Click Care; the facility's electronic health record system). The Adm stated that there were no other approved means to communicate through text messaging, such as WhatsApp, phone text messaging, or Facebook Messenger. The Adm further stated that staff were not allowed to use WhatsApp because it was not a secure messaging system and did not protect residents' health information.Review of the undated facility's P&P titled HIPAA Security Measures, the P&P indicated .The facility will guard against unauthorized access to EPHI [electronic protected health information] that is being transmitted over an electronic communications network [such as through text messaging or messaging applications].Encryption: mechanism to encrypt EPHI will be implemented whenever deemed appropriate .A review of a HIPPA journal, titled, Is WhatsApp HIPAA Compliant? by [NAME], dated 9/12/23, the article indicated .WhatsApp is not HIPPA complaint and should not be used for receiving, storing, or sending Protected Health Information.[WhatsApp] the platform should not be used to communicate PHI because it lacks the capabilities to support compliance with the HIPPA Security Rule. The article was retrieved from The HIPAA Journal website at: https://www.hipaajournal.com/whatsapp-hipaa-compliant/

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff on a 24-hour basis to meet residents' care needs in accordance with the facility assessment (a facility-wide evaluation to determine the specific resources, staff competencies, and operational systems needed) for a census of 95 when, the facility staffed multiple shifts below the number of Certified Nursing Assistants (CNAs) identified as needed in the facility assessment.This deficient practice resulted in delayed responses to residents' call lights and delayed assistance with care and placed residents at risk for unmet care needs, falls, and impaired skin integrity.Findings:During a concurrent observation and interview on 8/4/26 at 9:11 AM with Resident 92 in his room, Resident 92 was observed sitting in bed in a high-Fowler's position (sitting almost straight up while in bed). Resident 92 stated that his biggest concern was that the facility was short-staffed. Resident 92 stated that staff took a long time to respond to his call light, which resulted in delays in receiving care. Resident 92 stated that when he expressed his concern to staff that they were understaffed and that the staffing shortage caused delays in his care, staff told him that the facility had the required number of staff and was not short-staffed. Resident 92 further stated that, based on his personal experience with delays in receiving care, he believed that the facility was short-staffed.During an interview on 8/4/26 at 11:43 AM with Resident 93, Resident 93 stated that staff responded to the call light and the response time was usually longer, particularly during the night shift.During an interview on 8/4/26 at 11:56 AM with Resident 84, Resident 84 stated that she had been residing at the facility for approximately one month. Resident 84 stated that she knew how to use the call light and that staff typically responded to her call light within approximately 5 to 15 minutes.During an interview on 8/4/26 at 12 PM with Resident 111, Resident 111 stated that staff took a long time to respond to the call light, with response times ranging from approximately 15 to 45 minutes.During a follow-up concurrent observation and interview on 8/5/26 at 4:09 PM with Resident 111 in the dining room, Resident 111 was observed sitting in her wheelchair and watching television. Resident 111 stated that staff took a long time to respond to her call light. Resident 111 recalled an occasion when she was sitting on the bedside commode and activated her call light for assistance. Resident 111 stated that when a Certified Nursing Assistant (CNA) responded, the CNA told her that she had to pick up the meal trays first before assisting her. Resident 111 stated that she remained on the bedside commode and waited approximately 45 minutes before receiving assistance.During an interview on 8/4/26 at 2:45 PM with Resident 117, Resident 117 stated that he had been residing at the facility for approximately 14 days. Resident 117 stated that when he activated his call light, staff would sometimes enter his room, turn off the call light, and leave without providing the requested assistance or returning to his room. Resident 117 further stated that staff often took a long time to respond to his call light.Review of the facility's staffing records for selected dates in July and August 2026 showed that CNA staffing levels fell below the staffing needs identified by the facility. The Facility assessment dated [DATE] identified that, based on a resident census of 93, the facility needed 12 CNAs for the AM/Day shift, 10 CNAs for the PM/Evening shift, and six CNAs for the NOC/Night shift. During the dates reviewed from 7/1/26 through 8/5/26, the facility's resident census ranged from approximately 93 to 97 residents. Review of the staffing records showed the following: 7/1/26 - Census 93: NOC shift was staffed with approximately 5-6 CNAs. 7/3/26 - Census 93: NOC shift was staffed with approximately 5-6 CNAs. 7/10/26 - Census 94: Day shift was staffed with 11 CNAs, and NOC shift was staffed with approximately 5-6 CNAs. 7/13/26 - Census 96: PM shift was staffed with 9 CNAs. 7/14/26 - Census 93: PM shift was staffed with 9 CNAs. 7/17/26 - Census 96: Day shift was staffed with 11 CNAs, and PM shift was staffed with 9 CNAs. 7/20/26 - Census 93: PM shift was staffed with 8 CNAs, and NOC shift was documented with approximately 5-7 CNAs. 7/21/26 - Census 95: PM shift was staffed with 8 CNAs. 7/25/26 - Census 96: PM shift was staffed with 9 CNAs. 7/27/26 - Census 96: Day shift was staffed with 11 CNAs. 7/28/26 - Census 95: PM shift was staffed with 9 CNAs. 7/29/26 - Census 95: Day shift was staffed with 11 CNAs. 7/31/26 - Census 96: Day shift was staffed with 11 CNAs, and NOC shift was documented with approximately 5-7 CNAs. 8/3/26 - Census 97: Day shift was staffed with 11 CNAs, and NOC shift was documented with approximately 5-6 CNAs. 8/4/26 - Census 94: Day shift was staffed with 11 CNAs, and NOC shift was documented with approximately 4-5 CNAs. The staffing records demonstrated multiple dates and shifts when actual CNA staffing was below the staffing levels identified in the facility's Facility Assessment with resident censuses ranging from approximately 93 to 97 residents.During a concurrent interview and record review on 8/6/26 at 1:28 PM with the Staffing Scheduler (SS), the SS reviewed one of the facility's Nurse Staffing Information (PPD posting - a daily posted notice showing the facility's nursing staffing for the residents) forms and stated that she utilized the Master Staffing Matrix (a chart that tells the facility how many staff should be scheduled for each shift) provided to her by the Staffing Team as the guide for determining the facility's staffing needs. The SS stated that she did not use the Facility Assessment to guide staffing decisions and that the last time she reviewed the Facility Assessment was approximately three and a half months ago. The SS further stated that the staffing reflected on the PPD posting forms might not match the staffing guidance identified in the Facility Assessment because she followed the Master Staffing Matrix, as she had been instructed to do.During an interview on 8/7/26 at 8:54 AM with the Director of Nursing (DON), the DON stated that she expected the facility to provide sufficient and competent nursing staff to ensure that each resident received quality care and services. The DON stated that sufficient staffing played an important role in maintaining the quality and safety of resident care. The DON further stated that insufficient staffing could place residents at risk for delayed responses to call lights, inadequate assistance with activities of daily living (ADLs - basic everyday activities a person needs to do to take care of themselves), including grooming, showering, and toileting, and an increased risk for falls. The DON stated that insufficient staffing could also affect residents who required assistance during mealtimes and dependent residents who required continence care (helping a person with their bladder and bowel needs and keeping them clean, dry, and comfortable), which could negatively affect their skin integrity (keeping the skin healthy and preventing sores, wounds, or skin breakdown). The DON stated that insufficient staffing could result in inadequate or delayed turning and repositioning of dependent residents (residents who depend on staff to help with their everyday needs), further increasing their risk for impaired skin integrity.During an interview on 8/7/26 at 11:11 AM with the Administrator (ADM), the ADM stated that it was important for the facility to ensure adequate staffing in accordance with State requirements and to meet the acuity (how sick a resident is or how much care and help they need) and care needs of each resident. The ADM stated that the facility used the Facility Assessment as a guideline for determining staffing needs and that the Facility Assessment should be incorporated into staffing decisions. The ADM further stated that insufficient staffing could result in residents' care needs not being met and could negatively affect staff by contributing to increased workload and burnout. The ADM confirmed that the Facility Assessment was an important component of staffing decisions because it identified the resources and staffing needed to meet the needs of the facility's resident population.A review of the facility policy and procedure (P&P) titled, Facility Assessment Policy, revised date 8/1/26, the P&P indicated, . Facility will conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) . Purpose - To use this assessment to make decisions about direct care staff member needs and their capabilities to provide services to residents in the facility . To serve as the foundation in assessing our Resident population and determining direct care staffing and other resources to provide required care to them . The Facility Assessment will be used to: . Inform staffing decisions to facilitate sufficient numbers of staff . Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on the changes to the resident population . Consider the specific staffing needs for each shift, such as day, evening, night and adjust as necessary based on any changes to the resident population .Further review of the facility's P&P titled, Facility Assessment Policy, and the facility assessment document titled, Total Staffing Needs [Direct Care] per Shift, indicated that, based on a census of 93 residents, the facility identified a staffing need of 12 CNAs for the day shift, 10 CNAs for the evening shift, and six CNAs for the night shift.

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for three out of twenty three sampled residents (Resident 111, Resident 118, and Resident 97) when:1. The oxygen flow rate was not followed per physician order for Resident 111 and Resident 118; and2. The nebulizer (used to deliver medication to be inhaled) tubing was not changed at least weekly according to the facility's standards for Resident 97.These deficient practices had the potential to cause health decline, respiratory distress, and risk for infection. Findings: 1. A review of Resident 111's record titled Face Sheet indicated Resident 111 was admitted to the facility with multiple diagnoses including chronic obstructive pulmonary disease (COPD; a long-term lung disease that blocks airflow and makes it hard to breathe), pneumonia (an infection that inflames the air sacs in one or both lungs, causing them to fill with fluid or pus), and acute respiratory failure with hypoxia (a critical condition where the lungs cannot transfer enough oxygen into the blood). A review of Resident 111's record dated 7/21/26, titled Order Details indicated, .Oxygen at 2 LPM [Liters per minute] via NC [Nasal Cannula; a light, plastic device used to give extra oxygen to people who have trouble breathing] continuous. A review of Resident 111's record with an initiation date of 7/21/26, titled Care Plan Report, indicated, .Has Oxygen Therapy r/t [related to] COPD/SOB [Shortness of breath].Oxygen per MD [medical doctor] orders.OXYGEN SETTINGS: O2[Oxygen] via nasal prongs/mask@2L [at 2 liters] continuously. During a concurrent observation and interview on 8/6/26, at 8:21 a.m., Licensed Nurse (LN) 8 confirmed Resident 111 was receiving oxygen and the concentrator was set at 3 liters per minute. LN 8 stated Resident 118's order for oxygen was two liters per minute. LN 8 stated the risk of having the oxygen set at higher than prescribed could lead to labored breathing, shortness of breath, dry nasal passages and issues with congestion. A review of Resident 118's record titled Face Sheet indicated, Resident 118 was admitted to the facility with multiple diagnoses including COPD, acute respiratory failure with hypercapnia (the lungs cannot properly remove carbon dioxide), and chronic bronchitis (causes swelling in airways and makes too much mucus). A review of Resident 118's record dated 7/24/26, titled Order Details indicated, .Oxygen at 3 LPM [Liters per minute] via NC continuous. A review of Resident 118's record with initiation date of 7/24/26, titled Care Plan Report, indicated, .Has Oxygen Therapy r/t COPD.Oxygen per MD orders. During a concurrent observation and interview on 8/6/26, at 8:13 a.m., Licensed Nurse 8 (LN 8) confirmed Resident 118 was receiving oxygen and the concentrator (oxygen delivery device) was set at 4 liters per minute. LN 8 stated Resident 118's order for oxygen was for three liters per minute. LN 8 stated the risk of having the oxygen set at higher than prescribed could lead to labored breathing, shortness of breath, dry nasal passages and issues with congestion. During an interview with Director of Nursing (DON) on 8/6/26 at 5:09 p.m., the DON stated that giving too much oxygen to a resident could damage the cells in the lungs, especially in residents with COPD. The DON stated that the oxygen levels on the concentrator should have been correct and she expected the staff to follow the physician's orders correctly. During the review of an undated facility policy and procedure (P&P) titled Oxygen Administration, the P&P indicated, .Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences.Oxygen is ordered under orders of a physician. 2. A review of Resident 97's admission RECORD, indicated Resident 97 was admitted to the facility with diagnoses which included shortness of breath, COPD, and heart failure (when the heart is too weak to pump blood), According to the Minimum Data Set (MDS- an assessment tool) dated 7/16/26, Resident 97 scored 15 out of 15 in a Brief Interview for Mental Status (BIMS) which indicated he had intact cognition (normal reasoning, understanding and memory). During a concurrent observation and interview on 8/4/26, at 9:37 AM, Resident 97 was noted to be lying in bed with his head slightly elevated. Resident 97 stated he used his nebulizer machine twice a day to assist him with breathing. Review of Resident 97's Medication Administration Record (MAR - A place where medication and treatment orders are placed for staff to view and administer as indicated), dated 8/2026, indicated, .Ipratropium-Albuterol Solution [two medication mixed together that quickly opens the airway] 0.5-2.5mg [a unit of measurement] .inhale orally every 2 hours as needed for SOB [Shortness of Breath] or Wheezing via nebulizer . As of 8/7/26, Resident 97 was last administered an Ipratropium-Albuterol Solution treatment on 8/7/26. During a concurrent observation and interview on 8/4/26, at 9:45 AM, with the Director of Nursing (DON), the DON confirmed Resident 97's nebulizer mask and tubing was labeled as last changed on 7/26/26 and marked as needed to be changed on 8/2/26. The DON stated the nurses on night shift were the ones who would change the oxygen and nebulizer tubing on a weekly basis. The DON stated the tubing should have been changed when it was due. The DON stated this did not represent the facility's usual practice and did not meet her expectations. The DON stated the purpose for having the nurses change the nebulizer tubing weekly was for infection control practices. The DON stated if the nebulizer tubing was not changed when it was due it presented a risk for the residents to develop respiratory infections. During an interview on 8/7/26, at 9:09 AM, with the Infection Preventionist (IP- is a healthcare professional who acts like a safety detective to stop the spread of germs), the IP stated the nebulizer tubing should be changed at least weekly unless its damaged. The IP further explained if the tubing became soiled, cracked, or dirty then it would be changed right away. The IP stated the risk of not changing the nebulizer tubing when it was due placed the residents at risk for infection.

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices for a census of 95 residents when:1. Used urinals were found stored on the handrails in multiple shared bathrooms of Resident 10, Resident 4, Resident 96, Resident 26, Resident 22, Resident 54, and Resident 121;2. The facility did not ensure safe cleaning and sanitization of a shared glucometer (a device that measured blood sugar) in-between resident care for Resident 31, Resident 3, Resident 22 and Resident 10; and3. The facility did not follow Enhance Barrier Precaution (or EBP, infection prevention measures used in nursing homes to reduce the spread of germs; EBP involves healthcare staff wearing gowns and gloves during high-contact resident care activities) during tube feeding and resident care for Resident 68.These failures had the potential to spread infection in the facility. Findings: 1. During a concurrent observation and interview on 8/4/26, at 10:11 AM, with the Director of Nursing (DON), inside of the shared bathroom of Resident 26, Resident 96, and Resident 10, the DON confirmed two urinals without any form of resident label was hanging on the hand support rails located behind the toilet. The DON stated her expectations was for the urinals to be properly labeled with the residents information to prevent cross contamination. The DON stated the facility's process was to place the urinals in their specialized holders where they would be stored in each resident's private area. The DON further stated the unlabeled urinals and their placement presented an infection control risk for the residents that resided in the facility. During a concurrent observation and interview on 8/4/26, at 10:38 AM, with the DON, in the shared bathroom of Resident 22, Resident 4, Resident 121, and Resident 54, the DON confirmed an unlabeled used urinal was located on the support bars in the shared bathroom placed next to the toilet. The DON stated the unlabeled urinal, and its placement did not meet her expectations and placed the residents at risk of infection and cross contamination. During an interview on 8/7/26, at 9:59 AM, with the Infection Preventionist (IP- is a healthcare professional who acts like a safety detective to stop the spread of germs), the IP stated the facility's process for the usage and storage of the urinals was that the urinals, should have been properly labeled with the residents last or first name. The IP stated after use, the urinal should have been cleaned then placed in a plastic bag and in the resident's personal area. The IP stated the unlabeled urinals in the bathroom presented a risk of infection and cross contamination to the residents. A review of a facility provided policy and procedure titled, Infection Prevention and Control Program, dated 6/21, indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals.Goals.identify and correct problems relating to infection control.monitor personnel health and safety.The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection.Safe use of disposable and single use supplies and equipment. A review of an undated facility provided document titled, Bedpan/urinal/offering and removing, indicated, .After Assisting the Resident .Empty the bedpan or urinal into the commode.Clean the bedpan or urinal.Store the bedpan or urinal per facility policy. Do not leave it in the bathroom . 2a. During a medication administration observation, accompanied by Licensed Nurse 2 (LN 2), in hallway 1, on 8/4/26, at 11:35 AM, LN 2 gathered the supplies and glucometer inside Resident 31's room and placed the glucometer on top of the bedside table. With a gloved hand LN 2 first poked Resident 31's left index finger and then tried the middle finger to get enough blood to soak the test strip attached to the glucometer. LN 2 then stated the blood sugar was 201 (normal blood sugar number is 80-120 mg/dl or milligram per deciliter) and no insulin (drug used to treat high blood sugar) was needed based on the order. Once out of the room, LN 2 placed the glucometer on top of the med cart and changed her gloves. LN 2 then used one wipe from a container labeled as Sani-Wipe and very quickly cleaned the outer surface of glucometer. LN 2 then used the second wipe to wrap the glucometer. The medication cart countertop surface was not cleaned. 2b. During a medication administration observation, accompanied by LN 2, in hallway 1, on 8/4/26, at 11:41 AM, LN 2 gathered the supplies and used a second glucometer from her cart to take inside Resident 3's room and placed the glucometer on top of the bedside table. LN 2 with a gloved hand poked Resident 3's right middle finger with a lancet (a small, sharp medical tool used to prick the skin and get a tiny drop of blood) and soaked the test strip with the resident's blood. LN 2 stated the blood sugar was 108 and no insulin was required. LN 2 once out of the room, place the used glucometer on top of the medication cart, then replaced her gloves and used one wipe to quickly clean the outer surface of the glucometer. LN 2 then used a second wipe to wrap the glucometer and placed it on top of the cart. The medication cart countertop surface was not cleaned. In an interview with LN 2 on 8/5/26, at 2:30 PM, LN 2 stated her training was during her orientation when she started to work at the facility. LN 2 stated she followed another nurse for glucometer use and learned to use the second wipe to wrap the glucometer. LN 2 stated she should have used a tissue to place the glucometer on the resident bedside cart or on the medication cart. 2c. During a medication observation with LN 4, on 8/4/26 at 12:36 PM, in the 3rd hallway, LN 4 entered Resident 22's room with glucometer, and testing supplies in a plastic blue tray. LN 4 with gloved hands poked Resident 22's left middle finger to get blood and soaked the test strip attached to the glucometer to get the blood sugar number. LN 4 stated the blood sugar was 323 and it required insulin administration. LN 4 exited the room, with a gloved hand used one wipe to quickly clean the outer surface of the glucometer and then a second wipe sheet to wrap it around the glucometer. LN 4 then with a gloved hand prepared the insulin dose and administered it in Resident 22's left arm. LN 4 cleaned the inside of the plastic blue bin she carried into the room. 2d. During a medication observation with LN 4, on 8/4/26 at 12:46 PM, in the 3rd hallway, LN 4 entered Resident 10's room with the glucometer and testing supplies in a plastic blue tray. LN 4 with gloved hands poked Resident 10's left middle finger to get blood and soaked the test strip attached to the glucometer to get the blood sugar number. LN 4 stated the blood sugar was 246 and it required insulin administration. LN 4 once out of the room, with fresh gloves used one wipe to quickly clean the glucometer and the second wipe to wrap the glucometer and place it on top of the cart. LN 4 then cleaned the inside of the blue bin tray. LN 4 proceeded to administer the insulin into Resident 10's left upper arm. During an interview with LN 4, in 3rd hallway, on 8/5/26, at 2:46 PM, LN 4 stated she was trained to wrap the glucometer to keep it wet. LN 4 stated she was quick on using the first wipe due to survey observation. LN 4 acknowledged that the supply tray should have been cleaned both inside and outside to remove contamination. Review of the facility's policy, titled Blood Glucose Monitoring, dated 2024, the policy under Procedure indicated 18. Clean and disinfect the glucometer as per manufacturer instructions. Review of instruction sheet by the manufacturer of Assure Platinum glucometer (a brand name by ARKRAY, the manufacturer of glucometer used by the facility), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System, dated 9/24, the documents under Cleaning and Disinfecting FAQ (Frequently Asked Questions), indicated Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not clean and disinfected after use? . It is important that long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products. A review of the Center for Disease Control (A federal agency responsible for the health and safety of people) guideline, titled Considerations for Blood Glucose Monitoring and Insulin Administration, dated 8/7/24, last accessed on 8/14/26 via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the guideline indicated Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. The guideline further indicated Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared. A review of the manufacturer instructions for Sani-Wipe, titled, General Guidelines For Use, dated 2025, indicated, .Use on hard, nonporous [does not allow liquid or air to pass through] environmental surfaces .If present, use a wipe to remove visible soil prior to disinfecting .Unfold a clean wipe and thoroughly wet surface .Allow treated surface to remain wet for two (2) minutes. Let air dry . https://pdihc.com/wp-content/uploads/2025/05/Super-Sani-Cloth-IFU-1025-UPDATE_05168539.pdf 3. During a medication administration observation, accompanied by Licensed Nurse 5 (LN 5), in hallway 4, on 8/5/26, at 3:10 PM, LN 5 prepared medication to administer to Resident 68 via a Gastrostomy-tube (g-tube; tube inserted into the stomach). LN 5 crushed the drug called gabapentin (drug used for nerve pain) in a cup and with two cups of water entered the room marked as Enhanced barrier Precaution. LN 5 had gloves on and did not wear a gown when he entered the room, LN 5 with a gloved hand checked Resident 68's G-tube on her stomach while sitting on a reclining chair. LN 5 used a syringe to connect to the G-tube for checking residuals (volume of liquid remaining) inside the G-tube. LN 5 flushed the G-tube with water and then administered the medication. LN 5 then proceeded to administer a nutritional supplement liquid and then provide the final water flush of the G-tube. During a concurrent interview with LN 5, outside Resident 68's room, and review of EBP poster posted outside the room, on 8/5/26, at 3:29 PM, the EBP poster indicated STOP, . Staff: Wear gown and gloves for high contact resident care activities: . Device care or use of . Feeding tube . LN 5 stated he did not realize he had to put on a gown when giving medications or feeding supplements. During an interview with the Director of Nursing (DON), on 8/7/26, at 4:04 PM, the DON stated she expected the staff to follow EBP mandate and policy to prevent infection transmission to the residents and others. Review of the facility's policy, titled Infection Control, dated 4/25, the policy indicated, .It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. The policy further indicated, .EBP use in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDRO's (multi-drug-resistant organisms; when antibiotic won't kill the germs) to staff hands and clothing than indirectly transferred to resident or from resident to resident . The use of gown and gloves for high-contact activities is indicated when contact precautions do not otherwise apply, for nursing home residents with . feeding tubes .

Based on observation, interview, and record review, the facility failed to ensure residents were fully informed of and able to participate in their care and treatment for 1 of 23 sampled residents (Resident 57), when the facility failed to inform Resident 57, prior to implementation, of the purpose, risks, benefits, options, and alternatives related to the use of a Wanderguard (a small device worn by a resident that alert staff if the resident goes near or through certain doors or exits) device.This failure had the potential to limit Resident 57's ability to make an informed choice (being given enough information to understand your options and then choosing what you want) and participate in decisions regarding their care and treatment.Findings:Review of Resident 57's admission RECORD, indicated Resident 57 was admitted to the facility with diagnoses including major depressive disorder (severe and lasting depression that affects everyday life).Review of Resident 57's Minimum Data Set Section C (MDS- an assessment tool), dated 5/20/26, indicated, .BRIEF INTERVIEW FOR MENTAL STATUS (BIMS - a short test used to check a person's memory and thinking abilities).Score: 13 (BIMS score of 13-15: normal thinking/ intact cognition, score of 8-12: moderate cognitive impairment, and 0-7: severe cognitive impairment).Review of Resident 57's Order Summary Report, dated 6/3/25, indicated, .MD determines that Resident has the Mental Capacity to make Healthcare decisions as per History & Physical or Transfer orders or preferred intensity of care .Review of Resident 57's Order Summary Report, dated 10/13/25, indicated, .Wanderguard check function q [every] week every evening shifts every Wed [Wednesday] for Wandering . Further review of Resident 57's order summary report, dated 2/27/26, indicated, .Wanderguard - Check Placement to right arm every shift .During a review of Resident 57's clinical record titled, Care Plan Report, in the section titled Focus, indicated, .Risk for Wandering r/t [related to] forgetfulness, poor safety awareness date initiated 11/23/25, Revision on 12/9/25 . Further review of the document under the section titled, Interventions/Tasks, dated 11/23/25, indicated, .Make sure resident wear a wander guard .During a concurrent observation and interview on 8/4/26, at 11:13 AM, with Resident 57 in his room, Resident 57 was observed lying in bed and wearing a Wanderguard device on his right wrist. Resident 57 stated that he did not know why he was wearing the device. Resident 57 further stated that he did not know what the device was or its purpose and that no one had explained the device or its use to him. Resident 57 stated it would be important to know why I had it and could not remember signing anything or agreeing to its use.During a concurrent interview and record review on 8/6/26, at 8:59 AM, with the Minimum Data Set Coordinator (MDSC), Resident 57's electronic medical record (EMR) was reviewed. The MDSC stated that Resident 57 had a BIMS score of 13, indicating that the resident was cognitively intact. The MDSC reviewed Resident 57's physician orders and identified an order dated 10/15/25 to check the function of the Wanderguard device and an order dated 2/27/26 for Wanderguard placement. The MDSC reviewed an elopement assessment dated [DATE]. The MDSC stated that informed consent was needed for the use of the Wanderguard and that it was important to ensure the resident received information regarding the device, including its purpose and use for safety. The MDSC further stated that the informed-consent process provided an opportunity to educate the resident, discuss the device with the resident, and involved the resident in decisions regarding the plan of care. The MDSC stated that without providing this information, the resident would not be adequately informed or involved in the plan of care. Further review of Resident 57's EMR with the MDSC revealed no documentation demonstrating that informed consent for the use of the Wanderguard had been obtained or that its purpose and use had been explained to Resident 57. The MDSC stated that she was unsure whether the facility maintained the informed consent in paper form or documented the consent in the resident's progress notes.During a concurrent interview and record review on 8/7/26, at 8:35 AM, with the Director of Nursing (DON), Resident 57's EMR was reviewed. The DON stated that when a resident experienced a change in condition or other identified risk that could potentially lead to elopement, she expected the licensed nurse to initiate an elopement risk assessment. The DON further stated that based on the assessment findings, the physician would be notified and an order obtained for the use of a Wanderguard, as appropriate. The DON stated that the licensed nurse needed to document the assessment, physician notification, and related interventions in the resident's progress notes and update the resident's care plan to reflect the identified elopement risk and use of the Wanderguard. The DON further stated that prior to implementing the Wanderguard, the licensed nurse needed to explain to Resident 57 the purpose of the device, including that it was being used as a safety monitoring device and not as a restraint, and discuss the risks and benefits associated with its use. The DON stated that staff could not put anything on the resident without proper explanation. The DON further stated that the resident should not be forced to use the device; rather, the nurse should provide the resident with sufficient information and allow the resident an opportunity to understand and process the available options. The DON reviewed Resident 57's clinical record and confirmed that she found no documentation indicating that Resident 57 had been informed of the purpose, risks, benefits, options, or alternatives related to the use of the Wanderguard prior to its implementation. The DON stated that communicating information to Resident 57 was important for the resident's safety and demonstrated respect for the resident's right to participate in decisions regarding his care. The DON further stated that a lack of communication with Resident 57 represented a lack of respect for the resident.A review of an undated facility policy and procedure (P&P) titled, Dignity, indicated, .Policy Statement - Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation - Residents are treated with dignity and respect at all times.respect for residents by honoring resident goals, choices, preferences.this begins with the initial admission and continues throughout the resident's facility stay.Residents may exercise their rights without interference, coercion, discrimination or reprisal.A review of the facility P&P titled, Change in Condition, revised date 4/25, the P&P indicated, .Policy - It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care.Procedure - If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware.change in medical condition.The nurse will perform and document .identify need for additional interventions, considering implementation of existing orders.or through communication.The nurse will communicate the change.The resident.will be notified.any changes in the resident's medical or nursing care.

Based on interview and record review, the facility failed to provide adequate oversight regarding the assessment, accurate diagnosis, and documentation of mental health conditions for one out of five residents (Resident 9) reviewed for unnecessary medication use when, the mental health diagnosis for schizophrenia (a serious mental illness that makes it hard for a person to think, feel, and act clearly) and bipolar disorder (a mental health condition that causes extreme shifts in mood, energy, and activity levels) was not accurately evaluated, documented, and assessed according to evidence-based criteria and in compliance with professional standards for Resident 9. This failed practice may contribute to unsafe resident's care, use of medications with adverse effects, and inaccurate diagnosis in the medical record.Findings:Review of Resident 9's Electronic Health Record (EHR), titled Face Sheet: Diagnosis Information, dated 8/7/26, the record indicated Resident 9 was initially admitted to the facility on [DATE] and the most recent hospitalization and re-admission date was on 2/9/26. The diagnosis section included: Parkinson disease (movement disorder due to nerve dysfunction) as the main diagnosis, diabetes (blood sugar disease), stage 4 wound (deep wound), schizophrenia and bipolar disorder among others with a documented onset date of 2/19/25.A review of the Resdeint 9's doctor's order and Medication Administration Record (or MAR), dated 8/2026, the record indicated Resident 9 received the following mental health, Parkinson diseases, and other drugs that may affect mental health as follows: Abilify Oral Tablet 5 MG [Aripiprazole, MG is milligram, a unit of measure, drug used for schizophrenia, bipolar disorder, or depressive disorder]: Give 1 tablet by mouth one time a day for SCHIZOPHRENIA M/B [Manifested By] MOOD INSTABILITY/DELUSIONAL THINKING . -Order Date-4/01/26 Carbidopa-Levodopa Oral Tablet 25-100 MG [or Sinemet, used to treat and improve parkinsonian tremor, shaking and body frizzing]; Give 3 tablet by mouth four times a day for PARKINSON'S -Order Date- 2/09/26. Benztropine Mesylate Oral Tablet; 1 MG [or Cogentin; helped with muscle stiffness, and control of tremors in Parkinson's disease and antipsychotic drugs; side effects could include confusion, disorientation, memory impairment, visual hallucinations, nervousness, and worsening of depression or psychotic symptoms]; Give 1 tablet by mouth two times a day for PARKINSONS -Order Date-2/09/26 oxyBUTYnin Chloride Oral Solution 5 MG/5ML [or Ditropan, relaxes bladder muscles to reduce urinary urgency; Could cause mental and psychiatric side effects such as agitation, anxiety, trouble sleeping, hallucination especially in older adults; MG/ML is milligram per milliliter- a unit of concentration] Give 5 ml by mouth every 12 hours for URINARY FREQUENCY -Order Date-2/09/26 A review of Resident 9's latest History and Physical (H&P), dated 1/26/26, written by Medical Doctor 1 (MD 1), the record referred to Past Medical History: as mentioned in HPI [history of past illness]. The record under Assessment/Plan listed both bipolar disorder and schizophrenia diagnosis.A review of Resdeint 9's H&P, written by Medical Doctor 3 (MD 3) and the Nurse Practitioner 2 (NP 2), with a date range of 2017 to 2025, the handwritten H&P sheet under diagnosis sections indicated the followings:10/16/17: No mental health diagnosis; Written by MD 310/17/18: Bipolar was added to diagnosis; Written by a Nurse Practitioner (NP)10/23/19: No mental health diagnosis; Written by MD 312/5/19: No mental health diagnosis; noted developmental delay; Written by MD 312/16/20: No mental health diagnosis; noted developmental delay; [NAME] by MD 31/10/22: bipolar disorder was noted; Written by a NP and signed by MD 31/16/23: bipolar disorder and developmental delay was noted; Written by a NP and signed by MD 32/12/24: schizophrenia was noted on the Summary of Medical diagnosis; Written by a NP and signed by MD 32/20/25: No mental health diagnosis; noted developmental delay, body tremor; [NAME] by MD 3A review of Resident 9's hospital record, titled History and Physical [H&P], dated 10/8/17, from Hospital A, the record indicated Resident 9 was admitted from a board and care facility due to hip fracture. Hospital A's record under admission H&P did not indicate any mental health diagnosis.A review of Resident 9's hospital record, titled Discharge Summary, dated 10/13/17, from Hospital A, the record did not include any psychiatric diagnosis and listed Abilify (or Aripiprazole, a mental health drug used for various conditions) as a discharge medication. A review of Resident 9's Hospital A record, dated 11/24/19, titled admission History and Physical, the record indicated Resident 9 was admitted to the hospital with sepsis (serious infection affecting all the body) and included cognitive developmental impairment with no psychiatric diagnosis.A review of Resident 9's Hospital A record, dated 11/25/19, titled Progress Note, written by a Hospitalist (doctors that mainly care for hospital patients) during hospitalization, the record on the 2nd day of admission included schizophrenia as part of daily doctor's note. The progress note did not have a reference on how it was diagnosed or if a full psychiatric assessment was performed after one day of hospitalization for sepsis.A review of Resident 9's Hospital A record, dated 2/19/25, titled Discharge Summary, the record indicated Resident 9 was admitted with fever, urinary tract infection (UTI), and altered mental status. The record further indicated . past medical history significant for diabetes, schizophrenia, . who was brought from skilled nursing facility with chief complaint of altered mental status and febrile illness. The record indicated to continue aripiprazole among other drugs after hospital discharge.During a concurrent interview with facility's MDS coordinator (MDSC, Minimum Data Set or MDS, a federally mandated, standardized clinical assessment tool to guide care planning and track quality of care), and review of Resident 9's diagnosis and MDS section of the EHR, on 8/6/26, at 4:59 PM, the MDSC stated schizophrenia diagnosis was added to EHR, on 2/19/25 based on records from Hospital A, while MD 3's notes and H&P did not include the schizophrenia diagnosis. The MDSC stated the MDS document included a schizophrenia diagnosis after 2/19/25.During a concurrent interview with the facility's MDS coordinator and review of Resident 9's EHR, on 8/7/26, at 11:52 AM, the record did not show a physician admission note after return from hospital on 2/19/26. The medical record did not contain the primary care medical doctor monthly progress notes from February of 2026 to May 1st of 2026. The MDSC stated Resident 9 had been seen by a mental health agency via telehealth (long-distance care via phone or video conferencing). A review of Resident 9's mental health provider notes, written by Psychiatrist Doctor (Psych-MD), dated 5/6/25, the record indicated [Resident 9] with an unclear psychiatric history of schizophrenia and bipolar disorder and history of Parkinson disease per chart review . [Resident 9's] reliability of history is questionable. I would recommend neuropsychological evaluation for some clarification of her psychiatric diagnosis. It was unclear if the neuropsychiatric referral was acted upon.Review of Resident 9's mental health provider notes, written by mental health Nurse Practitioner (NP- Psych), with date range of 11/6/25 to 7/23/25, the progress notes written by the NP-Psych were as follows:NP-Psych notes for 11/6/25 and 11/25/25 repeated the recommendation for neuropsychological evaluation for clarification of [Resident 9's] psychiatric diagnosis.NP-Psych notes for 1/2/26 and 1/23/26 indicated denies any depression, anxiety, no sleep issues. With hx [history] of bipolar disorder as well as diagnosis in chart of psychological development disorder, schizophrenia . The NP-psych's recommendations indicated Continue current medications and non-pharmacological measures.NP-Psych notes for 3/31/26, indicated Pt [Patient] currently with diagnosis of bipolar disorder and schizophrenia. It is unclear from chart if this is correctly diagnosed as two separate concerns or should truly be a single diagnosis of schizoaffective disorder, bipolar type. Regardless, patient symptoms warrant improved treatment with medication trial. Provider recommends starting aripiprazole 5 mg po QD [daily]. Of note, patient is also being treated for Parkinson's disease which can alter mental status with progression of the disease.NP-Psych note dated 4/17/26, indicated Start Aripiprazole 5 mg po QD for Schizophrenia m/b mood instability, delusional thinking.The NP-Psych notes did not address if a neuropsychiatric referral or visit was completed to address and/or help clarify mental health diagnosis. The NP-Psych notes indicated re-start of aripiprazole for diagnosis of bipolar disorder and schizophrenia.During a phone interview with the NP-Psych, on 8/7/26 at 9:14 AM, the NP-Psych stated she relied on the medication list and diagnosis documented in the facility's computer system for information about Resident 9. The NP-Psych stated she did not re-evaluate or verify the documented diagnosis in the records. The NP-Psych stated she relied on conversation with staff caring for the resident and the resident herself for assessment. The NP-Psych stated she was not sure if a neuropsychiatric assessment was performed. The NP-psych stated the two diagnoses of bipolar, and schizophrenia did not go together. When asked if Parkinson medication side effects may have been a contributing factor to mental health issues, the NP-Psych stated other medications were reviewed during the telehealth visit and a medical mental health doctor performed the initial psychiatric visit.During a telephone interview with the facility's Medical Director 1 (MD 1), on 8/7/26, at 1:52 PM, MD 1 stated his medical group took over the care of residents in the facility on 12/2025. MD 1 stated his medical group and NP-1 visited the residents multiple times per month. MD 1 stated a schizophrenia diagnosis should have been confirmed or re-evaluated by psychiatrists. MD 1 stated he needed to re-evaluate the use of two drugs (benztropine and oxybutynin) that may potentiate mental health side effects for Resident 9.During an interview with the Director of Nursing (DON), on 8/7/26, at 4:04 PM, the DON stated new orders after discharge from the hospital were inputted in the computer by the admission Nurse, the entry in the computer were then double checked by the night supervisor for accuracy, and the 3rd check was done during the next Interdisciplinary team (a group of health care professionals) meeting. The DON stated the medical doctor saw the residents within 1-2 days after readmission and they reviewed the orders in person or online. The DON stated the staff relied on the doctor's order and the transfer documents (from the hospital) to enter information about drug use and diagnosis.A review of the facility's policy titled Psychotropic Drug Use, dated 2/25, the policy indicated .On admission, the admitting nurses will review the transfer orders for any psychotropic medications. All efforts will be made by the Licensed Nurses to obtain as much history regarding these medications, . Any information obtained will be documented in the resident's clinical record . The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician. The policy in section 6 indicated upon initial comprehensive assessment, . nursing designee shall review new admission for any psychiatric, mood or behavior disorder, mental and psychosocial difficulties, and/or physician's order for psychotropic medications. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the psychiatrist to ensure a. Psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record . c. Behavior is not related to Delirium or other reversible conditions .Further review of the facility's policy, titled Psychotropic Drug Use, dated 2/25, the policy's definition section indicated the term Indication for use definition as the identified, documented clinical rationale for administering a medication that is based upon as assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendation and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals.Review of the facility's undated policy titled Medical Director, the policy indicated .Physician services shall be under the supervision of the Medical Director. The Policy in section 3 further indicated, .Medical Director function also includes but not limited to: a. Acting as a liaison between administration and attending physician. d. Helping assure that the resident care plan accurately reflects the medical regimen. g. Assuring that physician services comply with current rules, regulations, and guidelines concerning long-term care.Review of the facility's undated policy titled Medication Orders, the policy under Supervision by a Physician, indicated, .Each resident must be under the care of a licensed physician authorized to practice medicine in this state and must be seen by the Physician at least every sixty (60) days.A review of the American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia, dated 9/20, last accessed on 8/14/26 via https://psychiatryonline.org/doi/10.1176/appi.ajp.2020.177901, the practice guideline indicated .The goal of this guideline is to improve the quality of care and treatment outcomes for patients with schizophrenia, as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (or DSM-5, the official handbook used by mental health and medical professionals in the United States to diagnose and classify mental disorders). The guideline additionally indicated a proper diagnosis required assessment of characteristic symptoms in addition to ruling out other medical diagnosis and medications used by individuals.

Based on observation, interview, and record review, the facility failed to provide necessary services to maintain personal hygiene for 1 of 23 sampled residents (Resident 46) when Resident 46's nail care was not provided.This failure had the potential to cause Resident 46 with poor hygiene, infection, and emotional distress.Findings:A review of Resident 46's admission RECORD, indicated that Resident 46 was admitted to the facility with diagnoses including hemiplegia (total paralysis on one side of the body) and hemiparesis (weakness or partial loss of movement on one side of the body) following cerebral infarction (a type of stroke) affecting left non-dominant side, and left elbow contracture (a permanent or severe tightening of muscles, tendons, skin, or other soft tissues that makes it hard to move or straighten a joint).A review of Resident 46's Minimum Data Set (MDS, a comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status), dated 6/24/26, under Section C for Brief Interview of Mental Status (or BIMS, determines the individual's attention, orientation and ability to register and recall new information), indicated Resident 46 had a BIMS score of 15 (score of 13 to 15 means cognition is intact or normal thinking).A review of Resident 46's MDS, dated [DATE], under Section GG (measures a resident's functional abilities and goals in self-care and mobility) indicated that Resident 46's personal hygiene performance was dependent on the assistance of staff to complete the activity and the helper or staff does all of the effort and resident does none of the effort to complete the activity.A review of Resident 46's Task: Nail Care, for the past 30 days and for the month of August, indicated that nail care was not provided to Resident 46.A review of Resident 46's Care Plan, dated 11/21/25, indicated that Resident 46 had an Activities of Daily Living (ADL, basic activities required to care for oneself such as bathing and eating) self-care performance deficit related to limited mobility, hemiplegia with contracture. Care plan interventions included total assistance with personal hygiene care, and providing skin care to keep clean and prevent skin breakdown.A review of Resident 46's Care Plan, dated 1/5/26, indicated that Resident 46 had an alteration in musculoskeletal status related to contracture to left upper extremity and neck. Care plan interventions included anticipating and meeting needs.During a concurrent observation and interview on 8/4/26, at 9:31 AM, with Resident 46, Resident 46's fingernails were observed long and dirty. Resident 46 stated the staff did not cut his fingernails. Resident 46 further stated that he scratched himself all over the place and had cuts because of his long fingernails. Resident 46 stated he had a stroke and could not use his left hand to cut his fingernails.During an interview on 8/5/26, at 10:15 AM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated that staff usually trimmed fingernails of the residents but for residents with diabetes (a medical condition with elevated blood sugar levels) the nurses would do it. During an interview on 8/6/26, at 4:18 PM, with the Director of Staff Development (DSD), the DSD stated she expected the CNAs to do the nail care check when they provided showers or bed bath to the residents. The DSD further stated that the nursing staff needed to make sure that the resident's fingernails were cleaned and trimmed. The DSD stated that if a resident refused nail care, they could document the refusal and report it to the charge nurse and they need to find out why the resident refused. The DSD further stated nurses would be be trimming fingernails for diabetic residents.During a concurrent interview and record review on 8/6/26, at 4:28 PM, with the Director of Nursing (DON), Resident 46's care plan was reviewed. The DON stated Resident 46 was known to refuse care. The DON confirmed that there was no documented behavior of Resident 46's refusal of trimming his fingernails. The DON stated that the fingernails were supposed to be trimmed by the CNAs and if the resident was diabetic, the nurses would trim it. The DON further stated that if fingernails were not cleaned and trimmed, there would be a risk of infection, the long and dirty fingernails could contaminate the food, and it could also affect resident's dignity. A review of the facility's undated policy and procedure titled, Nail Care, indicated, .Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible. a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.) .Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke.Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .Routine nail care, to include trimming and filing, will be provided on a regular schedule Nail care will be provided between scheduled occasions as the need arises.Principles of nail care: a. Nails should be kept smooth to avoid skin injury. b. Only licensed nurses shall trim or file fingernails of residents with diabetes.A review of facility's undated policy and procedure titled, Activities of Daily Living (ADLs), indicated, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.A review of facility's undated policy and procedure titled, Job Description Certified Nursing Assistant, indicated, .ESSENTIAL DUTIES AND RESPONSIBILITIES.Assist residents with personal care.Check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes.

Based on observation, interview, and record review, the facility failed to ensure safe use of a Continuous Glucose Monitoring sensor device (or CGM, a patch like sensor on skin which automatically estimated the blood sugar level throughout the day and night via a device and/or smart phone; the blood sugar recorded without pricking finger multiple times a day), when the device was in use without a policy guiding nursing or physicians to follow manufacturer specification and/or standards of practice in 1 out of 12 residents (Resident 74) observed for medication administration.This failed practice may contribute to unsafe diabetes (blood sugar disease) care and risky blood sugar management.Findings: During a medication administration observation with Licensed Nurse (LN 4), in hallway 3, on 8/4/26, at 12:53 PM, LN 4 prepared the noon time medication in pill form for Resident 74 and entered the room. LN 4 after administering the pill form, asked Resident 74 to show the blood sugar level posted in his mobile phone application called Dexcom (a CGM Brand name of product used to measure the blood sugar vial a skin patch and the blood sugar numbers transmitted to the phone). LN 4 stated the latest blood sugar level was 197 mg/dl ( mg/dl is milligram per deciliter, a measure of blood level; normal level is 80-120) as posted/recorded on the residents' mobile phone application. LN 4 stated the blood sugar level required administration of insulin (drug injection to lower blood sugar). LN 4 then proceeded to administer 2 units of insulin to Resident 74.During an interview on 8/4/26, at 1 PM, with Resident 74, in his room, Resident 74 stated he used the CGM device and testing prior to coming to the facility. Resident 74 stated his phone alerted him if his blood sugar was off. Resident 74 stated he was not tested with other methods of blood sugar measurement for calibration.During a concurrent interview with LN 4, on 8/4/26, at 2:46 PM, and the review of Resident 74 Electronic Health Record (EHR) titled, Medication Administration Record, (or MAR) dated 8/2026, the MAR record indicated two insulin orders and one order to place a new CGM Dexcom Patch every 2 weeks on Resident 74's arm as follows: Insulin Lispro .100 UNIT/ML (Insulin Lispro, a short acting insulin; UNITS/ML is units per milliliter- a unit of concentration): Inject as per sliding scale: if 151 - 200 = 2 units; . 401 - 999 = 12 units and CALL MD; subcutaneously (give under the skin) before meals and at bedtime . if blood sugar is <60 and >400 and notify MD -Order Date-7/17/26Tresiba 100 UNIT/ML (Insulin Degludec; a brand-name prescription, ultra-long-acting basal insulin injection); Inject 8 unit subcutaneously at bedtime for DM (diabetes) -Order Date-7/23/26 Dexcom G7 (brand name for CGM patch) 15 Day Sensor . (Continuous Glucose System Sensor); Apply to CLEAN SKIN, SHOULDER topically every evening shifts every 14 day(s) for DM2 -Order Date-7/17/26The MAR did not have an order for alternative blood sugar measurements such as using finger stick blood sugar (or FSBG, poking the finger to get small amount of blood to measure sugar level), performing a quality control comparison or controlled testing for accuracy of Dexcom measurements. The MAR and physician order did not address the use of resident's own phone for blood sugar documentation or other emergency situations when Resident's phone was not available. LN 4 stated she was not aware of a policy or training for use of CGM device, and they relied on Resident 74's mobile phone for blood sugar level for insulin administration.During a telephone interview with facility's Medical Director (MD 1), on 8/7/26, at 1:52 PM, MD 1 stated the facility was working on a new policy for safe use and needed to incorporate quality control and back-up blood sugar testing.During an interview on 8/7/26, at 4:04 PM, with Director of Nursing (DON), in her office, the DON stated she was aware of CGM device use for blood sugar testing using Resident 74's personal phone. The DON stated she had asked her staff to come up with a written policy for safe use of CGM devices following the manufacturer instructions. The DON stated she understood the risks of using CGM and relying on resident personal phone and there needed to be more safeguards and quality control on its use.Review of American Diabetic Association standard of care in the journal of Diabetes Care, titled, Diabetes Technology: Standards of Care in Diabetes-2025, last accessed on 8/12/26, via https://diabetesjournals.org/care/article/48/Supplement_1/S146/157557/7-Diabetes-Technology-Standards-of-Care-in, the document indicated, .When prescribing a device, ensure that people with diabetes and caregivers receive initial and ongoing education and training.Health care professionals working with diabetes technology should ensure that competencies are established within the health care team based on their specific roles and within specific settings. The standard of care further indicated, .The assessment of competencies in diabetes technology is crucial for prescribers, certified diabetes and education specialists, pharmacists, nurses, and anyone involved in the care of people with diabetes.People who wear CGM devices should be educated on potential interfering substances and other factors that may affect accuracy . The document further indicated, .Sensor interference due to several medications/substances is a known potential source of CGM measurement errors. While several of these substances have been reported in the various CGM brands' user manuals, additional interferences have been discovered after the market release of these products.Therefore, it is crucial to routinely review the medication list of the person with diabetes to identify possible interfering substances and advise them accordingly on the need to use additional BGM (Blood Glucose Monitoring) if sensor values are unreliable due to these substances .Review of the manufacturer of Dexcom G7 CGM information titled, User Guide.IMPORTANT SAFETY INFORMATION, last accessed on 8/13/26, via https://dexcompdf.s3.us-west-2.amazonaws.com/en-us/G7-15-CGM-Users-Guide.pdf, the document under warnings, indicated, .Don't use if you are on dialysis or critically ill.sensor readings may be inaccurate.Secure internet: Only use a cellular internet connection, a trusted Wi-Fi network (like your home or office).when using your Dexcom G7 CGM System.Those could expose your Dexcom G7 CGM System to viruses or hacking.Be accurate, be quick: If you calibrate your Dexcom G7 CGM System using your BG meter, enter the BG meter value on your meter within five minutes of measuring your BG . The manufacturer further indicated, .Acetaminophen (or Tylenol) interfering substance risks with the Dexcom G7 15 Day CGM System.Taking higher than the maximum dose of acetaminophen (e.g. > 1 gram every 6 hours in adults) may affect the sensor readings and make them look higher than they really are .

Based on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and for the prevention of a pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for 2 of 11 residents (Resident 42 and Resident 89) using a low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) when, the LAL mattress pump was not correctly adjusted according to the weight of Resident 42 and Resident 89. This deficient practice had the potential to delay wound healing and placed Resident 42 and Resident 89 at increased risk for worsening and developing a pressure injury and/or skin breakdown. Findings: A. Review of Resident 42's admission RECORD indicated Resident 42 was admitted to the facility with diagnosis that included deep tissue pressure ulcer/injury (DTI- a severe type of bedsore that forms from the inside out), muscle weakness, and chronic pain (pain that last more than 6 months). During a concurrent observation and interview on 8/4/26, at 3:55 PM, with Licensed Nurse (LN) 7, LN 7 observed and confirmed while in the room of Resident 42 that the LAL mattress was set at four light bars (a rating located on the mattress setting box that provide manufacture recommendations for the intensity of the amount of pressure being distributed to the resident) and was not set according to what the doctor ordered for Resident 42. LN 7 confirmed the LAL mattress should have been set at two light bars according to Resident 42's weight. LN 7 stated the LAL mattress was in working condition during our observation, and stated the only issue was that it was set at the wrong setting. LN 7 explained that the staff recently received training from the company that comes and sets up the mattress and LN 7 further stated the LAL mattresses were set according to the resident's weight. LN 7 stated if the mattress was not set at the correct settings, then the mattress will not serve its intended purpose. During a concurrent interview and record review on 8/7/26, at 10:12 AM, with LN 6, LN 6 confirmed Resident 42's last weight on 8/5/26 was 144 pounds. LN 6 confirmed Resident 42's medical doctor's order for the LAL mattress that was dated on 7/14/26 indicated, .low air loss mattress related to pressure injury. By weight setting: 2 light bars. LN 6 confirmed according to manufacture recommendations located on the setting box indicated four light bars would be for a resident whose weight was between 175-200 pounds. While concurrently reviewing Resident 42's medical record a document titled, Clinical Admission, dated 7/10/26, indicted, .Coccyx [the tailbone].Pressure ulcer/injury.unstageable pressure injuries presenting as deep tissue injury.length [cm-a unit of measurement] 2 width (cm) 1.5. LN 6 stated the purpose the LAL mattress was implemented was to aid in healing of Resident 42's DTI coccyx wound. LN 6 stated if a LAL mattress setting was set at a rating that was too firm the resident would be resident at risk for not receiving the intended benefit of the LAL mattress. During an interview on 8/7/26, at 4:34 PM, with Director of Nursing (DON), the DON stated she expected the LAL mattresses to be monitored every shift. The DON stated if the mattress settings did not align with the doctor's orders the mattress could have the opposite effect and make the wound worse. The DON stated if the mattress does not align with the orders the wound would not heal properly. B. A review of Resident 89's Face Sheet (single-page summary document in healthcare that provides a quick overview of a resident's administrative and clinical data), indicated Resident 89 was admitted to the facility with diagnosis that included protein-calorie malnutrition and generalized muscle weakness. A review of Resident 89's Weight Summary, indicated that Resident 89's current weight dated 7/29/26 was 81 pounds. A review of Resident 89's Order Summary Report, dated 7/14/26, indicated a physician order, .Low air loss mattress as ordered. A review of Resident 89's Order Summary Report, dated 7/14/26, indicated a physician order, .Monitor low air loss mattress related to pressure injury. By weight setting: 1 light bars. Ensure mattress remains plugged in at all times. Nursing to assess mattress function, air inflation, and alarm status every shift and PRN [as needed]. If incorrect, notify manufacture representative. every shift. A review of Resident 89's Clinical Interdisciplinary Assessment (CA), dated 7/17/26, indicated that Resident 89 was noted with pressure ulcer and skin care interventions in place which included bed-pressure reducing mattress. The IDT (interdisciplinary team; a group of healthcare professionals) evaluation of the skin integrity risk/current management plan included to continue LAL mattress. A review of Resident 89's Care Plan, dated 11/23/25, indicated that Resident 89 was admitted with a pressure ulcer to the sacrum (triangle-shaped bone at the base of the spine) related to immobility and incontinence. Care plan interventions included, .Low air loss mattress as ordered.monitor low air loss mattress related to pressure injury by settings: (1 light bar) by weight. Ensure mattress remains plugged in at all times. Nursing to assess mattress function, air inflation, and alarm status every shift. If incorrect, notify manufacture representative. every shift. A review of Resident 89's Care Plan, dated 2/11/26, indicated that Resident 89 has pressure injury to the sacrum. Care plan interventions included, .Monitor low air loss mattress related to pressure injury by settings:(1 light bar) by weight. Ensure mattress remains plugged in at all times. Nursing to assess mattress function, air inflation, and alarm status every shift. If incorrect, notify manufacture representative. every shift. A review of Resident 89's Minimum Data Set (MDS, an assessment tool) Section GG – Functional Abilities on the MDS (measures a resident's functional abilities and goals in self-care and mobility) dated 6/26/26, indicated that Resident 89's mobility performance with rolling left and right and chair/bed-to-chair transfer as dependent or needs assistance to complete the activity. A review of Resident 89's MDS Section M – Skin Conditions dated 6/26/26, indicated the Resident 89 has a stage 3 pressure ulcer or injury (a deep, open wound where the skin is completely gone) that was present upon admission to the facility. During an observation on 8/4/26, at 10:02 AM with Resident 89, Resident 89 was lying in bed with a LAL mattress with 2 lighted buttons. During an interview on 8/4/26, at 11:51 AM, with LN 2, LN 2 stated she was not sure how they would determine the pressure settings for the LAL mattress, but she knows that the nurses usually were responsible for setting up the pressure settings. During a concurrent observation and interview on 8/4/26, at 11:56 AM, with the Assistant Director of Nursing (ADON), Resident 89's LAL mattress pressure settings were observed. The ADON initially stated that Resident 89's LAL mattress was on 2 lighted bars. When the weight of Resident 89 (81 pounds) was made known to the ADON, the ADON stated that the settings should be at 1 lighted bar. Upon observation the weight settings indicated that 1 lighted bar should be used for residents with a weight that ranges from 90-120 pounds and 2 light bars were for residents that have a weight ranging from 120 to 145 pounds. The ADON stated she does not know what the process would be if it was below the weight range. The ADON stated the pressure setting was based on the resident's weight. The ADON stated if there was an initial order for LAL mattress, the treatment nurse usually set that up. During an interview on 8/4/26, at 3:51 PM, with the ADON, the ADON stated that if the resident's weight was below the range, they would still use the lowest selection on the settings for the LAL mattress which is 1 light bar. During an interview on 8/6/26, at 8:34 AM, with Resident 89, Resident 89 stated that her mattress was painful to use and if she can change it, she wanted it to be changed. During an interview on 8/6/26, at 4:57 PM, with the Director of Nursing (DON), the DON stated that the treatment nurse (TN) would fix the settings of a LAL mattress. The DON further stated that the pressure settings were based on the current weight of the resident. The DON stated that they contacted the manufacturer and were told that they should use the lowest setting if the resident's weight was below the weight range. A review of facility's policy and procedure titled, Skin and Wound Monitoring and Management, revised 4/25, indicated, .A resident having pressure injury(s) receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing.The purpose of this policy is that the facility provides care and services to: 1. Promote interventions that prevent pressure injury development; 2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and 3. Prevent the development of additional, avoidable pressure injury.Preventions: In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches and consistent with the resident's care plan.Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc.Treatment a. Continue preventive measures as appropriate, including but not limited to.Pressure reduction. A review of the facility provided undated document, titled, [Brand Name] Power Pro Elite Mattress System User Manual, indicated, .The Power Pro Elite Mattress System is an alternating mattress replacement system used in the prevention and relief for patients with, or vulnerable to, pressure ulcers.The Control Unit of the Power Pro Elite Mattress System is a Pump featuring a digital pressure adjustment function, mode selections, and audiovisual alarms.OPERATION GUIDE.According to the weight of the patient, adjust the pressure setting to the most suitable level without bottoming-out. User can determine an appropriate pressure by adjusting the Comfort Level. Please consult with your physician for a proper setting.Warning: the Pump unit should always be operating to prevent bedsore occurring.

Based on observation, interview and record review, the facility failed to ensure 1 of 23 sampled residents (Resident 37) received proper foot care and treatment when, Resident 37 had long overgrown, thick, yellowish toenails on both feet, had not received podiatry services in over 9 months, and Resident 37 was not referred to a podiatry (a branch of medicine devoted to the study, diagnosis, and treatment of disorders of the foot and ankle) services as needed.This failure had the potential to affect Resident 37's foot health and cause pain, injury, and infection. Findings:A review of Resident 37's Face Sheet (a quick overview of a resident's administrative and clinical data), indicated that Resident 37 has a diagnosis of, but not limited to, acute kidney failure (kidneys stop working), stage 4 chronic kidney disease (severe kidney damage), and type 2 diabetes mellitus (too much sugar in the blood).A review of Resident 37's Brief Interview of Mental Status (BIMS, determines the individual's attention, orientation and ability to register and recall new information), dated 6/9/26, indicated Resident 37 had a BIMS score of 15 (score of 13 to 15 means cognition is intact and has normal thinking).A review of Resident 37's Minimum Data Set (MDS, an assessment tool) Section GG (measures a resident's functional abilities and goals in self-care and mobility), dated 6/9/26, indicated Resident 37's personal hygiene performance and putting on or taking off footwear as dependent which means the resident was dependent on the assistance of staff to complete the activity and the helper or staff does all of the effort and resident does none of the effort to complete the activity.A review of Resident 37's progress notes dated 6/9/26, indicated that Resident 37 was dependent on putting on or taking off footwear.A review of Resident 37's Care Plan, dated 11/7/25, indicated that Resident 37 was at risk for potential or actual impairment to skin integrity related to immobility, incontinence, and shower refusal. Care plan interventions included keeping the skin clean and dry, using lotion on dry skin, avoiding scratching and keeping hands and body parts from excessive moisture and keeping the fingernails short.A review of Resident 37's Order Summary Report, did not indicate a physician order for podiatry appointment or referral.During a concurrent observation and interview on 8/5/26, at 8:22 AM, with Resident 37, Resident 37's toenails on both feet were observed with thick yellowish discoloration. Resident 37 stated that her toenails just grew like that. Resident 37 further stated that she wears socks whenever she was in a wheelchair, but she prefers to wear shoes if she could. Resident 37 stated that with the current state of her toenails, it was very hard for her to wear shoes.During an interview on 8/6/26, at 4:18 PM, with the Director of Staff Development (DSD), the DSD stated she expected the CNAs to do the nail care check when they provide showers or bed baths to the residents. The DSD stated the CNAs should report to the nurses if the resident might need podiatry services and the nurses will communicate to the doctor for referral to the podiatry. During an interview on 8/6/26, at 4:28 PM, with the Director of Nursing (DON), the DON stated she expected the nurses to talk to the doctor and get an order for a podiatry referral. The DON stated if the toenails were not taken care of by the podiatry, there would be a risk of the toenails getting infected. The DON confirmed that Resident 37's last podiatry referral was in October of 2025.During an interview on 8/7/26, at 9:34 AM, with the Social Service Director (SSD), the SSD stated podiatry services were an ancillary service, and the podiatrist comes to visit the facility with a 6-week interval. The SSD state podiatrist visits were important to ensure the maintenance of the resident's foot health. The SSD confirmed that Resident 37 was last seen by podiatrist on 10/27/25. The SSD stated that she followed up with the podiatrist office and found out that Resident 37 was scheduled to be seen last January 2026, but there were no notes that Resident 37 was seen and no follow up was made.A review of facility's undated policy and procedure (P&P) titled, Nail Care, the P&P indicated, .Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible. a. Report unusual or abnormal conditions of the nails to the physician and the responsible party (e.g., curling, color changes, separation from the nailbed, redness, bleeding, pain, odor, infection, etc.) .Obtain history and preferences regarding podiatrist. 2. Identify conditions that increase risk for foot or nail problems, such as diabetes, peripheral vascular disease, heart failure, renal disease, or stroke. 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis .4. Routine nail care, to include trimming and filing, will be provided on a regular schedule Nail care will be provided between scheduled occasions as the need arises.Principle of nail care: a. Nails should be kept smooth to avoid skin injury.Toenails of residents with diabetes or circulation problems shall be filed only.If a resident has a toe infection, diabetes mellitus, neurological disorders, renal failure, or PVD [Peripheral vascular disease, a blood circulation disorder], toenail trimming should be performed by a physician or practitioner.A review of facility's undated P&P titled, Activities of Daily Living (ADLs), the P&P indicated, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care.A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to ensure protection from potentially hazardous items for two out of twenty three sampled residents (Resident 74 and Resident 97) when, uncovered used shaving razor were found unattended on the sink next to the faucet in a shared bathroom, This failure placed the facility's residents at risk for an injury in the case of accidental access to sharp items, and placed the residents in this facility at risk for an infection and cross contamination.Findings:During an observation on 8/4/26, at 9:48 AM, in the shared bathroom of Resident 74 and Resident 97 an uncovered used razor was observed unattended on top of the sink next to the faucet. The bathroom was shared by two mobile residents.During a concurrent observation and interview on 8/4/26, at 9:50 AM, with the Director of Nursing (DON), the DON confirmed the uncovered used razor were left unattended on the side of the sink and accessible to the residents. The DON stated the razor placed residents in the facility at risk of injury and cross contamination. The DON further stated the razors should be disposed of in a designated container for sharp objects or covered and stored in the resident's personal area.During an interview on 8/7/26, at 9:09 AM, with the Infection Preventionist (IP), the IP stated the uncovered used razor observed in the shared bathroom left unattended did not meet her expectations. The IP stated this presented a risk for another resident accessing the razor and using it. The IP stated this placed the residents at risk for cross contamination. The IP further stated the facility's process was once the nurse aids were finished shaving the residents, the razor should have been discarded in the sharps container. The IP stated the razor placed the residents in the facility at risk for cross contamination and infection.A review of a facility policy titled, Accident Prevention and Intervention, dated 5/20, indicated, .It is the policy of this facility that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. The purpose is to ensure that the facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident to prevent avoidable accidents. This includes systems and processes designed to: Identify Hazard (s) and risk (s).

Based on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (procedure to remove wastes and excess fluids from the body when the kidneys stop working properly) received quality care and services consistent with professional standards of practice for 1 of 8 residents (Resident 14) on dialysis when, Resident 14's dialysis access line was not assessed and monitored when Resident 14's dialysis access site (a surgically created or placed pathway into the body) dressing was missing.This failure increased the potential risk for infection, delayed detection, reporting, and/or management of complications from the dialysis access site for Resident 14.Findings:A review of Resident 14's Face Sheet (single-page summary document that provides a quick overview of the resident's administrative and clinical data), indicated that Resident 14 had a diagnosis of, but not limited to, end stage renal disease (kidneys can no longer remove waste and extra fluid), vascular dementia (a decline in thinking, memory, and reasoning skills caused by reduced or blocked blood flow to the brain), bacteremia (presence of bacteria in the bloodstream), and dependence on renal dialysis (a person's kidneys have failed and they must rely on a machine permanently to filter waste, toxins, and extra fluid from their blood to stay alive).A review of Resident 14's Brief Interview of Mental Status (or BIMS, determines the individual's attention, orientation and ability to register and recall new information), dated 6/23/26, indicated Resident 14 has a BIMS score of 4 (scored from a scale of 0 to 10; 0-7 score means severe cognitive impairment (extreme trouble remembering, thinking, or making decision))A review of Resident 14's Order Summary Report, dated 1/29/26, indicated a physician order, .Dialysis.Access Line Dressing Changes and Flushes will be done by Dialysis Site Only.A review of Resident 14's Order Summary Report, dated 2/24/26, indicated a physician order, .Dialysis - (All Access) Inspect Dialysis Access Site right upper chest side site for Infection Daily: Localized Pain, Erythema [redness of the skin], Warmth, Edema [swelling caused by fluid], or Abnormal Drainage every shift.A review of Resident 14's Care Plan, dated 10/3/25, indicated that Resident 14 was at risk for a communication problem related dementia. Care plan interventions included anticipating and meeting resident's needs.During an interview on 8/5/26, at 2:42 PM with Licensed Nurse (LN) 2, LN 2 stated that they do not do the dressing changes of the dialysis access site for residents on dialysis because it was usually done by the dialysis center. LN 2 stated that if the dressing was soaked, the treatment nurse can do the dressing change.During a concurrent observation and interview on 8/6/26, at 9:46 AM, with Certified Nursing Assistant (CNA) 1, Resident 14's dialysis access line was observed without a dressing and food particles were seen around the access line. CNA 1 stated that the food particles were Resident 14's cereals that he ate this morning. CNA 1 stated the dialysis center used to put a dressing on Resident 14 but now he does not have a dressing on his dialysis access site.During an interview on 8/6/26, at 5:01 PM, with the Director of Nursing (DON), the DON stated that the CNA should have notified the nurse if there was no dressing present and the nurse would assess Resident 14. The DON further stated that the nurses could change the dressing on the dialysis access line and if there was no dressing they needed to put a new one immediately. The DON stated if there was no dressing on the dialysis access line, there would be a risk of infection. The DON stated that she expected the nurses to clean and monitor the dressing and if it gets dislodged, to put on a new dressing. During a phone interview on 8/6/26, at 5:08 PM, with the Infection Preventionist (IP), the IP stated that the dialysis access line should be covered with a dressing. The IP further stated that the RN (registered nurse) should apply the dressing if there was none. The IP stated the dialysis access site was a portal of entry and there would be risk for infection if left uncovered. The IP stated she expected the nurses to assess and re-apply the dressing.A review of the facility's policy and procedure titled, Dialysis (Renal), Pre- and Post-Care, revised 4/2025, indicated, .Assess and maintain patency of renal dialysis access .Assess resident daily for function related to renal dialysis.A review of the facility provided document titled, NURSING FACILITY DIALYSIS AGREEMENT, indicated, .DUTIES AND RESPONSIBILITIES OF THE PARTIES.Care of Access Site. Nursing Facility will cooperate in monitoring and caring for each resident's access sites.

Based on interview, observation, and record review, the facility failed to ensure safe pharmaceutical services for a resident census of 98 when:1.Resident 22's opioid pain medication called Norco (a combination opioid pain drug containing hydrocodone and acetaminophen) was not consistently documented in the Medication Administration Record (MAR, a legal document for medication administration) based on the physician order; 2. Resident 120's medications were not available for two days: metoprolol (lowers blood pressure) and and a iron supplement; and 3. Hazardous medications (substances that pose health risks to workers who handle, prepare, or dispose of them) were not safely stored, labeled, or handled, and glove usage precautions were missing from the MAR and Electronic Health Record (EHR) during medication administration.These failed practices may lead to negative outcomes such as sudden drug withdrawal, an increased risk of drug diversion due to insufficient accountability documentation, and improper handling of hazardous drugs that could endanger staff and residents.1. During a review of Resident 22's electronic health record (EHR), titled MAR, with a date range of 6/2026 to 7/2026, the MAR record indicated two orders for treating pain as follows: HYDROcodone-Acetaminophen Oral Tablet 5-325 MG [or Norco, MG is milligram, a unit of measure]; Give 1 tablet by mouth every 4 hours as needed for moderate pain (4-6 on pain scale)-Order Date-4/6/26 HYDROcodone-Acetaminophen Oral Tablet 5-325 MG; Give 2 tablet by mouth every 4 hours as needed for severe pain (6-10 on pain scale)-Order Date-4/6/26.The record indicated to use one Norco tablet for moderate pain level of 4 through 6 (on a pain scale from 1-10) and 2 Norco tablets for severe pain levels of 6 through 10.During a review of Resident 22's record titled Controlled Drug Record, (or CDR, a handwritten record of opioid drug use for accountability), with a date range of 5/1/26 to 8/2/26, the record was used to track Norco administration based on the MAR order for moderate or severe pain levels. The record indicated on 7/24/26 one Norco tablet was removed from the CDR and was not documented as administered in the MAR record.A comparative review of Resident 22's MAR and Controlled Drug Record, with date ranges of 5/1/26 to 8/2/26, the record indicated the Norco MAR order did not match the pain level documented and the number of Norco pills administered as follow:7/13/26; Pain level of 7; Nurse administered one Norco tablet versus 2 tablets6/16/26; Pain level of 7; Nurse administered one Norco tablet versus 2 tablets6/15/26; Pain level of 7; Nurse administered one Norco tablet versus 2 tablets6/10/26; Pain level of 8; Nurse administered one Norco tablet versus 2 tablets6/08/26; Pain level of 7; Nurse administered one Norco tablet versus 2 tablets6/04/26; Pain level of 8; Nurse administered one Norco tablet versus 2 tabletsIn an interview with Director of Nursing (DON), in her office, on 8/5/26, at 4:18 PM, the DON stated she expected nursing staff to follow the doctor's order for pain medication use and document in the MAR. The DON stated she could not locate any nursing notes to explain the deviation from the doctor's order. The DON stated she needed to reeducate the staff on accurate documentation and risks of drug diversion. Review of the facility's policy titled Medication Administration, dated 1/1/20, the policy indicated, .It is the policy of this facility to accurately prepare, administer and document oral medications.2. During a medications administration observation of Resident 120, accompanied by Licensed Nurse 2 (LN 2), on 8/4/26, at 9:06 AM, LN 2 administered a total of 6 drugs that were due at 8 AM or 9 AM. LN 2 did not administer two drugs that were due at 9 AM due to unavailability. The two drugs not administered were a heart pill called Metoprolol (used to lower blood pressure and the heartbeat) and an iron supplement called ferrous gluconate (iron pill).Review of Resdeint 120s MAR, dated 8/2026, the record indicated the following drugs marked as not given for 2 days in a row as follow: Ferrous Gluconate Tablet 324 MG.; Give 1 tablet by mouth one time a day .-Order Date-7/29/26 and Metoprolol Succinate ER 25 MG (Extended Release) .; Give 1 tablet by mouth one time a day for HTN (hypertension) . -Order Date-7/29/26. Both drug orders were marked by code 7 which meant See Nurse Notes for 8/4/26 and 8/5/26.Review of nursing notes for Resident 120, under E-MAR Notes (Electronic MAR), dated 8/4/26 and 8/5/26, the notes indicated the medication were On Order (means ordered from pharmacy).In an interview with the Resident 120, in her room, on 8/5/26, at 2:28 PM, Resident 120 was laying down in her bed and stated she had been more anxious recently and nurses did not tell her she did not receive her heart medicine metoprolol.In an interview with LN 2, at nursing station 1, on 8/5/26, at 2:36 PM, LN 2 stated she ordered Resident 120's metoprolol through the computer from the new pharmacy provider, and the iron pill through the facility supplier for non-prescription drugs. LN 2 stated the facility was transitioning from one pharmacy provider to the new one.In an interview with DON, in her office, on 8/5/26, at 4:18 PM, the DON stated the medication availability, and delay was not acceptable for 2 days in a row. The pharmacy provider delivered medication at least two times per day when needed. Review of the facility's policy titled Pharmacy Services, dated 2025, the policy indicated, .The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing and administering of all routine and emergency drugs . to meet the needs of each resident, are consistent with state and federal requirements, and reflect current stance of practice .3. During a medication administration observation, with LN 2, on 8/4/26, at 8:56 AM, LN 2 administered a drug in pill form called divalproex (or Depakote; drug used to treat mood disorder and seizure) to Resident 69, which was labeled as hazardous for handling. LN 2 did not use gloves during handling and drug administration.During a concurrent interview with LN 2, and review of the drug label and MAR for Resident 69 on 8/5/26, at 2:36 PM, LN 2 stated that the MAR order for Depakote did not have any instruction to use gloves and the pharmacy label was written in fine lines and small fonts to read or see the hazardous drug on the label. LN 2 stated most hazardous drugs had a bright pink or yellow label for an alert.During a concurrent interview with License Nurse 4 (LN 4) and inspection of medication cart #3, at station 3, the cart stored hazardous labeled medications in pill form and liquid form. The hazardous medications were not contained in a Ziplock bag to prevent touch contamination. The cart stored bottles of a hazardous liquid medication called megestrol (or Megace, a hormone like drug used to treat cancer or used to improve appetite) with no containment to prevent touch contamination. One Megace bottle had sticky contamination on the outer surface of the bottle. LN 4 acknowledged use of gloves and there needed to have plastic bags to prevent hand contamination by nursing staff.During a concurrent interview with License Nurse 1 (LN 1) and inspection of medication cart #2, at station 1, the cart stored hazardous medications in both pill and liquid form. The cart stored two hazardous medications in liquid form called Valproic Acid with one bottle located inside a sealed bag and the other did not have protective cover. LN 1 stated she needed to put them in a big, sealed bag to prevent hand contamination from spills. Cart #2 stored another hazardous drug in a pill bottle called Cabometyx (a cancer treatment drug) without hazardous labeling. LN 4 was not aware of the hazardous status of the Cabometyx pills.In an interview with the DON, in her office, on 8/5/26, at 4:18 PM, the DON stated the staff should have been using gloves when they see a hazard label on a drug to protect themselves. The DON stated the pharmacy provider will be asked to help provide protective plastic covers to prevent touch contamination.Review of the facility's policy titled Hazardous Drug Handling, dated 2020, the policy indicated, .This policy applies to all healthcare personnel who handle HD (Hazardous Drugs) preparation all entities that store, prepare, transport or administer HD's. The policy further indicated, .Appropriate PPE (Personal Protective Equipment, such as glove, gown, mask and eye protection) must be worn when handling HD's . during receipt, ., storage, administration, and waste disposal.Review of the Center for Disease Control's National Institute for Occupational Safety and Health (CDC, and NIOSH, a federal agency sets standard of safety in health care) document titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 4/23, last accessed on 8/11/26 via https://www.cdc.gov/niosh/docs/2023-130/2023-130.pdf and https://www.cdc.gov/niosh/docs/2023-130/default.html , the document indicated, .Many . drugs intended for individual use can be hazardous to healthcare workers with potential occupational exposure to those who handle, prepare, dispense, administer, or dispose of these drugs. Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes.PPE (or Personal Protective Equipment, items like glove or mask) provides worker protection to reduce exposure to hazardous drugs.Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. Further review of the document indicated to use single glove for handling intact tablet form and double glove for handling oral liquid form of the hazardous medications as directed.

Based on observation, interview, and record review the facility failed to ensure safe medication use practices in one out of 5 residents (Resident 9) reviewed for unnecessary drug use when, Resident 9's prolonged use of esomeprazole (or Nexium, a proton pump inhibitor; PPI) drug used to treat gastroesophageal reflux disease (GERD; used for bleeding stomach ulcers, and excessive acid conditions) was not evaluated against manufacturers and the FDA (Food and Drug Administration, a federal agency regulated safe drug use) warnings regarding possible adverse effects in the elderly population.This failures had the potential to put Resident 9 at risk of adverse effects related to long term use of PPI in elderly population such as osteoporotic-related fractures (weak and brittle bone disease), Clostridium difficile infection (infection in the gut), pneumonia (lung infection), vitamin B12 deficiency, kidney disease, and magnesium deficiency in addition to drug-drug interactions.Findings:During a review of Resident 9's electronic health record (EHR), titled Face Sheet, dated 8/7/26, the record indicated Resident 9 was recently re-admitted on [DATE] after a hospitalization for infection. Resident 9's record further indicated a diagnosis of Parkinson disease (a neurological disease affecting a brain nerve that helped control body movement), Diabetes (blood sugar disease), GERD (gastroesophageal reflux disease) with onset date of 2/19/26, and mental health issues among others. The record did not show any recent history of stomach ulcers or bleeding ulcers.A review of Resident 9's Medication Administration Record (or MAR, a document that listed drugs ordered by doctor and administered by nursing staff), dated 8/2026, the record indicated an order for esomeprazole (or Nexium, a PPI drug) as follow: Esomeprazole . 40 MG (or Nexium, MG is milligram, a unit of measure); Give 1 packet by mouth one time a day for GERD-Order Date-3/19/26A review of Resident 9's re-admission orders, written by Medical Doctor (MD 1), dated 2/9/26, the record indicated the same order for esomeprazole (or Nexium) once daily with no end date.Review of Resident 9's history and physical (H&P), written by MD 1, dated 1/26/26, the record did not include a GERD diagnosis.During a concurrent interview on 8/7/26 at 11:52 AM, with the Minimum Data-Set Nurse Coordinator (MDSC nurse, a nurse that document and submit resident information to government) and review of Resident 9's EHR, for date ranges of 1/2026 to 8/2026, titled Physician Progress Notes and H&P, the record did not show any progress notes from the primary medical doctor for 2/2026, 3/2026, and 4/2026. The EHR did not show a medical doctor's note after Resident 9's re-admission to the facility from hospital on 2/9/26 to address the PPI use after hospitalization.A review of Resident 9's progress notes, written by Nurse Practitioner 1 (NP 1), dated 5/18/26, the note indicated continue famotidine [or Pepcid, known as H2-blocker, medication that lowers the amount of acid made in the stomach] for management of GERD symptoms . Continue with anti-reflux precautions. The note did not address use of the ongoing esomeprazole (or Nexium, a PPI drug).Review of Resident 9's EHR documents titled, Nursing Notes and Weekly Evaluations, with date range of 7/29/26 to 8/7/26, the record did not indicate any gastrointestinal (or GI, stomach/abdomen problems) issues related to GERD.In an interview with Licensed Nurse 1 (LN 1), on 8/7/26, at 3:54 PM, LN 1 stated Resident 9 was aware of her surroundings and followed direction. LN 1 stated she did not notice any stomach pain or distress, and Resident 9 was tolerating the tube feedings (nutrition given through a tube inserted into the stomach). LN 1 stated Resident 9 took her medication orally.In a telephone interview with Medical Doctor 1 (MD 1), on 8/7/26, at 1:52 PM, MD 1 stated the PPI medication should be stopped after 6-8 weeks as it had multiple risk factors for long term use. MD 1 stated he will review Resident 9's medical record as there was safer alternatives to PPI drugs.Review of the pharmacy's consultation report dated 3/13/26, the record indicated the facility's consultant pharmacist requested clarification and an update on the esomeprazole ordered route of administration. The facility's consultant pharmacist was not available for interview due to changes in contract services.Review of facility's policy titled Medication (Drug) Regimen Review (MRR), dated 4/25, the policy indicated, .It is the policy of this facility that the drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist . The report will be sent to attending physician, the facility's Medical Director and the Director of Nursing Services (DNS) to be acted upon. The policy further indicated .The MRR includes identification of irregularities, medication related errors, adverse consequences, and use of unnecessary drugs. Unnecessary drug is defined as medications ordered in excessive dosage including duplicate drug therapy; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate that those should be reduced or discontinued.Review of Beer's criteria (Beers Criteria, also known as the American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, a set of guidelines that help healthcare professionals identify medications that may be harmful or unnecessary for older adults), dated 4/23, last accessed on 8/10/26 via https://www.americangeriatrics.org/media-center/news/many-older-adults-take-multiple-medications-updated-ags-beers-criteriar-will-help, and https://sbgg.org.br/wp-content/uploads/2023/05/1-American-Geriatrics-Society-2023.pdf, the document indicated, .Treating GERD with a PPI for longer than 8 weeks should be avoided for most older adults. Rationale: Risk of C difficile infection, pneumonia, . bone loss and fractures . Recommendation: Avoid scheduled use for >8 weeks [more than 8 weeks] unless for high-risk patients . ; Strength of Recommendation: high.Review of an article published in the journal of Therapeutic Advances in Drug Safety, dated 5/19/17, titled Adverse effects of proton-pump inhibitor use in older adults: a review of the evidence, last accessed on 8/10/26 via https://pmc.ncbi.nlm.nih.gov/articles/PMC5557164/pdf/10.1177_2042098617715381.pdf the article's summary and conclusion indicated, .Long-term PPI use in older adults links to increased risks of fractures, Clostridium difficile infection, pneumonia, vitamin B12 deficiency, kidney disease, and dementia. Many prescriptions are unnecessary, with guidelines recommended limiting use to under 8 weeks. Regular evaluation of ongoing needs was essential to minimize adverse effects and optimize safety in this vulnerable population.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a resident census of 95. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 7 errors out of 40 opportunities which resulted in a facility wide medication error rate of 17.5% in 5 out of 12 residents (Resident 120, Resident 69, Resident 111, Resident 118, and Resident 109) observed for medication administration with the errors noted as follows:1. Resident 120 was not administered ferrous Gluconate (Iron supplement), and metoprolol (heart medication) as ordered by the doctor;2. Resident 69 was administered aspirin Enteric Coated (EC- coated aspirin with protective property) instead of chewable aspirin, and an incorrect dose of laxative called Docusate (or DSS) as ordered by the doctor;3. Resident 111 lidocaine patch (a numbing pain patch) order was not followed when the old patch was still on resident's body when the morning patch was applied;4. Resident 118 received an incorrect dose of Acetylcysteine (or Mucomyst, product used to loosen up thick mucus in the lung) during inhalation therapy; and5. Resident 109's laxative called Docusate was not given during the morning medication administration.These failures may result in unsafe medication use and not following the doctor's order which could affect residents' health and well-being.Findings:1. Review of Resident 120's admission RECORD indicated Resident 120 was admitted to the facility with diagnoses of anemia (low red blood cells or hemoglobin), anxiety disorder (a condition that causes excessive worry or fear), hypertension (high blood pressure), paroxysmal atrial fibrillation (episodes of irregular heartbeat), cerebral infarction (stroke caused by blocked blood flow to the brain), and presence of a cardiac pacemaker (a device that helps control the heartbeat).During a medication administration observation at the facility's Station 1, on 8/4/26 at 9:06 AM, accompanied by Licensed Nurse (LN) 2, LN 2 entered Resident 120's room when Resident 120 complained of chest pressure. LN 2 took Resident 120's blood pressure (BP - normal around 120/80 mmHg- mmHg is millimeters of mercury, the standard unit of measurement used to record blood pressure), which revealed a reading of 140/100 mmHg (high blood pressure). LN 2 then administered six routine morning medications to Resident 120.Review of Resident 120's Medication Administration Record (or MAR, a legal document listed medications administered by the nurse), dated 8/26, indicated an order dated 7/29/26 for metoprolol 50 mg (milligrams - unit of measure), one tablet for hypertension, to hold if systolic BP (SBP - the top number of a blood pressure reading) was less than 110 and heart rate was less than 60 on 7/29/26, and an order dated 7/29/26 for ferrous gluconate 324 mg on 7/29/26. The MAR indicated Resident 120 did not receive the medications on 8/4/26 and 8/5/26, both scheduled for administration at 9 AM and were marked on order.During an interview on 8/5/26 at 11:55 AM, LN 2 stated that the metoprolol and ferrous gluconate were not available on 8/4/26 for Resident 120's routine morning medications due at 9 AM and that she placed an order for the medications with the pharmacy through the facility's computer system. LN 2 stated that metoprolol and ferrous gluconate were still not available on 8/5/26 for Resident 120's routine morning medications due at 9 AM. LN 2 further stated that she did not call the MD (medical doctor) regarding Resident 120 not receiving metoprolol and ferrous gluconate for two days. LN 2 further stated that if a resident had cardiac medications (medications used to treat heart conditions), the vital signs (VS - measurements of basic body functions such as blood pressure, heart rate, breathing rate, and temperature) were within the parameters (ordered limits for when a medication should be given or withheld), and the medications were not available, the MD should have been notified.During an interview on 8/5/26 at 2:27 PM, Resident 120 stated that she had anxiety, which contributed to chest tightness. Resident 120 stated that she was not informed that she did not receive her metoprolol on 8/4/26 and 8/5/26 and stated that her doctor advised her to take metoprolol every day.During an interview on 8/5/26 at 4:19 PM, the Director of Nursing (DON) stated that when medications were not available, the LN was expected to call the pharmacy, utilize the E-Kit (emergency kit - a supply of medications available for urgent resident needs), and if the medications were not available, to call the doctor. The DON acknowledged that missing a medication like metoprolol to control the heart rate could cause rebound symptoms (return or worsening of symptoms after a medication is stopped), which could cause palpitations (feeling of a fast, pounding, or irregular heartbeat).2. During a medication administration observation, at the facility's Station 1, on 8/4/26 at 8:56 AM, accompanied by LN 2, LN 2 administered aspirin 81 mg EC and DSS 100mg to Resident 69.Review of Resident 69's MAR, dated 8/26, indicated an order dated 12/1/25 for aspirin chewable tablet 81 mg daily for CAD (coronary artery disease - narrowing or blockage of the blood vessels that supply blood to the heart) and an order dated 12/1/25 for DSS 250 mg capsule for constipation. The MAR showed both medications marked as given on 8/4/26 at 8 AM, although LN 2 administered aspirin 81 mg EC and DSS 100 mg dose.During interview on 8/5/26 at 2:33 PM, LN 2 confirmed that she administered aspirin EC instead of the ordered chewable aspirin and DSS 100 mg instead of the ordered DSS 250 mg and did not follow the physician's order on the MAR.During an interview on 8/5/26 at 4:19 PM, the DON stated that the ordered dosage form for aspirin and medication strength for DSS were not followed by the staff.3. During a medication administration observation at the facility's Station 4, on 8/4/26 at 9:12 AM, accompanied by LN 3, LN 3 applied a lidocaine 5% patch to Resident 111's lower back. LN 3 stated that previous lidocaine patch was still on Resident 111's lower back before he applied the new patch.Review of Resident 111's MAR, dated 8/26, showed an order dated 7/21/26 for lidocaine 5% patch, one patch to the lower back once daily for pain, to be applied at 8 AM and removed at 8 PM. The MAR showed the patch was documented as removed on 8/3/26 at 8 PM, although the patch remained on Resident 111's lower back when LN 3 applied a new patch on 8/4/26 at 9:12 AM.During an interview on 8/5/26 at 2:31 PM, LN 3 confirmed that the previous lidocaine patch remained on Resident 111's lower back when he applied the new patch on 8/4/26. LN 3 acknowledged that leaving the previous patch on could affect the effectiveness of the medication because the skin could become less responsive to the medication over time. LN 3 stated that he should have removed the previous patch, notified the physician, and informed the resident and resident's family.During an interview on 8/5/26 at 4:09 PM, Resident 111 stated that the lidocaine patch was not removed on the night of 8/3/26 and a new patch was applied the following morning, leaving two patches on her lower back. Resident 111 stated that staff did not explain why the previous patch was not removed.During an interview on 8/5/26 at 4:19 PM, the DON acknowledged that not following the physician's order for the scheduled removal and application of the lidocaine patch could decrease the skin's response to the medication and make the medication less effective.4. During a medication administration observation at the facility's Station 4, on 8/4/26 at 4:51 PM, accompanied by LN 5, LN 5 administered acetylcysteine 20% inhalation solution, 4 mL (milliliters, a unit of liquid measurement), to Resident 118 using a nebulizer (a machine that turns liquid medication into a mist that is breathed into the lungs) with tubing and a face mask.Review of Resident 118's MAR, dated 8/26, indicated a physician's order dated 7/24/26 for acetylcysteine inhalation solution 20%, 3 mL by nebulizer every six hours as needed for shortness of breath. The MAR documented that acetylcysteine 20%, 3 mL, was administered on 8/4/26 at 4:57 PM.During an interview on 8/5/26 at 3:31 PM, LN 5 confirmed that he administered acetylcysteine 20%, 4 mL, to Resident 118 on 8/4/26 and acknowledged that the administered dose did not follow the physician's order for 3mL acetylcysteine.During an interview on 8/5/26 at 4:19 PM, the DON stated that staff did not administer acetylcysteine according to the physician-ordered dose.5. During a medication administration observation at the facility's Station 4, on 8/4/26 at 9:29 AM, accompanied by LN 3, LN 3 administered six routine morning medications to Resident 109.Review of Resident 109's MAR, dated 8/26, indicated a physician's order dated 7/29/26 for DSS 100 mg capsule, one capsule by mouth twice daily for constipation. The MAR indicated that the DSS 100 mg dose scheduled for 9:00 AM on 8/4/26 was marked as administered to Resident 109.During an interview on 8/5/26 at 2:52 PM, LN 3 confirmed that he did not administer the DSS 100 mg capsule to Resident 109 during the morning medication administration on 8/4/26.During an interview on 8/5/26 at 4:19 PM, the DON acknowledged that the DSS 100 mg was not administered as ordered and that staff did not follow the physician's order.Review of facility policy and procedure (P&P) titled, Medication Administration - Oral, revised in 1/20, the P&P indicated, .Preparing Non-Unit Dose Medications [medications supplied in a container containing multiple doses].Verify medication cards with medication sheets.Read the label on the container as it is removed from the shelf and check label with medication card.Read the label again prior to pouring the drug.Read label before returning container to the shelf.Verify medication card as drug is placed on medication tray.Administering Unit Doses [medications individually packaged for a single dose].Read resident's medication sheet and select appropriate drugs from unit dose drawer.

Based on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 93 residents who ate facility prepared meals when:1. Cucumbers stored in the refrigerator were found with mold in a box of 36 cucumbers;2. Food items (pork sausage patties) were found stored but exposed to air; and3. Eight baking pans were found with food residue and grease buildup.These failures had the potential to put residents at risk for foodborne illnesses.Findings:1. During the initial kitchen tour on 8/4/26, at 8:26 AM, with the Certified Dietary Manager (CDM), a box of cucumber with white, fluffy, cotton-like items were found stored in the refrigerator. The CDM confirmed that the white fluffy cotton-like items around the cucumber was mold. During an interview on 8/6/26, at 2:52 PM, with the Registered Dietician (RD), the RD stated that the cucumbers with white fluffy items on them were mold and that her expectations were for the cucumbers to be free of mold. The RD further stated that the mold present on the cucumbers presented a risk of food born illness to the residents.A review of the facility's undated policy and procedure titled, STORAGE OF FOOD AND SUPPLIES, indicated, .STORING PRODUCE.Check boxes of fruit and vegetables for rotten, spoiled items. Throw away spoiled items upon delivery.2. During a concurrent observation and interview on 8/4/26, at 2:44 PM, with the CDM, a box of pork sausage patties was found stored in an untied plastic bag and exposed to air. The CDM stated the facility just used it during breakfast and those were the leftovers. The CDM confirmed that the plastic bag had been left open and stated that it should have been tied up and kept closed properly. The CDM further stated that when left exposed to air, it could cause freezer burn.During an interview on 8/6/26, at 2:52 PM, with the RD, the RD stated that when the pork sausage patties were left open in the freezer, it could cause freezer burn on the meat and when the plastic bag was left open that placed a risk of bacteria from entering the bag and there would be potential for food borne bacteria. The RD further stated that it could also affect the quality and flavor of the food.A review of the facility's undated policy and procedure titled, STORAGE OF FOOD AND SUPPLIES, indicated, .PROCEDURE FOR REFRIGERATED STORAGE.Leftovers will be covered, labeled and dated.Individual packages of refrigerated or frozen taken from the original packing box need to be labeled and dated. Freezer burn may occur before that and reduce the maximum shelf life. Food that has been freezer burned must be discarded.The Food and Drug Administration (FDA) Food Code 2022, 3-305.13, titled, Vended Time/Temperature Control for Safety Food, Original Container, dated 1/18/23, indicated, .The possibility of product contamination increases whenever food is exposed .Once the original seal is broken, the food is vulnerable to contamination (https://www.fda.gov/food/fda-food-code/food-code-2022) 3. During a concurrent observation and interview on 8/4/26, at 2:54 PM, the CDM confirmed there were a total of 8 baking pans were found with food residue and grease buildup stored in the ready-to-use area. During an interview on 8/6/26, at 2:52 PM, with the RD, the RD stated the baking pans that were layered with a brown sticky debris posed a risk for food contamination. The RD acknowledged that the brown debris was not only at the bottom of the pan but it was also around the edges at the top of the pan as well where the food would touch it if used to cook with. The RD further stated that it could potentially cause food borne illness.A review of the USFDA 2022 Food Code, section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, dated 1/18/23, indicated, .The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations . (https://www.fda.gov/food/fda-food-code/food-code-2022)A review of the facility's undated policy and procedure titled, STORAGE OF FOOD AND SUPPLIES, indicated, .SANITATION.All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas.

Based on interview, and record review, the facility failed to ensure safe use, monitoring, and accurate diagnosis of psychotropics medications (mind altering drugs) for two out of 23 sampled residents (Resident 9 and Resident 99) when:1. Resident 9's psychiatric diagnosis for schizophrenia (a serious mental health diagnosis with visual and auditory hallucination and lack of executive function often seen in early life) and bipolar disorder (mental health disease with cycles of mood swings) was not accurately documented and assessed by providers based on standards of practice and professional standards.2. Resident 99 did not have safe monitoring and management of an antidepressant medication used to treat the depression symptoms.These failed practices could contribute to unsafe care, monitoring, and excessive use of psychotropic medications that can worsen resident outcomes. Findings: 1. A review of Resident 9's Electronic Health Record (EHR) titled, Face Sheet: Diagnosis Information, dated 8/7/26, the record indicated resident was initially admitted to the facility on [DATE] and the most recent hospitalization and re-admission date was on 2/9/26. The diagnosis section included: Parkinson disease (movement disorder due to nerve dysfunction) as the main diagnosis, diabetes (blood sugar disease), stage 4 wound (deep wound), schizophrenia and bipolar disorder among others with documented onset date of 2/19/25. A review of the Resident 9's doctor's order and Medication Administration Record (or MAR), dated 8/2026, the record indicated Resident 9 received the following mental health, Parkinson diseases, and other drugs that may affect mental health as follows: Abilify Oral Tablet 5 MG (Aripiprazole, MG is milligram, a unit of measure, drug used for schizophrenia, bipolar disorder, or depressive disorder): Give 1 tablet by mouth one time a day for SCHIZOPHRENIA M/B (Manifested By) MOOD INSTABILITY/DELUSIONAL THINKING . -Order Date-4/01/26 Carbidopa-Levodopa Oral Tablet 25-100 MG (or Sinemet, used to treat and improve parkinsonian tremor, shaking and body frizzing); Give 3 tablet by mouth four times a day for PARKINSON'S -Order Date- 2/09/26. Benztropine Mesylate Oral Tablet; 1 MG (or Cogentin; helped with muscle stiffness, and control of tremors in Parkinson's disease and antipsychotic drugs; side effects could include confusion, disorientation, memory impairment, visual hallucinations, nervousness, and worsening of depression or psychotic symptoms); Give 1 tablet by mouth two times a day for PARKINSONS -Order Date-2/09/26 oxyBUTYnin Chloride Oral Solution 5 MG/5ML (or Ditropan, relaxes bladder muscles to reduce urinary urgency; Could cause mental and psychiatric side effects such as agitation, anxiety, trouble sleeping, hallucination especially in older adults; MG/ML is milligram per milliliter- a unit of concentration) Give 5 ml by mouth every 12 hours for URINARY FREQUENCY -Order Date-2/09/26 A review of Resident 9's latest History and Physical (H&P), dated 1/26/26, written by Medical Doctor (MD) 1, the record referred to Past Medical History: as mentioned in HPI (history of Past Illness). The record under Assessment/Plan indicated both bipolar disorder and schizophrenia. A review of Resident 9's H&P, written by MD 3 and the Nurse Practitioner (NP-2), with date range of 2017 to 2025, the handwritten H&P sheet under diagnosis sections indicated the followings: 10/16/17: No mental health diagnosis; Written by MD 3 10/17/18: Bipolar was added to diagnosis; Written by a Nurse Practitioner (NP) 10/23/19: No mental health diagnosis; Written by MD 3 12/5/19: No mental health diagnosis; noted developmental delay; Written by MD 3 12/16/20: No mental health diagnosis; noted developmental delay; [NAME] by MD 3 1/10/22: bipolar disorder was noted; Written by a NP and signed by MD 3 1/16/23: bipolar disorder and developmental delay was noted; Written by a NP and signed by MD 3 2/12/24: schizophrenia was noted on the Summary of Medical diagnosis; Written by a NP and signed by MD 3 2/20/25: No mental health diagnosis; noted developmental delay, body tremor; [NAME] by MD 3 A review of Resident 9's hospital record titled, History and Physical or H&P, dated 10/8/17, from Hospital A, the record indicated Resident 9 was admitted from a board and care facility due to hip fracture. Hospital A's record under admission H&P did not indicate any mental health diagnosis. A review of Resident 9's hospital record titled, Discharge Summary, dated 10/13/17, from Hospital A, the record did not include any psychiatric diagnosis and listed Abilify (or Aripiprazole, a mental health drug used for various conditions) as a discharge medication. A review of Resident 9's Hospital A record titled, admission History and Physical, dated 11/24/19, the record indicated Resident 9 was admitted to the hospital with sepsis (serious infection affecting all the body) and included cognitive developmental impairment with no psychiatric diagnosis. A review of Resident 9's Hospital A record titled, Progress Note, dated 11/25/19, written by a Hospitalist (doctors that mainly care for hospital patients) during hospitalization, the record on the 2nd day of admission included schizophrenia as part of daily doctor's note. The progress note did not have a reference on how it was diagnosed or if a full psychiatric assessment was performed after one day of hospitalization for sepsis. A review of Resident 9's Hospital A record titled, Discharge Summary, dated 2/19/25, the record indicated resident was admitted with fever, urinary tract infection (or UTI) and altered mental status. The record further indicated .past medical history significant for diabetes, schizophrenia.who was brought from skilled nursing facility with chief complaint of altered mental status and febrile illness . The record indicated to continue aripiprazole among other drugs after hospital discharge. During a concurrent interview with facility's MDS coordinator (MDSC, Minimum Data Set or MDS, a federally mandated, standardized clinical assessment tool to guide care planning and track quality of care), and review of Resident 9's diagnosis and MDS section of the EHR, on 8/6/26, at 4:59 PM, the MDSC stated schizophrenia diagnosis was added to EHR, on 2/19/25 based on records from Hospital A, while MD 3's notes and H&P did not include the schizophrenia diagnosis. MDSC stated the MDS document included schizophrenia diagnosis after 2/19/25. During a concurrent interview with facility's MDS coordinator (MDSC), on 8/7/26, at 11:52 AM, and review of Resident 9's Electronic Health Record titled, Care Plan Report, with revision date of 5/7/26, the plan of care for Anti-psychotic [mind altering drug] medication use, indicated, Antipsychotic medication use Abilify r/t [related to] bipolar disorder m/b [manifested by] constant yelling. Date initiated: 4/2/26 .The goal. [Resident 9] will not have reactions related to use of antipsychotic drug therapy . The Plan of care further included behavior and side effect monitoring in addition to non-drug interventions. The Care Plan additionally indicated the warning, Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Aripiprazole is not approved for the treatment of patients with dementia-related psychosis. It was not clear why care plan did not include schizophrenia diagnosis. The MDSC stated the social worker and MDS staff helped with completing the care plan. During a concurrent interview with MDSC, on 8/7/26, at 11:52 AM, and review of Resident 9's EHR, the MDSC stated Resident 9 had been seen by a mental health agency via telehealth (long-distance care via phone or video conferencing). The EHR indicated mental health notes and provider visits 0-2 times per month from 5/6/25 to 8/5/26. Review of Resident 9's EHR titled, Interdisciplinary Team or IDT, meetings with date range of 1/13/26 to 7/28/26, the record written by social service mostly repeated the NP-Psych provider recommendations after each visit. A review of Resident 9's mental health provider notes, written by Psychiatrist Doctor (Psych-MD), dated 5/6/25, the record indicated .[Resident 9] with an unclear psychiatric history of schizophrenia and bipolar disorder and history of Parkinson disease per chart review.[Resident 9's] reliability of history is questionable. I would recommend neuropsychological evaluation for some clarification of her psychiatric diagnosis . It was unclear if the neuropsychiatric referral was acted upon by the facility. Review of Resident 9's mental health provider notes, written by mental health Nurse Practitioner (NP- Psych), with date range of 11/6/25 to 7/23/25, the NP-Psych visit note assessments was as follows: Notes for 11/6/25 and 11/25/25 repeated the recommendation for neuropsychological evaluation for clarification of [Resident 9's] psychiatric diagnosis. Notes for 1/2/26 and 1/23/26 indicated denies any depression, anxiety, no sleep issues.With hx (history) of bipolar disorder as well as diagnosis in chart of psychological development disorder, schizophrenia. The NP-psych's recommendations indicated Continue current medications and non-pharmacological measures. Notes for 3/31/26, indicated Pt (Patient) currently with diagnosis of bipolar disorder and schizophrenia. It is unclear from chart if this is correctly diagnosed as two separate concerns or should truly be a single diagnosis of schizoaffective disorder, bipolar type. Regardless, patient symptoms warrant improved treatment with medication trial. Provider recommends starting aripiprazole 5 mg po QD (daily). Of note, patient is also being treated for Parkinson's disease which can alter mental status with progression of the disease. Note for 4/17/26, indicated Start Aripiprazole 5 mg po QD for Schizophrenia m/b mood instability, delusional thinking. The NP-Psych notes did not address if neuropsychiatric referral or visit was completed to address and/or help clarify mental health diagnosis. In a phone interview with NP-Psych, on 8/7/26 at 9:14 AM, NP-Psych stated she relied on medication list and diagnosis documented in the facility's computer system for information about Resident 9. NP-Psych stated she did not re-evaluate or verify the documented diagnosis in the records.NP-Psych Stated she relied on conversation with staff caring for the resident and resident herself for assessment. NP-psych stated she was not sure if neuropsychiatric assessment was performed. NP-psych stated the two diagnoses of bipolar and schizophrenia don't go together. Asked if Parkinson medication side effects may have been contributing to mental health issues, NP-Psych stated other medications were reviewed during telehealth visit and a medical mental health doctor performed the initial psychiatric visit. During a telephone interview with the facility's Medical Director (MD 1) on 8/7/26, at 1:52 PM, MD 1 stated his medical group took over the care of residents in the facility on 12/2025. MD 1 stated his medical group and NP-1 visited the residents multiple times per month. MD 1 stated schizophrenia diagnosis should have been confirmed or re-evaluated by psychiatrists. MD 1 stated he needed to re-evaluate use of two drugs (benztropine and oxybutynin) that may potentiate mental health side effects for Resdeint 9. MD 1 could not comment on documentations done by previous medical doctors and NP providers. During an interview with Licensed Nurse (LN 1) on 8/7/26, at 3:54 PM, LN 1 stated Resident 9 was aware of her surroundings and followed direction. LN 1 stated Resident 9 took her medication orally and at times refused blood sugar measurement. LN 1 stated she had not seen any aggressive behavior or hallucination (hearing unreal voices or seeing unreal items). During an interview with Director of Nursing (DON) on 8/7/26, at 4:04 PM, the DON stated the new orders and admission from hospital were inputted in the computer by the admission Nurse, the entry in computer then double checked by the night supervisor for accuracy and the 3rd check was in the next interdisciplinary (IDT) team meeting. The DON stated the medical doctor saw the residents within 1-2 days and they reviewed the orders in person or online. The DON stated the staff relied on doctor's order and the transfer documents to enter information about drug use and diagnosis. A review of the facility's policy titled, Psychotropic Drug Use, dated 2/2025, indicated .On admission, the admitting nurses will review the transfer orders for any psychotropic medications. All efforts will be made by the Licensed Nurses to obtain as much history regarding these medications.Any information obtained will be documented in the resident's clinical record.The Licensed Nurses shall review the classification of the drug, the appropriateness of the diagnosis, its indication/behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician . The policy on section 6 indicated, .upon initial comprehensive assessment. nursing designee shall review new admission for any psychiatric, mood or behavior disorder, mental and psychosocial difficulties, and/or physician's order for psychotropic medications. These residents will be referred to the facility's Psychotropic Drug Review Committee and/or the psychiatrist to ensure a. Psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record.c. Behavior is not related to Delirium or other reversible conditions. Further review of the facility's policy titled, Psychotropic Drug Use, dated 2/2025, the policy's definition section indicated the term, Indication for use definition as, the identified, documented clinical rationale for administering a medication that is based upon as assessment of the resident's condition and therapeutic goals and is consistent with manufacturer's recommendation and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals. Review of the facility's undated policy titled, Medical Director, indicated, .Physician services shall be under the supervision of the Medical Director. The Policy on section 3 further indicated Medical Director function also includes but not limited to: a. Acting as a liaison between administration and attending physician.d. Helping assure that the resident care plan accurately reflects the medical regimen.g. Assuring that physician services comply with current rules, regulations, and guidelines concerning long-term care . 2. Review of Resident 99's admission RECORD, indicated Resident 99 was admitted to the facility with a diagnosis of, but not limited to unspecified mood disorder (having ongoing problems with mood or emotions but the exact type has not been clearly identified), alcohol abuse, and tobacco use. Review of Resident 99's clinical record titled, Minimum Data Set Section C (MDS- an assessment tool), dated 5/21/26, indicated, .BRIEF INTERVIEW FOR MENTAL STATUS (BIMS – a short test used to check a person's memory and thinking abilities).Score: 11 (BIMS score of 13-15: normal thinking/ intact cognition, score of 8-12: moderate cognitive impairment, and 0-7: severe cognitive impairment). Review of Resident 99's Order Summary Report, dated 7/6/26, indicated, .MD determines that Resident has the Mental Capacity to make Healthcare decisions as per History & Physical or Transfer orders or preferred intensity of care . Further review of Resident 99's order summary report, dated 7/14/26, indicated, .Sertraline [antidepressant medication] HCl Oral Tablet.Give 1 tablet by mouth one time a day for depression m/b [manifested by] verbalization of sadness.Closely monitor all antidepressant-treated patients for clinical worsening, and for emergence of suicidal thoughts and behaviors . During a review of Resident 99's clinical record titled, PSYCHOTHERAPEUTIC DRUG INFORMED CONSENT FORM, for an antidepressant, dated 7/6/26, under the section titled, COMMON SIDE EFFECTS, indicated, .Nausea, dry mouth, insomnia, weight gain/loss, sexual dysfunction, dizziness, fatigue. Less common: agitation, anxiety, increased HR . Further review of the document, under the section titled, FDA [Food and Drug Administration] (BLACK) BOXED WARNINGS [BBW – the FDA's strongest warning that a medication may cause serious or potentially life-threatening risks] SUMMARY, indicated, .Suicidality: Increased risk of suicidal thinking/behavior in children/young adults (< 24). Reduced risks seen in adults 65+ . During a concurrent observation and interview on 8/6/26, at 2:46 PM, with Resident 99 and Resident 99's Family Member (FM), in Resident 99's room, Resident 99 was observed lying in bed on her right side with her eyes closed. FM was seated in a chair on the right side of the Resident 99's bed. FM stated that Resident 99 had been taking an antidepressant medication prior to her admission to the facility and continued to need the medication. FM further stated that it was her opinion that Resident 99's antidepressant medication should be reviewed because the resident might need an increase in the dosage or possibly a change to a different antidepressant medication. During the interview, Resident 99 opened her eyes and participated in the conversation. Resident 99 stated that it was important to her that facility staff review her antidepressant medication and monitor whether the medication was effective. Resident 99 further stated that she would like the physician to review the medication to determine whether an increase in the dosage might be appropriate. Resident 99 stated that, at times, her stomach-related problems affected her emotional state. During a concurrent interview and record review on 8/6/26, at 9:42 AM, with the MDSC, Resident 99's electronic medical record (EMR) was reviewed. The MDSC stated that Resident 99 was admitted to the facility with a diagnosis of unspecified mood disorder. The MDSC further stated that Resident 99 was admitted without an antidepressant medication order. Further review of the EMR showed that Resident 99 subsequently received a physician's order for Sertraline, an antidepressant medication, for the diagnosis of depression. The MDSC further reviewed Resident 99's EMR and confirmed that there was no documented monitoring of the resident's behavioral manifestations or target symptoms related to the diagnosis for which Sertraline was prescribed, no documented monitoring for potential adverse side effects associated with the medication, and no documented nonpharmacological interventions (NPIs - ways to help a person without using medication) to address the resident's symptoms or behaviors. The MDSC stated that monitoring the resident's behaviors, potential side effects, and the use of NPIs were important components of managing a resident receiving an antidepressant medication. The MDSC further reviewed Resident 99's comprehensive care plan and confirmed that no care plan had been initiated addressing the resident's depression, use of Sertraline, behavioral or symptom monitoring, potential adverse side effects, or nonpharmacological interventions. The MDSC confirmed that no documentation addressing these components was found in Resident 99's EMR. During an interview on 8/7/26, at 8:46 AM, with the DON, the DON stated that it was her expectation that when a resident received an order from the physician for an antidepressant medication, the licensed nurse would enter the medication order but would not activate the order until informed consent had been obtained. The DON further stated that appropriate psychotropic medication management included identifying the resident's diagnosis and the behavioral manifestations or symptoms associated with the diagnosis, establishing monitoring for the resident's target behaviors, and potential adverse side effects of the medication, and identifying and implementing nonpharmacological interventions. The DON stated that these components were important and should be incorporated into the associated medication orders because they were part of the resident's overall psychotropic medication management. The DON further stated that behavior monitoring was particularly important because the information was reviewed during the facility's monthly psychotropic medication meeting and was needed to evaluate the resident's response to the medication and to assist in determining the appropriateness of a gradual dose reduction (GDR – slowly lowering the dose of a medication to see if the person can safely manage with less medicine when clinically appropriate). The DON stated that monitoring for potential adverse side effects was also important to identify whether the resident was experiencing negative effects from the medication. The DON further stated that NPIs were important because staff should not rely solely on medication to address a resident's symptoms and should identify other approaches or alternatives that may help the resident. The DON explained that it was also her expectation that the licensed nurse would initiate a care plan addressing Resident 99's psychotropic medication use and update the care plan as appropriate. A review of the facility policy and procedure (P&P) titled, Chemical Restraints and Psychotropic Medication Management, revised date 4/25, indicated, .It is the policy of this facility to ensure that residents are free from chemical restraints.Psychotropic medications shall not be administered for the purpose of discipline or convenience.To ensure residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated.The LN [Licensed Nurse] shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician.The facility's Interdisciplinary Team [IDT – a group of healthcare staff from different professions who work together to plan and provide a resident's care] will review to ensure.Monitoring for adverse consequences and effectiveness of medications are in place. Review of plan of care shows individualized, person-centered care approaches to manage behavior with non-pharmacological interventions.

Based on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing information accurately and completely reflected the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for a census of 95 residents when, the facility's daily nurse staffing posting did not identify the number and actual hours worked by Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs), and did not reflect the actual hours worked per shift by nursing staff responsible for resident care.This deficient practice had the potential to prevent residents, staff, visitors, and the public from having access to complete, accurate, and current nurse staffing information for a facility census of 95 residents.Findings:During a concurrent interview and record review on 8/6/26 at 1:28 PM with the Staffing Scheduler (SS), the SS reviewed the facility's Nurse Staffing Information, which she referred to as the PPD posting. The SS stated that she prepared and posted the staffing information daily from Monday through Friday, while the RN Supervisor was responsible for completing the posting on weekends. The SS reviewed the facility's PPD posting and stated that it included the facility name, date, total resident census, target total hours, and the number of nurses and Certified Nursing Assistants (CNAs) scheduled for each shift. The SS stated that the target total hours represented the facility's projected hours. The SS further stated that the nursing staff listed on the posting were not categorized separately as Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs). Instead, RNs and LVNs were grouped together and identified as shift nurses or cart nurses. When asked whether the staffing posting reflected the actual hours worked by nursing staff for each shift, the SS stated that the posting contained only the projected hours and confirmed that actual hours worked were not included on the daily staffing posting. The SS stated that the actual hours worked would not be available until the following day. When asked where the actual hours worked were subsequently posted or made available, the SS stated that she did not know where the facility posted that information.During a concurrent interview and record review on 8/7/26 at 8:54 AM with the Director of Nursing (DON), the DON reviewed the facility's Nurse Staffing Information, also referred to as the PPD posting form. The DON confirmed that the licensed nurses assigned to the medication carts were not separately categorized as Registered Nurses (RNs) or Licensed Vocational Nurses (LVNs) on the staffing posting. The DON stated that the licensed nurses performed the same functions and she believed there was no need to categorize them separately as RNs and LVNs. The DON also reviewed the staffing hours documented on the PPD posting and confirmed that the form reflected only the projected hours and not the actual hours worked by nursing staff per shift. The DON stated that it was her expectation for the facility to comply with all applicable requirements related to the daily nurse staffing posting. The DON further stated that it was important for the facility to post the PPD information daily so that residents, family members, visitors, and staff were informed of the facility's daily nursing staffing status. The DON stated that accurate and complete nurse staffing information played an important role in the delivery of quality care and services to residents.A review of the facility's undated policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers, the P&P indicated, Policy Statement - Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation - Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location . Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: . The resident census at the beginning of each shift . Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift . The actual time worked during that shift for each category and type of nursing staff . Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator .

Based on interview and record review, the facility failed to ensure a Registered Dietitian (RD -licensed healthcare expert who handles patient nutrition) was on site enough time to carry out the responsibilities of kitchen and dietary oversight for a census of 94 residents who eat from the kitchen when the RD did not conduct any kitchen or sanitation audits (evaluation of food service operation to ensure compliance with food safety laws and hygiene standards), in-service trainings (education about food safety to employees) and observation of meal preparations or tray line (food assembly location used in healthcare facilities) services. This failure placed the residents at risk of compromised food safety, insufficient nutritional care and risk for foodborne illness (any sickness caused by eating harmful bacteria, viruses or toxic chemicals).Findings: A review of the facility provided document INDEPEDENT SERVICES AGREEMENT, dated 7/1/2025 with the service provider, Nutrition That Works, LLC, indicated the following expectations: .A. Scope of Services.DIETARY CONSULTING SERVICES.1. Assess nutritional needs of residents and complete nutritional assessments.2. Review resident's health care plan.3. Counsel with residents and their families on special diets and nutritional assessments.5. Provide guidance and training to the Food Service Director and dietary staff.6. Planning and conducting in-service education programs related to dietary rules, policies, and procedures.12. Inspect all area of the dietary department, including sanitation, equipment functioning and food service operations.Service Provider shall be available at various mealtimes to observe dining operations. During a concurrent interview and record review on 5/27/26 at 1:07 PM, with the Certified Dietary Manager (CDM), the printed reports titled, DIETARY SERVICES - KITCHEN SANITATION/FOOD STORAGE, dated 3/16/26, 4/17/26, and 5/14/26, were reviewed. The CDM confirmed that he completed the kitchen sanitation and food storage monthly audit reports. The CDM confirmed that the RD was responsible for the kitchen sanitation and food storage audits and reports. The CDM stated his process was to complete the monthly audit of the kitchen and sanitation and forward a copy to the infection preventionist, then file the original report in his office. The CDM further stated the RD did not review or sign off on the monthly kitchen and sanitation audit reports. The CDM stated that the RD was on site at the facility approximately once per week for a meeting. The CDM further stated that the RD did not provide education or in-service training for the kitchen staff. The CDM further added that the RD did not observe tray line. The CDM stated it was important for the RD to complete the kitchen and sanitation audit monthly because they were another set of eyes to visualize potential problems with sanitation and food storage. The CDM added it was important for the RD to have oversight of the kitchen since the RD was a clinician and trained to make sure that everything done in the kitchen was done to dietary standards. During an interview on 5/27/26 at 12:07 PM with the RD, the RD confirmed that she was contracted through Nutrition That Works, to provide registered dietician services to the facility. The RD stated her duties included weekly weight meetings, admission assessments, record reviews and completed documentation. The RD explained that she did not go into the kitchen or provide oversight of dining operations, complete in-service training, or kitchen sanitation audits and reports. The RD further explained that she was only contracted for 24 hours per week and that amount of time was not enough to complete the required tasks. The RD added that she only had time to review charts, make recommendations based on record reviews, and could not physically observe and assess each new resident that was admitted due to time restraints. During an interview 5/27/26 at 1:51 PM with the Director of Nursing (DON), the DON stated the RD usually came to the facility once per week on Thursdays for the weekly weight meetings. The DON stated she was aware that the CDM was completing the kitchen and sanitation monthly audit reports and did not know why the RD was not completing them. The DON added it was her expectation that the RD also physically observed each new resident. The DON added it was important to gather the objective data with observation and then compared if needed to medical records. The DON stated an important part of assessment was to gather information that included using all the senses like sight and touch. The DON stated the RD needed to see the residents to gather information and make informed decisions about the residents' nutritional well-being and needs. During an interview on 6/2/26 at 8:13 AM, the Administrator stated he was unaware that the RD did not have oversight of the kitchen as required by their contract. The ADM further stated that he had been trying to hire an RD for more hours to be on-site at the facility. The ADM added that the risk to the residents for not having RD oversight in the kitchen was risk in quality of care and optimal nutritional care. A review of the facility provided advertisement job posting published on the internet site Indeed for a Registered Dietitian opening, dated August 2025, indicated, .Duties.Conduct comprehensive patient assessments to evaluate nutritional needs.Supervise dietary department staff, ensuring compliance with established protocols and high standards of care.

Based on interview and record review, the facility failed to ensure professional standards of practice were met for two of five sampled residents (Resident 4 and Resident 5) when Resident 4 and Resident 5's Registered Dieticians (RD) nutritional assessments were not completed and the RD did not complete in-person nutritional assessments on the residents at the facility.This failure had the potential to negatively impact Resident 4 and Resident 5's overall physical and nutritional health.Findings: a. A review of Resident 4's admission RECORD indicated that Resident 4 was admitted to the facility with diagnoses which included diabetes type II (a chronic condition that affects the way the body processes blood sugar), chronic kidney disease (kidneys that filter waste and save nutrients the body needs are damaged and cannot filter the blood properly), severe malnutrition (when the body does not get the right balance of nutrients, calories, or vitamins it needs to function properly) and colon cancer (a disease where cells in the large intestine [colon] grow out of control and form tumors). A review of Resident 4's care plan (a formal process which identifies existing needs and recognizes potential needs or risk for residents) dated 5/12/26 indicated that Resident 4 had a nutritional problem with an intervention for the RD to evaluate. A review of Resident 4's care plan dated 5/12/26 indicated that Resident 4 had potential for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with friction) development with an intervention to monitor Resident 4's nutritional status. A review of Resident 4's Mini Nutritional Status Assessment (MNA- a screening tool used in older adults by healthcare staff to easily identify if they are malnourished or at risk for malnourishment) dated 5/13/26 indicated that Resident 4 was malnourished with an intervention box checked to consult a dietitian per order. A review of the RDN [Registered Dietitian Nutritionist] Nutritional Assessment/Evaluation dated 5/13/26, was blank and not completed. The section labeled as the nutritional plan of care was also blank and not completed. b. A review of Resident 5's admission RECORD indicated that Resident 5 was admitted to the facility with diagnoses which included, encounter for surgical aftercare following surgery on the digestive system (organs that work together to break down and absorb food for nutrients), diabetes type II, colostomy status (a medical term indicating that a person has a surgically created opening in their stomach that connects their colon [large intestine]), pressure ulcer stage 2 (a partial thickness loss of skin layers, either dermis or epidermis, that presents clinically as an abrasion, blister, or shallow crater), post hemorrhagic anemia (a sudden drop in healthy red blood cells caused by severe blood loss), and diverticulitis of the large intestine with perforation and abscess (a serious digestive problem where small, balloon-like pouches in the large intestine [colon] become infected and burst open). A review of Resident 5's care plan dated 5/13/26 indicated that Resident 5 had a potential for malnutrition. A review of Resident 5's care plan dated 5/8/26 indicated Resident 5 had a nutritional problem due to recent colostomy surgery (procedure that creates an opening called a stoma in the abdominal wall). A review of Resident 5's MNA dated 5/13/26 indicated that she was at risk for malnutrition with a box marked to consult a dietitian if Resident 5 MNA results came back as at risk for malnutrition. A review of the RDN Nutritional Assessment/Evaluation dated 5/13/26 was blank and not completed. The section labeled as the nutritional plan of care was also blank and not completed. During a concurrent interview and record review on 5/27/26 at 1:07 PM with the Certified Dietary Manager (CDM), Resident 4's Mini Nutritional assessment dated [DATE] was reviewed. The CDM confirmed he completed the assessment for Resident 4, and it came back with a score of 5 points which indicated malnourished (MNA scoring is based on a score of 0-14, 12-14 points indicated normal nutritional status; 8-11 points indicated at risk of malnutrition; and 0-7 points indicated malnourished). The CDM further stated he completed all the face-to-face MNAs on the residents including Resident 4 and Resident 5 when he did his portion of the nutritional assessment on each newly admitted resident. The CDM explained he entered his results into the residents' medical records. The CDM stated he did not consult the RD regarding the results of the MNA evaluations. The CDM further stated that the RD usually reviewed the MNA and Part 1 of the nutritional assessment that included the residents' food preferences and food allergies, when she would complete her portion Part 2 of the admission nutrition assessment. During an interview on 5/27/26 at 12:07 PM with the RD, the RD confirmed that she was contracted through Nutrition That Works, to provide registered dietitian services to the facility. The RD stated her duties included weekly weight meetings, admission assessments, reviewing records and completing documentation. The RD stated she did not complete the nutritional assessments at bedside or observe them in person. The RD stated she did not have time and was only contracted for 24 hours per week. The RD further stated she compiled her information from record review and that the CDM saw the residents face to face. The RD confirmed the CDM was not a clinical position and could not assess the residents nutritional status or make nutritional determinations via observation. During an interview and concurrent record review on 5/27/26 at 1:51 PM with the Director of Nursing (DON), the DON reviewed Resident 4 and Resident 5's RDN Nutritional Assessment/Evaluation dated 5/13/26. The DON confirmed the assessments were not completed. The DON confirmed the CDM did not have a clinical license and could not visually assess the residents' nutritional status. The DON stated she was not aware the RD did not do face-to-face nutritional assessments on the residents and added it was her expectation the assessments were done in person. The DON added it was important for the RD to physically see the residents and gathered the objective data with observation and then compared it to the medical records. The DON stated an important part of an assessment was to gather information that included observation which used all the senses like sight and touch. The DON stated the RD needed to observe the residents to gather information and make informed decisions about the residents nutritional well-being and needs. The DON stated the risk of not being observed in person by the RD was that something could be missed. The DON added because the residents' appearance told them a lot about their nutritional status. The DON further added the risk to the residents was that the residents could become malnourished or acquired failure to thrive which would put them at risk for rehospitalization and not properly heal which was a barrier to their care plan and treatment goals. During an interview on 6/2/26 at 8:13 AM, the Administrator stated he expected the CDM to communicate findings of the assessments with the RD. The ADM further stated that he had been trying to hire an RD for more hours to be on-site at the facility. The ADM explained he expected the RD to complete all of the required tasks in the dietary consulting services contract. The ADM added that the risk to the residents for not having RD observations of the residents was a risk in quality of care and a lack of optimal nutritional care. A review of a facility policy and procedure tilted Nutrition Risk Screening (MNA), revised 4/2025, indicated, .4. Staff will communicate the results of the nutrition screening process with the Registered Dietician (RD) .Staff will notify the RD or designee and provided information for individuals with: Malnutrition as indicated by the screening tool (MNA scores 7 or less) Risk for malnutrition or (as indicted by MNA screening score of 8-11) .5. The facility RD, nutrition support staff and/or nurse manager will initiate appropriate interventions .The RD or designee will complete a comprehensive nutrition assessment and determine appropriate nutrition interventions . A review of the facility provided document, INDEPEDENT SERVICES AGREEMENT, dated 7/1/2025, indicated, .A. Scope of Services.DIETARY CONSULTING SERVICES.1. Assess nutritional needs of residents and complete nutritional assessments.2. Review resident's health care plan.3. Counsel with residents and their families on special diets and nutritional assessments. A review of the facility provided advertisement job posting published on the internet site Indeed for a Registered Dietitian opening, dated August 2025, indicated, .Duties.Conduct comprehensive patient assessments to evaluate nutritional needs. A review of the on-line document by the Post-Acute and Long-Term Care Nutrition (PALTC) Scope of Practice Standards for Registered Dietitian Nutritionists (RDN), published February 2025, indicated that each RDN in Post-Acute and Long-Term Care Nutrition, .7.2 Conductions nutrition assessment.identify and collect pertinent nutrition assessment data.through interview, observations, review of medical records.7.3.4 Documents nutrition diagnosis(es).clear/concise written statement(s).as part of a comprehensive nutrition assessment and the resident's individualized care plan. https://www.cdrnet.org/vault/2459/web//20250213%20PALTC%20Scope%20and%20Standards%20Article%20and%20Figures_Final_CLEAN.pdf

§483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and- (i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. Based on interview and record review, the facility failed to provide sufficient preparation for a safe and orderly discharge for one of three sampled residents (Resident 1), when Resident 1 had a change in condition (C[NAME]) on the day prior to the planned date of discharge. Resident 1 was not given sufficient time before discharge to determine if the intervention that was done for the change in condition was effective. Resident 1 was discharged to an assisted living facility less than twenty-four hours after the intervention for the change in condition was implemented. As a result of this failure, Resident 1 was admitted to the Acute Care Hospital (ACH) within 24 hours of transfer to the assisted living facility for altered level of consciousness, dehydration, electrolyte (solutions needed for the normal functioning of the body) abnormalities, urinary tract infection (infection in the system of urine production),[MEDICAL CONDITION] (a life threatening complication of an infection) and [MEDICAL CONDITION] ([MEDICAL CONDITION]- damage to the brain from interruption of its blood supply (stroke)), and ultimately death. Finding: Resident 1's clinical record titled, Admission Record, dated 3/22/18, Indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's clinical record titled, Minimum Data Set assessment (MDS) (a resident assessment tool for cognitive and functional needs and abilities), dated 2/20/18, indicated Brief Interview for Mental Status (BIMS - an assessment of memory and recall) score of 11/15 points which indicated Resident 1 had slightly impaired memory and recall. Review of Resident 1's clinical record from the Acute Care Hospital (ACH) titled, Inter-Facility Report, dated 2/1/18, indicated Resident 1 was independent in toileting, bathing, dressing, eating and required an assistive device with ambulation and transfer. Review of Resident 1's clinical record titled, IDT (Interdisciplinary Team-group of professionsals who meet to discuss resident's status) Admission Assessment, dated 2/7/18, indicated Resident 1 was independent with sit to stand; chair/bed-to-chair transfer and able to walk. Review of Resident 1's clinical record titled, MDS assessment, dated 2/20/18, indicated Resident 1 needed extensive assistance with one-person physical assist with bed mobility, transfer, dressing, toilet use and hygiene. Review of Resident 1's clinical record titled, IDT Discharge/Recapitulation of Stay,dated 2/23/17, indicated Resident 1 needed partial/moderate assistance with sit to stand and chair/bed-to-chair transfer, and was unable to walk. Review of Resident 1's Care Plan dated, initiated 2/6/18, indicated, Focus Resident had potential risk for fluid volume deficit with interventions labs (laboratory) as ordered for 2/23/18; . monitor vital signs and clinical condition for at least 72 hours and Intravenous (IV) hydrations as needed. Review of Resident 1's clinical record titled, Progress Notes, dated 2/20/18 at 2:09 p.m., indicated . (Laboratory) Lab, X-ray (a photographic or digital image of the internal composition of a part of the body), reviewed: . (Carbon [MEDICATION NAME]-a colorless, odorless, incombustible gas expelled during exhalation,) CO2 (Carbon [MEDICATION NAME]) 25 (normal range 21-31); (Blood Urea Nitrogen) BUN (test is done to see how well kidneys are working) 21 (normal range 7-25); (Creatinine) Cr (assess kidney function) 0.7 (normal range 0.6 - 1.3); (White Blood Count) WBC (test to check for infections) 5.1 (normal range 4.0 - 10.0). Review of Resident 1's clinical record titled, Progress Notes, dated 2/21/18 at 2:25 p.m., indicated, Contacted Placement Services stated that Assisted Living in (name of town) is willing to accept patient . Review of Resident 1's clinical record untitled dated 2/21/18, indicated, . Discharge Assisted Living facility (ALF) with current medications. (Home Health)HH/(Registered Nurse)RN (Registered Nurse)/(Physical Therapy) PT/PT to assess (Occupational Therapy) OT need. Review of Resident 1's clinical record titled, Progress Notes, dated 2/22/13 at 10:49 a.m., Patient stated she's weak and tired, notified doctor for recommendation of hydration due to verbalization of being lethargic (stuporous), noted breakfast not eaten or fluids taken, obtain order from the doctor for sodium chloride (Salt solution administered intravenously to rehydrate) as ordered . Review of resident 1's clinical record titled, Change in Condition Evaluation, dated 2/22/18 at 3:17 p.m., indicated C[NAME] as lethargy with vital signs (clinical measurements, that indicate the state of a patient's essential body functions) of blood pressure 91/59; pulse 49 irregular . Mental Status Evaluation 2. Decrease level of consciousness . Review of Resident 1's clinical record titled, Progress Notes, dated 2/22/18 at 3:30 p.m., indicated, Patient lethargic in the morning, did not eat breakfast, stated she feels weak and tired. Review of Resident 1's clinical record, untitled, dated 2/22/18 at 11:05 a.m., indicated, Order Summary: Sodium Chloride Solution 0.9 % Use 75 (milliliter)mL/(hour) hr intravenously every shift for 3 administrations x1 liter. Review of Resident 1's clinical record titled, Progress Notes, dated 2/22/18 at 4:49 p.m., indicated, Received Medical Doctor (MD) order for (Complete Blood Count ) CBC (analyze the different components of blood), (Basic Metabolic Panel) BMP (panel of 8 tests that gives important information about the current status of a person's metabolism, including health of the kidneys, blood glucose level (level of sugar in the blood), and electrolyte and acid/base balance) for 2/23/18 . Review of Resident 1's clinical record titled, Progress Notes, dated 2/23/18 at 3:11 a.m., indicated, Change of Condition Note 2 for lethargy, continue on (Intravenous) IV hydration . Review of Resident 1's clinical record titled, Progress Notes, dated, 2/23/18 at 2:37 p.m., indicated,Patient (discharge) d/c today at 1:30 p.m . Review of Resident 1's clinical record titled, Physician Discharge Summary, dated 2/26/18 at 7:25 a.m., indicated Resident 1 was transferred to the assisted living facility in fair condition. On 3/22/18 at 12:50 p.m., during an interview, the Director of Nursing (DON) stated follow-up laboratory tests were not necessary. On 3/22/18 at 1:51 p.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 was only up in the wheelchair for meals and in bed the rest of the time. On 3/22/18 at 2:22 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated she took care of Resident 1 on a regular basis. CNA 1 stated Resident 1 was more oriented and independent when first came in the facility and only required supervision. CNA 1 stated Resident 1 was now weaker, unmotivated and required extensive assistance on the day of discharge. CNA 1 stated she reported to LN 1 that Resident 1 had yellowish skin. CNA 1 stated she was instructed by the Case Manager (CM) to cover up resident 1's intravenous (IV) access site prior to getting a shower that day because, They were not sure if she was going home or not. CNA 1 stated, I had the hardest time to get her up that morning. I had to ask some other CNA to help me get her up . she just looked so tired and weak. CNA 1 stated Resident 1 ate her meals in bed instead of getting up in her wheelchair . On 3/22/18 at 4:05 p.m., during an interview, the Administrator (Admin) stated the IDT decided Resident 1's,Change of condition status the day before discharge was resolved so we went ahead and discharged her. On 6/5/18 at 3:10 p.m., during a telephone interview, the Resident Care Director (RCD) of the ALF stated she evaluated Resident 1 on 2/19/18 at the facility. RCD stated Resident 1 was brought over to ALF by her niece on 2/23/18. The RCD stated Resident 1, Stayed weak and tired from the time she arrived here and got worse when transferred out. On 6/5/18 at 3:10 p.m., during a telephone interview, the Executive Director (ED) of the ALF, stated Resident 1 was weak and requested to eat dinner in her room on her first day at the facility. The ED stated Resident 1's niece and the RCD assisted Resident 1 to get in bed. The ED stated on the following day, Resident 1 felt weak, refused to get out of bed and complained of being tired. The ED stated the morning staff reported to her the difficult time they had with Resident 1's transfer. The ED stated the staff reported their observation of Resident 1's generalized weakness. The ED stated that it was at dinnertime when Resident 1 was slow to respond and her speech was slurred. The ED stated Resident 1 was sent out to the ACH. On 6/12/18 at 2:21 p.m., during a telephone interview, the DON stated there were no follow-up laboratory tests done on 2/23/18. The DON stated the facility did not follow the Care Plan intervention to monitor Resident 1's vital signs and clinical condition for at least 72 hours after the intravenous hydration on 2/22/18. On 6/12/18 at 3:35 p.m., during a telephone interview, the DON stated that she had a discussion with the SSD. The DON stated that the SSD admitted that she overlooked at the discharge order of HH/RN/PT to assess OT need. The DON stated a Home Health visit was not arranged for Resident 1 for continued therapy, and there had not been a referral made to the home health agency as ordered by the MD. On 7/23/18 at 4:10 p.m., during an interview, the ADON stated what should have been done was to delay the discharge until the C[NAME] had resolved, and the labratory (results) were reviewed with the doctor. The ADON stated the lab work order received on 2/22/18 at 4:49 p.m., indicated the MD ordered it to be done after the one liter of IV hydration was given on 2/23/18. The ADON stated LN 1 did not wait for the lab results before infusing the IV solution. On 7/23/18, at 1:12 p.m., during an interview, the DON stated Resident 1's blood samples were drawn on 2/22/18 at 9:30 p.m., during the tenth hour of the intravenous infusion of Normal Saline. The DON stated about 750 milliliter (mL) of the 1,000 mL of Normal Saline had infused when Resident 1's blood samples were drawn. The DON stated the LN that reviewed Resident 1's blood test results on 2/23/18 at 2:45 p.m., failed to report the blood test results to the MD. The DON stated the LN that reviewed the blood test results, learned that Resident 1 was discharged , And her review of the results stopped there. The DON stated, The results should have been called or faxed to the MDs office. The DON stated on 2/22/18, Resident 1's C[NAME] and discharge plans were discussed at the Care Management Meeting attended by the IDT. The DON stated the IDT, Didn't think they needed to meet about Resident 1's change of condition. The DON stated, I would be concern(ed) about the Pulse (P) 54 and blood pressure (BP) 105/75 specially after one liter of IV fluid. The DON stated the 72 hour monitoring on Resident 1's Care Plan was prompted with Resident 1's change in condition and would not hold up the discharge process. On 7/25/18, during a telephone interview, the Medical Doctor (MD) stated his approval of Resident 1's discharge was based on the report of the facility staff that Resident 1's vital signs (clinical measurements) were stable and that Resident 1 perked up after getting one liter of Normal Saline through intravenous as he ordered. The MD stated that he would have had concerns with Resident 1's discharge vital signs if they were reported to him, the slow pulse of 54 beats per minute (BPM) and low blood pressure (bp) of 105/75. The MD stated that he expected the facility to report laboratory (lab) results even when residents were already discharged , more importantly, when the lab results were outside the normal parameters. The MD stated that Resident 1's lab results were not reported to him, otherwise, he would have called the resident, or the resident's Responsible Party (RP-responsible for financial decisions for the resident), or the Home Health Agency, or the resident's Primary Care Physician (PCP), or the Assisted Living Facility and advised to send Resident 1 to ACH for evaluation. The MD stated that Resident 1, Could have had been recalled back to the facility and canceled the discharge. The MD stated With those lab values, I would not have discharged the resident. The MD stated that the lab work was ordered for the day after the infusion of the Normal Saline. The MD stated that he was not aware that his order for Home Health care for Resident 1 was not followed through. On 8/2/18 at 12:43 p.m., during a telephone interview, the PT stated Resident 1's Short Term Goals were revised every week and the Long Term Goal was not revised, carried over from admission to the day of discharge. Review of Resident 1's clinical record from the ACH titled, Emergency Department Note, dated 2/24/18 at 8:08 p.m., indicated . Resident 1 . who presents to the Emergency Department (ED) for evaluation of altered mental status. Patient just moved into ALF yesterday and was noted to be altered today, which staff noted was different than before, Onset of symptoms was unknown.was sating 70% on Room Air (RA) (breathing room air, normal readings range from 95 to 100%), with [MEDICAL CONDITION] Fibrillation (AFib - a quivering or irregular heartbeat) and [MEDICAL CONDITION] (low blood pressure) 105 systolic and Blood Sugar (BS) of 191. Review of Resident 1's clinical record from the ACH titled, Hospitalist Discharge Summary, dated 2/25/18, indicated, admitted : 2/24/18 Date of Expiration: 2/25/19 at 2:16 p.m. Prinicipal Discharge [DIAGNOSES REDACTED]. Potassium is a chemical that is critical to the function of nerve and muscle cells, including the heart), NSTEMI (a type of [MEDICAL CONDITION]), Acute Encepalopathy (sudden malfunction of the brain) . Review of Resident 1's Certificate of Death indicated . date of death [DATE] . Cause of Death: Cardiopulmonary Arrest, Septic Shock, Gram Negative [MEDICAL CONDITION], Acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. The facility policy and procedures titled, Admission, Transfer, Discharge and Bed-Holds, dated (MONTH) (YEAR), indicated, . The facility will provide sufficient preparation and orientation to residents and resident representatives in order to ensure a safe and orderly discharge from the facility.

§ 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Based on interview and record review, the facility staff failed to appropriately act upon a change of condition for one of three sampled residents (Resident 1), and failed to follow Resident 1's care plan when Resident 1 had a change in condition on the day prior to the planned date of discharge; Resident 1 was not given sufficient time before discharge to determine effectiveness of the rehydration therapy given intravenously for critical laboratory values. Resident 1 was discharged to an assisted living facility less than twenty-four hours after the intervention for the change in condition implementation. As a result of this failure, Resident 1 was admitted to the Acute Care Hospital (ACH) within 24 hours of transfer to the assisted living facility (ALF) for altered level of consciousness, dehydration, electrolyte (solutions needed for the normal functioning of the body) abnormalities, urinary tract infection (infection in the system of urine production),[MEDICAL CONDITION] (a life threatening complication of an infection) and [MEDICAL CONDITION] ([MEDICAL CONDITION]- damage to the brain from interruption of its blood supply), and ultimately death. Finding: Review of Resident 1's clinical record titled, Admission Record, dated 3/22/18, indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool for cognitive and functional needs and abilities) assessment, dated 2/20/18, indicated Brief Interview for Mental Status (BIMS - an assessment of memory and recall) score of 11/15 points which indicated Resident 1 had slightly impaired memory and recall. Review of Resident 1's clinical record from the ACH titled, Inter-Facility Report, indicated Resident 1 was independent in toileting, bathing, dressing, eating and required an assistive device with ambulation and transfer. Review of Resident 1's clinical record titled, IDT (Interdisciplinary Team-group of professionals who meet to discuss resident's status) Admission Assessment, dated 2/7/18, indicated Resident 1 was independent with sit to stand; chair/bed-to-chair transfer and able to walk. Review of Resident 1's clinical record titled, MDS assessment, dated 2/20/18, indicated Resident 1 needed extensive assistance with one-person physical assist with bed mobility, transfer, dressing, toilet use and hygiene. Review of Resident 1's clinical record titled, IDT Discharge/Recapitulation of Stay, dated 2/23/17, indicated Resident 1 needed partial/moderate assistance with sit to stand and chair/bed-to-chair transfer, and was unable to walk. Review of Resident 1's Care Plan dated initiated 2/6/18, indicated, Focus Resident had potential risk for fluid volume deficit with interventions labs (laboratory) as ordered for 2/23/18; . monitor vital signs and clinical condition for at least 72 hours and Intravenous (IV) hydrations as needed. Review of Resident 1's clinical record titled, Progress Notes, dated 2/20/18 at 2:09 p.m., indicated . (Laboratory) Lab, X-ray (a photographic or digital image of the internal composition of a part of the body), reviewed: . (Carbon [MEDICATION NAME]-a gas exhaled upon expiration of the air in the lungs) CO2 (Carbon [MEDICATION NAME]) 25 (normal range 21-31); (Blood Urea Nitrogen) BUN (test is done to see how well kidneys are working) 21 (normal range 7-25); (Creatinine) Cr (assess kidney function) 0.7 (normal range 0.6 - 1.3); (White Blood Count) WBC (test to check for infections) 5.1 (normal range 4.0 - 10.0). Review of Resident 1's clinical record titled, Progress Notes, dated 2/21/18 at 2:25 p.m., indicated, Contacted Placement Services stated that Assisted Living in (name of town) is willing to accept patient . Review of Resident 1's clinical record untitled, dated 2/21/18, indicated, .Discharge Assisted Living facility with current medications. (Home Health)HH/(Registered Nurse)RN (Registered Nurse)/(Physical Therapy) PT/PT to assess (Occupational Therapy) OT need. Review of Resident 1's clinical record titled, Progress Notes, dated 2/22/13 at 10:49 a.m., Patient stated she's weak and tired, notified doctor for recommendation of hydration due to verbalization of being lethargic, noted breakfast not eaten or fluids taken, obtain order from the doctor for sodium chloride as ordered . Review of resident 1's clinical record titled, Change in Condition Evaluation, dated 2/22/18 at 3:17 p.m., indicated, Change in condition as lethargy (stuporous) with vital signs (clinical measurements, that indicate the state of a patient's essential body functions) of blood pressure 91/59; pulse 49 irregular . Mental Status Evaluation 2. Decrease level of consciousness . Review of Resident 1's clinical record titled, Progress Notes, dated 2/22/18 at 3:30 p.m., indicated, Patient lethargic in the morning, did not eat breakfast, stated she feels weak and tired. Review of Resident 1's clinical record, untitled, dated 2/22/18 at 11:05 a.m., indicated, .Order Summary: Sodium Chloride Solution 0.9 % (A salt solution used intravenously to rehydrate a dehydrated state) Use 75 (milliliter)mL (Measurement of fluid)/(hour) hr intravenously every shift for 3 administrations x1 liter. Review of Resident 1's clinical record titled, Progress Notes, dated 2/22/18 at 4:49 p.m., indicated, Received Medical Doctor (MD) order for (Complete Blood Count ) CBC (analyze the different components of blood), (Basic Metabolic Panel) BMP (panel of 8 tests that gives important information about the current status of a person's metabolism, including health of the kidneys, blood glucose level, and electrolyte and acid/base balance) for 2/23/18 . Review of Resident 1's clinical record titled, Progress Notes, dated 2/23/18 at 3:11 a.m., indicated, Change of Condition . for lethargy, continue on (Intravenous) IV hydration . Review of Resident 1's clinical record titled, Progress Notes, dated 2/23/18 at 2:37 p.m., indicated, Patient (discharge) d/c today at 1:30 p.m Review of Resident 1's clinical record titled, Lab Results Report, dated .2/23/18 at 8:29 a.m., indicated, Laboratory: 2/23/18 AT 2:45 p.m., Random/Basic Metabolic/CBC W/Diff Reviewed by: LN 7 0n 2/23/18 at 2:45 p.m. Glucose Random (measures the glucose/sugar in the blood), 139 milligram/deciliter (mg/dl-unit of measure) Normal Range: (70-99) High (H) . BUN (Urea Nitrogen) (assesses kidney function) 57 mg/dl (7-25) High (H) Creatinine (assesses kidney function) 3.6 mg/dl (0.6 -1.3) High (H) . WBC (White blood Count) (check for infection) 12.0 x10/s/3/uL (4.0-10.0) High (H) . Review of Resident 1's clinical record titled, Physician Discharge Summary, dated 2/26/18 at 7:25 a.m., indicated Resident 1 was transferred to an ALF in fair condition. On 3/22/18 at 12:50 p.m., during an interview, the Director of Nursing (DON) stated follow-up laboratory tests were not necessary. On 3/22/18 at 1:51 p.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 was only up in the wheelchair for meals and in bed the rest of the times. On 3/22/18 at 2:22 p.m., during an interview, Certified Nursing Assistant (CNA) 1 stated she took care of Resident 1 on a regular basis. CNA 1 stated Resident 1 was more oriented and independent when she first came into the facility and at that time only required supervision. CNA 1 stated Resident 1 was weaker, unmotivated and required extensive assistance on the day of discharge. CNA 1 stated she reported to LN 1 that Resident 1 had yellowish skin. CNA 1 stated she was instructed by the Case Manager (CM) to cover up resident 1's intravenous (IV) access site prior to getting a shower that day because They were not sure if she was going home or not. CNA 1 stated, I had the hardest time to get her up that morning. I had to ask some other CNA to help me get her up . she just looked so tired and weak. CNA 1 stated Resident 1 ate her meals in bed instead of getting up in her wheelchair. CNA 1 stated that Resident 1 was already discharged when she came back from lunch break. On 3/22/18 at 4:05 p.m., during an interview, the Administrator (Admin) stated the IDT decided Resident 1's Change of condition status the day before discharge was resolved so we went ahead and discharged her. On 6/5/18 at 3:10 p.m., during a telephone interview, the Resident Care Director (RCD) of the ALF stated she evaluated Resident 1 on 2/19/18 at the facility. The RCD stated Resident 1 was brought over to the ALF by her niece on 2/23/18. The RCD stated Resident 1 Stayed weak and tired from the time she arrived here and got worse when transferred out. On 6/5/18 at 3:10 p.m., during a telephone interview, the Executive Director (ED) of the ALF, stated Resident 1 was weak and requested to eat dinner in her room on her first day at the facility. The ED stated Resident 1's niece and the RCD assisted Resident 1 to get in bed. The ED stated on the following day, Resident 1 felt weak, refused to get out of bed and complained of being tired. The ED stated the morning staff reported to her the difficult time they had with Resident 1's transfer. The ED stated the staff reported their observation of Resident 1's generalized weakness. The ED stated that it was at dinnertime when Resident 1 was slow to respond and her speech was slurred. The ED stated Resident 1 was sent out to the ACH. On 6/12/18 at 2:21 p.m., during a telephone interview, the DON, stated there were no follow-up laboratory tests done on 2/23/18. The DON stated the facility did not follow the Care Plan intervention to monitor Resident 1's vital signs and clinical condition for at least 72 hours after the intravenous hydration on 2/22/18. On 6/12/18 at 3:35 p.m., during a telephone interview, the DON stated that she had a discussion with the SSD. The DON stated that the SSD admitted that she overlooked the discharge order of HH/RN/PT to assess OT need. The DON stated there was no referral made to a Home Health Agency and no Home Health visit arranged for Resident 1's continued therapy. On 7/23/18 at 1:12 p.m., during an interview, the DON stated the MDS assessment for C[NAME] triggered with a change in resident's level of care and or changes in two of the resident's Activities of Daily Living (ADL). Resident 1 had a change in mental status which was lethargy; decrease in appetite and an increase in assistance needed with ADLs. The DON stated, It (MDS- Change of Condition) should have been triggered. On 7/23/18 at 1:12 p.m., during an interview, the DON stated Resident 1's blood samples were drawn on 2/22/18 at 9:30 p.m., during the tenth hour of the intravenous infusion of Normal Saline. The DON stated about 750 milliliter (mL) of the 1,000 mL of Normal Saline had infused when Resident 1's blood samples were drawn. The DON stated the LN that reviewed Resident 1's blood test results on 2/23/18 at 2:45 p.m., failed to report the blood test results to the MD. The DON stated the LN that reviewed the blood test results, learned that Resident 1 was discharged , And her review of the results stopped there. The DON stated, The results should have been called or faxed to the MD's office. The DON stated the charge nurses check the lab results. The DON stated, I expect the charge nurses to check lab results twice in their shifts. The DON stated new orders and new lab results Pop-up in the licensed staff's computer dashboard - yellow for abnormal values and red for critical values. The DON stated on 2/22/18, Resident 1's C[NAME] and discharge plans were discussed at the Care Management Meeting and the IDT members were present. The DON stated the IDT Didn't think they needed to meet about Resident 1's C[NAME]. The DON stated in reference to Resident 1's discharge vital signs, I would be concern about the Pulse (P) 54 and blood pressure (BP) 105/75 specially after one liter of IV fluid. The DON stated the 72 hour monitoring on Resident 1's Care Plan was prompted with Resident 1's C[NAME] and would not hold up the discharge process. On 7/23/18 at 2:30 p.m., during an interview, LN 2 stated a C[NAME] was when a resident experienced something new. LN 2 stated when there was a C[NAME], she documented her assessments, notified the doctor, carried out any orders, updated the resident's care plan, and reported to the following shift. LN 2 stated the training on C[NAME] was done when she was hired and the DON did inservice on it last year. LN 2 stated the C[NAME] training taught that, Resident should not have any pending labs before discharge, the C[NAME] had been corrected and resident had stabilized. On 7/23/18 at 2:47 p.m., during an interview, LN 3 stated a C[NAME] was when there was a sudden, new onset change on the patient. LN 3 stated when there was a C[NAME], she evaluated the patient, checked vital signs, checked recent labs, notified the doctor and implemented any doctor's orders. LN 3 stated the facility had a C[NAME] form in the electronic documentation system that was generated when a C[NAME] occurred. LN 3 stated the patient's discharge was delayed until the lab results were reported to the doctor. LN 3 stated that she had training on C[NAME] when she was hired. LN 3 stated the training included: how to fill up the C[NAME] form in the computer system and what to report the doctor. On 7/23/18 at 3:16 p.m., during an interview, LN 4 stated C[NAME] were changes in a patient's status, usually unexpected. LN 4 stated when there was a C[NAME], she assessed the patient, notified the doctor, implemented the doctor's orders and notified the Responsible Party (RP-person who takes responsibility for resident decisions and finances). LN 4 stated the C[NAME] Form was generated and the 72 hour monitoring and documentation were initiated. LN 4 stated, The C[NAME] was taught/inserviced on hire by the Director of Staff Development (DSD) and the DON did inservice training Through the year as incidents arise. LN 4 stated, Even if the resident looked better, that's all external, we don't know internally so we still need to wait for the lab results. A resident can perk up after one liter (Normal Saline) but that can be a temporary perk up . On 7/23/18 at 3:33 p.m., during an interview, LN 5 stated a C[NAME] when A patient was having anything abnormal. LN 5 stated when there was a C[NAME], she did an assessment first, then initiated a C[NAME] form, notified the doctor, carried-out the doctor's orders, initiated the 72 hour monitoring and documentation of C[NAME]. LN 5 stated, Do not discharge patient until orders cleared. Definitely hold discharge until lab results come back and reported to doctor. On 7/23/18 at 3:54 p.m., during an interview, LN 6 stated a C[NAME] was any change on the patient's normal. LN 6 stated that when there was a C[NAME], she assessed the patient, notified the doctor, followed the orders and initiated the C[NAME] form and 72 hours monitoring. LN 6 stated that C[NAME] training was done on hire by the DSD. LN 6 stated, No discharge without lab results because that tells you the patient's condition internally. On 7/23/18 at 4:10 p.m., during an interview, the Assistant Director of Nursing (ADON) stated C[NAME] were changes not present on resident's admission. The ADON stated C[NAME] were changes or deviations from the resident's baseline. The ADON stated that when a C[NAME] occurred, the LN gathered information, did assessment, notified the doctor, and notified the family. The ADON stated the LNs were prompted to do the 72 hour monitoring. The ADON stated the DON trained him on hire and an inservice (training) was given When (the) C[NAME] incident happened. The ADON stated, Delay the discharge until C[NAME] resolved, lab reviewed with doctor (MD). The ADON stated the lab work order received on 2/22/18 at 4:49 p.m.,MD ordered it to be done after the one liter of IV hydration to be done on 2/23/18. The ADON stated that LN 1 did not wait for the infusion to finish before obtaining the blood sample for the lab results. On 7/23/18 at 4:49 p.m., during an interview, the DON stated Resident 1's blood samples were drawn on 2/22/18 at 9:30 p.m., during the tenth hour of the intravenous infusion of Normal Saline. The DON stated about 750 milliliter (mL) of the 1,000 mL of Normal Saline had infused when Resident 1's blood samples were drawn. The DON stated the LN that reviewed Resident 1's blood test results on 2/23/18 at 2:45 p.m., failed to report the blood test results to the MD. The DON stated the LN that reviewed the blood test results, learned that Resident 1 was discharged , And her review of the results stopped there. The DON stated, The results should have been called or faxed to the MD's office. The DON stated on 2/22/18, Resident 1's C[NAME] and discharge plans were discussed at the Care Management Meeting and the IDT members were at the meeting.The DON stated the IDT Didn't think they needed to meet about Resident 1's change of condition. The DON stated, I would be concern about the Pulse (P) 54 and blood pressure (BP) 105/75 specially after one liter of IV fluid. The DON stated the 72 hour monitoring on Resident 1's Care Plan was prompted with Resident 1's change in condition, it does not hold up the discharge process. On 7/25/18 at 12:45 p.m., during a telephone interview, the Medical Doctor (MD) stated his approval of Resident 1's discharge was based on the report of the facility staff that Resident 1's vital signs (clinical measurements) were stable and Resident 1 had Perked up after getting one liter of Normal Saline through an IV as he ordered. The MD stated that he would have had concerns with Resident 1's discharge vital signs if they were reported to him, the slow pulse of 54 beats per minute (BPM) and low blood pressure (bp) of 105/75. The MD stated he expected the facility to report the laboratory (lab) results to him even when residents were already discharged , and more importantly, when the lab results were outside the normal parameters. The MD stated Resident 1's lab results were not reported to him, otherwise, he would have called the resident, or the resident's RP, or the HHA, or the resident's Primary Care Physician (PCP), or the ALF and advised to send Resident 1 to the ACH for evaluation. The MD stated tResident 1 Could have had been recalled back to the facility and the discharge cancelled. The MD stated, With those lab values, I would not have discharged the resident. The MD stated the lab work was ordered for the day after the infusion of the Normal Saline. The MD stated that he was not aware that his order for Home Health care for Resident 1 was not followed through. On 8/2/18 at 12:43 p.m., during a telephone interview, the PT stated Resident 1's Short Term Goals were revised every week and Long Term Goal was not revised, carried over from admission to day of discharge. Review of Resident 1's clinical record from the ACH titled, Emergency Department Note, dated 2/24/18 at 8:08 p.m., indicated, . presents to the Emergency Department (ED) for evaluation of altered mental status. Patient just moved into ALF yesterday and was noted to be altered today, which staff noted was different than before, Onset of symptoms was unknown.was sating (the amount of oxygen saturating the blood) 70% on Room Air (RA) (breathing room air, normal readings range from 95 to 100%), with [MEDICAL CONDITION] Fibrillation (AFib - a quivering or irregular heartbeat) and [MEDICAL CONDITION] (low blood pressure) 105 systolic and Blood Sugar (BS) of 191. Review of Resident 1's clinical record from the ACH titled, Hospitalist Discharge Summary, dated 2/25/18, indicated, .Date of Expiration: 2/25/19 at 2:16 p.m. Prinicipal Discharge [DIAGNOSES REDACTED]. Potassium is a chemical that is critical to the function of nerve and muscle cells, including the heart), NSTEMI (a type of [MEDICAL CONDITION]), Acute Encepalopathy (sudden malfunction of the brain) . Review of Resident 1's Certificate of Death indicated . date of death [DATE] . Cause of Death: Cardiopulmonary Arrest, Septic Shock, Gram Negative [MEDICAL CONDITION], Acute [MEDICAL CONDITION] with [MEDICAL CONDITION]. The facility policy and procedures titled, Managing Change of Condition Within PCC (Point Click Care-a software for the computer) dated (MONTH) (YEAR), indicated, . Practise Standards: . 5. Notify the physician of assessment findings and subsequent actions. 7. Document assessmen findings and communications. 8. Report change of condition to DON, ED, and other members of the IDT per facility practise.

Based on interview and record review, the facility failed to ensure medication administered to residents was free of significant errors for one of 20 sampled residents (Resident 36) when Resident 36's physician ordered 7.5 milligrams (mg), (unit of measurement) of [MEDICATION NAME] (a medication which decreases the ability of blood to clot) and Resident 36 was administered [MEDICATION NAME] 12.5 mg. This failure resulted in administration of an incorrect dose of [MEDICATION NAME] to Resident 36 and development of gastrointestinal (GI, pertaining to the stomach and the intestines) bleeding which required transportation to the General Acute Care Hospital (GACH) and transfusion of five units of blood. Findings: Review of Resident 36's clinical record titled, Admission Record (document containing resident personal information) indicated Resident 36 was admitted to the skilled nursing facility (SNF) on 10/26/17 with [DIAGNOSES REDACTED]. Review of Resident 36's clinical record titled Minimum Data Set (MDS, a resident assessment tool used to plan care) dated 11/2/17, indicated Resident 36 had a Brief Interview for Mental Status (BIMS) score of 15 points out of a possible 15 points which indicated he was able to be understood, able to answer questions, knew the day, month and year and had good recall of recent information. On 11/22/17 at 8:55 a.m., during an interview and concurrent record review, the SNF Director of Nursing (DON) reviewed Resident 36's record and stated Resident 36's Medical Doctor (MD) ordered [MEDICATION NAME] 5 mg one time a day on 10/31/17 for prevention of [MEDICAL CONDITION] ([MEDICAL CONDITION], development of a blood clot in a blood vessel). The DON stated the MD ordered blood tests on 10/31/17 to monitor for the safety and effectiveness of the [MEDICATION NAME] dosage. The DON stated the blood tests were ordered to be done every Monday, Wednesday and Friday and included [MEDICATION NAME] time (PT, a blood test used to determine how long it takes the Resident's blood to clot and if the dosage of [MEDICATION NAME] is at a safe and effective level) and International Normalized Ratio (INR, a blood test used to determine the effectiveness and safety of [MEDICATION NAME] therapy). The DON stated Resident 36's MD wanted Resident 36's INR value to stay between 2.0 and 3.0 as an indication of safe and effective [MEDICATION NAME] therapy. The DON reviewed Resident 36's clinical record and indicated the following PT and INR results and medication adjustments: 11/1/17 PT 12.5 INR 1.0 [MEDICATION NAME] increased to 7.5 mg for two days starting 11/2/17 and then resume 5 mg daily 11/3/17 PT 15 INR 1.2 [MEDICATION NAME] 7.5 mg daily then resume 5 mg dose on 11/5/17 11/5/17 [MEDICATION NAME] 5 mg daily 11/6/17 PT 35.7 INR 3.0 [MEDICATION NAME] 7.5 mg daily 11/7/17 [MEDICATION NAME] 7.5 mg daily 11/8/17 PT 94.7 INR 7.9 No [MEDICATION NAME] administered The DON stated on 11/7/17 Licensed Nurse (LN) 1 had not realized [MEDICATION NAME] 5 mg was discontinued and the dosage changed to 7.5 mg daily. The DON stated on 11/7/17 LN 1 gave both the discontinued dosage of 5 mg of [MEDICATION NAME] and the new order for 7.5 mg of [MEDICATION NAME] for a total dose of 12.5 mg of [MEDICATION NAME]. The DON stated the error was discovered by the Assistant Director of Nursing (ADON) during clinical review on 11/8/17. The DON stated Resident 36's MD was notified of the error on 11/8/17 because the extra dose of [MEDICATION NAME] placed Resident 36 at risk for bleeding. The DON stated on 11/9/17 Resident 36 had coffee ground emesis (vomited blood that resembles coffee grounds) and was sent to the GACH for evaluation. The DON stated the medication error occurred for two reasons. The DON stated first reason for the medication error was on 11/6/17 LN 2 transcribed the new order for [MEDICATION NAME] 7.5 mg one time a day but did not discontinue the order for [MEDICATION NAME] 5 mg one time a day. The DON stated LN 2 should have reviewed the record to see if there was a previous [MEDICATION NAME] order, but did not. The DON stated the Medication Administration Record [REDACTED]. The DON stated her expectation was LN 1 should double check the order for [MEDICATION NAME] and question why Resident 36 had two orders for [MEDICATION NAME]. On 11/22/17 at 10:10 a.m., during an interview, the ADON stated the administration of 12.5 mg of [MEDICATION NAME] instead of the ordered 7.5 mg of [MEDICATION NAME] on 11/7/17 was a significant medication error because it placed Resident 36 at high risk for bleeding. The ADON stated adverse outcomes of the excessive dose of [MEDICATION NAME] could include bleeding, [MEDICAL CONDITION], (low blood pressure), weakness and lethargy (feeling very tired). The ADON stated LN 1 should have clarified the [MEDICATION NAME] order with Resident 36's MD because [MEDICATION NAME] 12.5 mg was a very high dose of [MEDICATION NAME]. On 11/22/17 at 10:35 a.m., during an interview, LN 3 stated the extra dose of [MEDICATION NAME] given to Resident 36 on 11/7/17 could have placed Resident 36 at risk for bleeding. LN 3 stated [MEDICATION NAME] administered at the SNF was routinely ordered for 8 p.m. LN 3 stated the [MEDICATION NAME] medication error occurred because there were two orders of [MEDICATION NAME] in place scheduled at different times. LN 3 stated LN 1 should have seen there were two orders for [MEDICATION NAME] and clarified the orders with Resident 36's MD. On 11/22/17 at 11 a.m., during a telephone interview, LN 1 stated on 11/7/17 she administered two doses of [MEDICATION NAME] to Resident 36; [MEDICATION NAME] 5 mg at 4 p.m. and [MEDICATION NAME] 7.5 mg at 8 p.m. LN 1 stated Resident 36 received a total of 12.5 mg of [MEDICATION NAME] on 11/7/17. LN 1 stated on 11/7/17 the Medication Administration Record [REDACTED]. LN 1 stated at 8 p.m. she forgot she gave Resident 36 [MEDICATION NAME] 5 mg at 4 p.m. and she gave Resident 36 [MEDICATION NAME] 7.5 mg. LN 1 stated the extra dose of [MEDICATION NAME] given to Resident 36 on 11/7/17 placed Resident 36 risk for bleeding. LN 1 stated 12.5 mg of [MEDICATION NAME] was a high dose of [MEDICATION NAME]. On 11/22/17 at 11:25 a.m., during a telephone interview, LN 2 stated she received the order for [MEDICATION NAME] 7.5 mg once a day from Resident 36's MD on 11/6/17. LN 2 stated she didn't know there was also an active order for [MEDICATION NAME] 5 mg once a day at 4 p.m. LN 2 stated she transcribed the new order for 7.5 mg of [MEDICATION NAME] but didn't discontinue [MEDICATION NAME] 5 mg scheduled at 4 p.m. LN 2 stated she should have double checked the orders but she didn't. LN 2 stated the extra dose of [MEDICATION NAME] given to Resident 36 placed Resident 36 at risk for bleeding and over dosage of [MEDICATION NAME] could even cause death. On 12/19/17 at 2:15 p.m., during a telephone interview, the SNF Consultant Pharmacist (CP) stated she was informed on 11/6/17 that [MEDICATION NAME] 5 mg was discontinued. The CP stated LN 1 administered two doses of [MEDICATION NAME] on 11/7/17; [MEDICATION NAME] 5 mg at 4 p.m. and [MEDICATION NAME] 7.5 mg at 8 p.m. The CP stated Resident 36 received a total of 12.5 mg of [MEDICATION NAME] on 11/7/17. The CP stated the increased dosage of [MEDICATION NAME] could possibly contribute to bleeding problems. On 12/22/17 at 11 a.m., during a telephone interview, Resident 36's MD stated he ordered [MEDICATION NAME] 7.5 mg on 11/6/17; not both 7.5 mg and 5 mg of [MEDICATION NAME]. The MD stated [MEDICATION NAME] was a blood thinner and increased the risk for bleeding. The MD stated he was informed that [MEDICATION NAME] 5 mg was discontinued on 11/6/17 but LN 1 administered two doses of [MEDICATION NAME] on 11/7/17; [MEDICATION NAME] 5 mg at 4 p.m. and [MEDICATION NAME] 7.5 mg at 8 p.m. Resident 36's clinical record titled, (SNF) - Order Summary Report dated 10/31/17 indicated .PT/INR In House (perform the lab test within the SNF) every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday), For [MEDICATION NAME] Therapy. Keep INR between 2.0 - 3.0. Notify MD if INR is out of therapeutic range . Resident 36's Order Summary Report indicated, [MEDICATION NAME] Tablet 7.5 mg. Give 7.5 mg by mouth on time a day for [MEDICAL CONDITION] prevention. Order date 11/6/17. Start Date 11/6/17. End date 11/8/17. Resident 36's clinical record titled, Progress Notes dated 11/8/17 at 11:30 a.m., indicated, This writer was made aware of current INR taken minutes ago of 7.9. Upon further investigation appears resident received 12.5 mg total of [MEDICATION NAME] on last night shift 11/7/17. MD notified, resident stable. No s/s (signs or symptoms) of bleeding .Orders to hold all [MEDICATION NAME] until INR is within parameter of 2.0 - 3.0. Continue with PT/INR check MWF (Mondays, Wednesdays and Fridays) .Monitor closely for any s/s of bleeding. The progress note was electronically signed by the ADON. Resident 36's Progress Notes dated 11/9/17 at 1:11 a.m. indicated, Patient (Resident 36) noted with coffee ground emesis and hypoxic (low oxygen levels), notified (MD) and obtain order for (MD) for acute transfer for eval (evaluation) and treat (treatment). Resident 36's GACH clinical record titled, (GACH) ED- (Emergency Department) Physician Final Report, dated 11/9/17, indicated .Chief complaint: From (SNF) via (transported by) ambulance .more frequent apnea (breathing stops) periods per staff. Also reported coffee ground emesis prior to transport with possible aspiration (vomit enters the lungs). Pt (Resident 36) takes [MEDICATION NAME], none x (times) 2 days for INR 7.9 .History of Present Illness .Patient (Resident 36) presents with altered mental status. The onset was 1 day ago .The character of symptoms is disoriented (does not know who he is, where he is or what day it is). Baseline status (Resident 36's normal mental status) A&O x 3 (alert and oriented to person, time and place) .INR today elevated greater than 6.7 .Noted melanotic (blood in the stool giving it a tarry appearance) stool . Resident 36's GACH clinical record titled, Admission H&P (History and Physical) dated 1/10/17 at 10:30 a.m., indicated, Chief Complaint: direct admission from SNF, low Hb (hemoglobin, part of the red blood cell that carries oxygen to the tissues of the body, a low result can be an indicator of blood loss, normal range is 14 - 18 mg/dl (milligrams per deciliter, a measurement of the amount of the hemoglobin molecule in a volume of blood)) at 4.8 (mg/dl), INR 7.8, coffee ground emesis, melena (dark sticky feces containing partly digested blood) .History of Present Illness : pt (patient) obtunded (difficult to wake up or obtain any response from) .ED Course: transfusion (blood transfusion) protocol initiated . Vitamin K (medication used to treat over dosage of [MEDICATION NAME]) x 1 dose .Assessment: [MEDICAL CONDITION] (low red blood count) secondary to acute blood loss .Supratherapeutic INR (INR results indicate [MEDICATION NAME] therapy is at a much higher than therapeutic dosage) .Coffee ground emesis .Dispo (Disposition) guarded, remain in ICU (intensive care unit) . Resident 36's GACH clinical record titled, (GACH) History and Physical, dated 11/10/17, indicated .Patient (Resident 36) is 61 y/o (year old) male with h/o (history of) [MEDICAL CONDITION] on HD ([MEDICAL TREATMENT], a treatment to replace the functions of the kidney when kidney failure has occurred) admitted with confusion, melena, emesis. Acute Blood Loss: due to GI bleed .Coagulopathy (disorder of blood clotting) / Supratheraputic INR . Resident 36's GACH clinical record titled, (GACH) Final Report, Endoscopy (a procedure in which an instrument is introduced into the body to obtain a view of its internal parts) dated 11/11/17, indicated .[DIAGNOSES REDACTED] ulcer (a crater-like wound in the lining of part of the small intestine) .Suspect that the ulcer bled primarily because of his being placed on [MEDICATION NAME] and the INR supratherapeutic on admission. Resident 36's GACH clinical record titled, (GACH) Discharge Summary dated 12/1/17 indicated, .Diagnosis .Acute (sudden onset) [DIAGNOSES REDACTED] ulcer with bleeding-patient admitted into ICU and received 5 units of packed red blood cells (transfusion of 5 measured bags of blood) . Review of professional reference, Pagnana, Kathleen. Mosby's Diagnostic and Laboratory Test Reference, ninth edition. St. Louis: Mosby Inc., 2009, indicated, Possible Critical Values: INR: greater than 5.5 .Possible critical values: these values give an indication of results that are well outside the range of normal. These results require physician notification and usually result in some type of intervention. Review of the SNF policy and procedure titled, Medication Administration Operating Guideline dated 12/2013, indicated, 1 .Administer medications using 5 rights, right dosage .Watch for odd orders . The SNF policy and procedure titled, Job Description / Performance Evaluation undated, indicated, Job title LVN/LPN (Licensed Vocational/Practical Nurse) .Takes, transcribes, and carries orders in accordance with professional standards .Clarifies incomplete, unclear, or atypical orders and instructions accordingly .Administers and safely monitors [MEDICATION NAME] Therapy .

Based on observation, staff and resident interview, and clinical record review, the facility failed to ensure seven of seven sampled residents (Residents 4, 6, 3, 2, 7, 1, and 5) were permitted to remain in the facility when the residents were transferred to other skilled nursing facilities (SNF) without medical justification as necessary for resident welfare, needs or safety. These failures displaced residents from their home and caused residents to encounter unnecessary changes in staff, environment and routines. These unnecessary and avoidable changes resulted in the residents feeling emotional distress and sadness. Findings: 1. Review of Resident 4's clinical record face sheet indicated Resident 4 was admitted to SNF 1 on 1/29/07 and resided at the facility until 3/13/15 (8 years) when she was transferred to SNF 2 located 38 miles from SNF 1. Review of Resident 4's Physician Orders dated 3/13/15 indicated, May transfer to (SNF 2) with current orders and treatment. Review of Resident 4's Transfer/Discharge Report dated 3/13/15, had not contained any documentation of the reason for transfer. Resident 4's Interdisciplinary Discharge Summary indicated, Reason for discharge/discharge diagnosis(es) as Transferred to (SNF 2). There was no documented evidence of a rationale for the transfer or of a planned discharge. There was no documented evidence for medical justification for the transfer. On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the Social Services Director (SSD) stated Resident 4's clinical record had not contained documentation which indicated a reason for Resident 4's transfer. The SSD stated no discharge planning care plan had been completed for Resident 4. Review of Resident 4's MDS dated [DATE] indicated, Resident 4's Cognitive Skills for Daily Decision Making were Severely Impaired - never/rarely made decisions. On 5/14/15 at 11:15 a.m., during a telephone interview, Resident 4's Responsible Party (RP) stated Resident 4 had lived at the facility For years. The RP stated Resident 4 was elderly and spoke only Cantonese ( a dialect of Chinese). The RP stated Resident 4 had a large extended family living in the area near SNF 1 and who spoke Cantonese. The RP stated Resident 4's family visited often. The RP stated he had not requested Resident 4 be transferred to SNF 2. The RP stated he received a phone call from the facility on 3/13/15 and was told the facility was getting rid of long term care residents and Resident 4 would be transferred to SNF 2. The RP stated he was not given written notice, advance notice or right to appeal information. The RP stated Resident 4 was transferred later that same day. The RP stated he would have preferred Resident 4 stay at the facility but had not known if that would have been possible. The RP stated family was not able to visit SNF 2 often due to SNF 2's distance away and transportation difficulties. The RP stated he had wanted to visit Resident 4 on Mother's Day but did not have transportation and felt very sad about it. The RP stated he was concerned for Resident 4 not having family and staff speak in Cantonese (at SNF 2) because Resident was used to being spoken to in Cantonese at SNF 1. The RP voiced concern that he could not be there for Resident 1 at SNF 2 as he was at SNF 1 and questioned the reasons for the transfer. On 5/19/15 at 12 p.m., during an interview in SNF 1's conference room, Certified Nursing Assistant (CNA) 1 stated Resident 4 had always eaten meals in the facility dining room. CNA 1 stated Resident 4's RP and other family members visited often and would take home cooked food to the dining room for her. CNA 1 stated Resident 4 could not communicate verbally but would look at her family members and smile. CNA 1 stated, It looked like she was happy to see them. CNA 1 stated the RP and other family members would speak to Resident 4 in her native language and she would attempt to talk back to them. CNA 1 stated, as far as she knew, there was no change in Resident 4's behavior that led to the transfer and believed Resident 4's needs were being met at SNF 1 prior to the transfer. On 5/19/15 at 1 p.m., during an interview in the SNF 1 conference room, CNA 2 stated Resident 4's family visited often. CNA 2 stated the RP and other family members would speak in Resident 4's language and her expression would change; she seemed happy to see her family. CNA 2 stated Resident 4's RP often went to the dining room to help her eat and would bring her home cooked food. CNA 2 stated Resident 4 seemed to enjoy the food brought in by the family. CNA 2 stated Resident 4's needs were being met at SNF 1 and she was unaware of any medical justification for the transfer. On 5/20/15 at 8:30 a.m., during an observation in Resident 4's room at SNF 2, Resident 4 was lying in bed, sleeping. Resident 4 had not responded to a verbal command to open eyes. On 5/20/15 at 8:35 a.m., during an interview in the hallway of SNF 2, CNA 3 stated Resident 4 sleeps a lot. CNA 3 stated Resident 4 ate breakfast and dinner in her room and went to the dining room for lunch. On 5/20/15 at 9:50 a.m., during an interview in SNF 2's Administrator's (Adm) 2 office, Adm 2 stated SNF 2 provided similar services for Resident 4 as SNF 1. On 5/21/15 at 11 a.m., during a telephone interview, Social Services Aid (SSA) 3 stated she had worked as a social services assistant at SNF 1 during March 2015. SSA 3 stated there had been no SSD working at SNF 1 during March 2015. SSA 3 stated she had been shown by SSA 1 how to discharge residents and what paperwork had to be completed. SSA 3 stated she had reviewed clinical records and decided which resident might be a good candidate to transfer. SSA 3 stated she had asked the residents or their RPs if they would like to transfer. SSA 3 stated if the resident or the RP had agreed to the transfer, she completed the paperwork. SSA 3 stated there had not been any assessments done to determine if the transfer was in the best interest of the resident. SSA 3 stated, I ' m not sure what you mean by assessment. I was not instructed (by SSA 1) to do anything like that. 2. Review of Resident 6's clinical record face sheet indicated Resident 6 had been admitted to SNF 1 on 4/16/14 and had resided at the facility until 3/13/15 when he was transferred to SNF 2, 38 miles away. Review of Resident 6's Physician Orders dated 3/13/15 indicated, May transfer to (SNF 2) with current orders and treatment. On 5/5/15 at 11 a.m., during a concurrent interview and record review, the SSD stated the Transfer/Discharge Report did not contain any documentation of reason for transfer. The SSD stated Resident 6's, Interdisciplinary Discharge Summary, was incomplete. On 5/5/15 at 2:15 p.m., during an interview, Resident 6 stated he had been admitted to SNF 2 in March 2015. Resident 6 stated, They (staff at SNF 1) told me all long term people had to leave. Resident 6 stated his Family Member (FM) 1 had contacted SNF 2 and had him transferred back to the facility. Resident 6 stated he wanted to be at SNF 1, not at SNF 2. On 5/6/15 at 8 a.m., during an interview in the facility conference room, FM 1 stated she was Resident 6's only family in the state. FM 1 stated she was the agent Durable Power of Attorney for Healthcare and Power of Attorney for financial matters for Resident 6. FM 1 stated she had visited Resident 6 at SNF 1 frequently since he had been admitted in April 2014. FM 1 stated she (FM 1) had become ill in January 2015 and had been unable to visit until March 2015. FM 1 stated she had gone to visit Resident 6 in March 2015 and found his room empty. FM 1 stated staff at SNF 1 told her he had been transferred to SNF 2. FM 1 stated she had been upset because no one had called to tell her Resident 6 had been transferred. FM 1 stated she had not been given an opportunity to talk with Resident 6 prior to the transfer. FM 1 stated she spoke with one of the SSA's in March and had asked why he had been transferred to SNF 2 without consulting her. FM 1 stated the SSA she had told her she had no right to be notified because Resident 6 was alert and had not requested any family be notified. )FM I was not informed of any medical justification to transfer Resident 6 for his welfare or needs. As far as FM 1 was aware Resident 6's care needs were being adequately and appropriately met by SNF 1. FM 1 stated she had become upset with the response she had been given. FM 1 stated she asked the SSA, How well do you know (Resident 6)? He would agree to do whatever you ask him to do whether he wanted to or not! FM 1 stated she was Resident 6' s emergency contact. FM 1 stated prior to the transfer, SNF 1 had always notified her if Resident 6 had a change in his condition or had needed anything. FM 1 stated SNF 2 was two hours driving time from her home and she would not have been able to visit Resident 6. FM 1 stated she called SNF 2 and spoke with Adm 2. FM 1 stated she had requested Resident 6 return to SNF 1 where she could visit. FM 1 stated, The transfer to (SNF 2) was not right. I'm his only family, the only one to look out for him, and they didn't even call me. Review of Resident 6's clinical record, Advance Health Care Directive, dated 7/11/14, contained Resident 6's witnessed signature that appointed FM 1 as my agent to make health care decisions for me. 3. Review of Resident 3's clinical record face sheet indicated Resident 3 had been admitted to the facility on [DATE] and had resided at the facility until 3/13/15 when he was transferred to another skilled nursing facility (SNF 2) 38 miles away. Review of Resident 3's Physician Orders dated 3/13/15 indicated, May transfer to (SNF 2) with current orders and treatment. Review of Resident 3's Transfer/Discharge Report dated 3/13/15, had not contained any documentation of reason for transfer. Resident 3's Interdisciplinary Discharge Summary contained no documentation of Reason for discharge/discharge diagnosis(es). On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the Social Services Director (SSD) stated Resident 3's clinical record contained no documented evidence of a social services note or nursing progress note that indicated a reason for Resident 3's transfer. SSD stated no discharge planning care plan had been completed for Resident 3. On 5/20/15 at 9:35 a.m., during a concurrent observation and interview in Resident 3's room in SNF 2, Resident 3 was sitting in a wheelchair watching television. Resident 3 stated he had not requested to transfer to SNF 2. Resident 3 stated a female staff member had gone into his room at SNF 1 on 3/13/15 and told him there was a room available at SNF 2. Resident 3 stated he had not requested to transfer but had agreed to move. Resident 3 stated the staff at SNF 1 packed his belongings and moved him within about two hours of informing him of the possible transfer. Resident 3 stated he had not had enough time prior to the transfer to call his family to tell them of the transfer or where he was going. Resident 3 stated his only child lived over 38 miles away from SNF 2 and would not be able to visit him due to a lack of transportation. Resident 3 stated, The bad part is I miss my daughter. She can't get here. Resident 3 stated he was unaware of any medical justification for the transfer and stated SNF 1 was providing for his needs in a satisfactory manner; he had no complaints on. 4. Review of Resident 2's clinical record face sheet indicated Resident 2 had been admitted to SNF 1 on 5/5/13 and had resided at the facility until 3/13/15 when she was transferred to SNF 2, 38 miles away. Review of Resident 2's Physician Orders dated 3/13/15 indicated, May transfer to (SNF 2) with current orders and treatment. Review of Resident 2's Transfer/Discharge Report dated 3/13/15, did not contain documentation of reason for transfer. Resident 2's Interdisciplinary Discharge Summary contained no documentation of Reason for discharge/discharge diagnosis(es). On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the Social Services Director (SSD) stated Resident 2's clinical record had no documented evidence of a social services note or a nursing progress note that indicated a reason for Resident 2's transfer. SSD stated No discharge planning care plan had been completed for Resident 2. On 5/20/15 at 8:45 a.m., during a concurrent observation and interview in Resident 2's room at SNF 2, Resident 2 was sitting up in bed eating breakfast. Resident 2 stated she remembered being transferred to SNF 2. Resident 2 stated one morning a female employee had come to her in SNF 1 very excited and told her there was a bed available at SNF 2 and had stated it was a very nice place. Resident 2 stated she had not known anything about SNF 2. Resident 2 stated the employee told her she had to decide very quickly, within 15 minutes, if she wanted to transfer to SNF 2. Resident 2 stated it hadn't been her idea to transfer to SNF 2 but she had agreed to try it. Resident 2 stated the facility staff at SNF 1 packed her belongings immediately and within a couple of hours she was placed in the facility van with other residents and on her way to SNF 2. Resident 2 stated, It was very fast! So quick I did not have time to call my friends to tell them I was leaving or where I was going. Resident 2 stated she had not had any visits from her friends since moving to SNF 2. Resident 2 stated she spoke with SSA 2 at SNF 2 to request returning to her previous skilled nursing facility. Resident 2 was unaware of any medical justification for the transfer and stated SNF 1 was providing for her needs in a satisfactory manner; she had no complaints on her care and would have preferred to be permitted to stay at SNF 1. On 5/20/15 at 10 a.m., during an interview in the SNF 2 conference room, SSA 2 stated Resident 2 approached her on 5/19/15, two months after transfer to SNF 2, and had requested to return to SNF 1. SSA 2 stated Resident 2 had wanted to return to the area where her friends and her primary doctor resided. On 5/21/15 at 2:35 p.m., during a telephone interview, Resident 2's Geriatric Psychiatry Consultant (GPC) stated he had visited Resident 2 in the early morning hours of 5/20/15. The GPC stated the visit was scheduled at the request of (SNF 2)'s staff who reported Resident 2 had been generally upset. The GPC stated Resident 2 had discussed her desire to return to SNF 1 during the visit. The GPC stated a move had likely been distressing for Resident 2 due to her age and diagnosis. The GPC stated, She is not a person who makes close attachments easily. 5. Review of Resident 7's clinical record indicated Resident 7 was admitted to SNF 1 on 12/5/13 and had resided in the facility until 3/17/15 when she was transferred to another skilled nursing facility (SNF 2) 38 miles away. Review of Resident 7's physician's orders [REDACTED]. Review of Resident 7's Transfer/Discharge Report dated March 17, 2015, indicated Resident 7 was transferred on 3/17/15 with the reason for transfer documented, Transfer to (SNF 2). Review of Resident 7's Social Service Progress Note dated 3/16/15 indicated, Spoke with resident about possible transfer to (SNF 2). Resident is agreeing to transfer at this time. Review of Resident 7's Minimum Data Set Assessment, dated 2/19/15 indicated a brief interview for mental status (BIMS) score of 3 (on a scale of 0 to 15 with 15 indicating cognitively intact and a score below 7 indicated severe cognitive impairment). On 5/14/15 at 12 p.m., during a telephone interview, Resident Friend (RF) 1 stated she was a longtime friend of Resident 7. RF 1 stated she had visited Resident 7 two to three times per week at SNF 1. RF 1 stated she had gone to SNF 1 to visit Resident 7 one day in March and Resident 7 was gone. RF 1 stated she had just taken clean clothes to Resident 7 two days before and no one had said anything about a transfer at that time. RF 1 stated Resident 7 had completed a Durable Power of Attorney for Healthcare in the past naming her (RF 1) as the agent to speak for her in the event she became unable to speak for herself. RF 1 stated she had been upset the facility had not called her prior to the transfer. RF 1 stated she talked to a SSA at SNF 1 and was told the SSA could not find any Durable Power of Attorney for Healthcare with her name on it and therefore they did not have to notify her or explain the transfer to her. RF 1 stated, For some reason once (Resident 7) got to (SNF 2), the Durable Power of Attorney for Healthcare turned up. Now they (SNF 2 staff) call me to sign consents. RF 1 stated she was not able to visit Resident 7 very often at SNF 2 due to health issues and the expense of traveling to SNF 2. RF 1 stated when she had visited, shortly after the transfer, Resident 7 did not seem to understand why she had been transferred. RF 1 stated, They just sent her. There was no warning. She was not prepared. RF 1 stated she was unaware of any medical justification for the transfer and as far as she was aware, Resident 7's needs were being met at SNF 1. On 5/20/15 at 12:05 p.m., during a concurrent observation and interview in the dining room at SNF 2, Resident 7 sat in a wheelchair at a dining table with three ladies, waiting for lunch to be served. When asked, Resident 7 was unable to state the name of the facility where she currently resided. When asked how she arrived at the facility, Resident 7 moved her legs back and forth and stated, I walked. When asked in what city the facility was located, Resident 7 looked at her tablemates and asked, Any of you girls know what city this is? Resident 7 stated she had lived at SNF 2 for a couple of hours. Review of Resident 7's clinical record, Social Service Assessment at SNF 2 dated 3/23/15, indicated, Resident reported trouble sleeping and feeling tired at times due to new environment. Review of Resident 7's clinical record, Care Plan from SNF 2, dated 5/1/15 indicated, The resident has a psychosocial well-being problem r/t (related to) risk for isolation, risks of frustration as resident having episodes of perceiving current routine is very different from prior patterns. Review of Resident 7's clinical record, Care Plan from SNF 2, dated 5/4/15, indicated, The resident has depression r/t verbalizing depression and frustration upon admission to facility. Resident had difficulties adjusting to environment and verbalized, Things just aren't going right for me. Review of Resident 7's clinical record, Power of Attorney for Healthcare dated 12/5/14 contained documentation of Resident 7's notarized signature that appointed RF 1 as my agent to make health care decisions for me. 6. Review of Resident 1's clinical record indicated Resident 1 was admitted to skilled nursing facility (SNF) 1 on 9/14/2004 and had resided in the facility until 3/27/15 when she was transferred to another skilled nursing facility (SNF 2) located 38 miles away. Review of Resident 1's physician's orders [REDACTED]. Review of Resident 1's Transfer/Discharge Report dated 3/27/15, (a report to be completed by the facility and the resident's physician upon transfer or discharge from the facility) indicated Resident 1 was transferred on 3/27/15 with the reason for transfer documented, Res transferred to (SNF 2). Review of Resident 1's Interdisciplinary Discharge Summary (form completed by the facility resident care team including social services, nursing, dietary, activities and therapy) contained no entry for Reason for discharge/discharge diagnosis(es). On 4/28/15 at 10:55 a.m., during an interview in the facility conference room, the Administrator (Adm) 1 stated Resident 1 did not have any family who participated in her care. Adm 1 stated the facility's interdisciplinary team (IDT) was Resident 1's responsible party and could make healthcare decisions. On 4/28/15 at 11:10 a.m., during an interview in the facility conference room, Social Service Assistant (SSA) 1 stated Resident 1 was transferred to (SNF 2) on 3/27/15. SSA 1 stated the purpose of Resident 1's transfer was to free up more space for short term care residents. SSA 1 stated the facility was focusing on admitting more residents from the acute care setting who needed short term rehabilitation. SSA 1 stated Resident 1 had been asked if it was ok to transfer her and she said it was. Review of Resident 1's Minimum Data Set (a resident assessment tool to identify resident care problems) assessment, dated 3/27/15 included a brief interview for mental status (BIMS) score of 0 (on a scale of 0 to 15) a score of 15 indicated no cognitive deficits and scores below 7 indicated severe cognitive impairment. Review of Resident 1's Physician Orders dated March 2015 indicated, MD (medical doctor) determine that Resident does NOT have the Mental Capacity to make healthcare decisions. On 4/28/15 at 2:30 p.m., during an interview in the hallway at SNF 1, licensed nurse (LN) 1 stated Resident 1 was unable to verbalize needs but staff could sometimes figure out what she needed by her expressions and gestures. LN 1 stated she did not think Resident 1 understood she was being transferred to another facility on 3/27/15 when she left in the facility van. On 4/29/15 at 9:20 a.m., during an observation in Resident 1's room at SNF 2, Resident 1 was sitting in a wheelchair. Resident 1's room contained a dollhouse size firehouse, two Barbie dolls, a fireman's hat, 2 toy firetrucks and several boxes stacked against the wall. Resident 1 stated, fireman and pointed at the toy firehouse. Resident 1 stated baby and produced a photo album with family pictures. Resident 1 nodded her head or responded yes to questions but was unable to respond in complete sentences. On 4/29/15 at 1 p.m., during an interview in the facility conference room, Adm 1 stated Resident 1 had not experienced any change of condition which would have necessitated a transfer from the facility. The Adm stated the facility IDT had not met to assess the Resident ' s needs before the resident had been transferred to the receiving SNF. The Adm stated there was no documented assessment, discharge care plan, or IDT note, which would have indicated the transfer was in the best interest of Resident 1. 7. Review of Resident 5's clinical record face sheet indicated Resident 5 had been admitted to the facility on [DATE] and had resided at the facility until 3/17/15 when she was transferred to another skilled nursing facility (SNF 3) 35 miles away. Review of Resident 5's Physician Orders dated 3/17/15 indicated, May transfer to (SNF 3) with current orders and treatment. Review of Resident 5's Transfer/Discharge Report dated 3/17/15, had not contained any documentation of reason for transfer. Resident 5's, Interdisciplinary Discharge Summary indicated, Reason for discharge/discharge diagnosis(es) as Transferred to (SNF 2). On 5/19/15 at 9 a.m., during a concurrent interview and clinical record review, the Social Services Director (SSD) stated Resident 5's clinical record contained no documented evidence which indicated a reason for Resident 5's transfer had been determined. SSD stated no discharge planning care plan had been completed for Resident 5. Review of Resident 5's Social Service Progress Note dated 3/12/15 indicated, Spoke with Resident regarding transfer to (SNF 3). Resident agreed to transfer to (SNF 3). Referral sent to (SNF 3). Review of Resident 5's Minimum Data Set ( a resident assessment tool to identify resident care problems) dated 3/24/15 included a brief interview for mental status (BIMS) score of 5 (on a scale of 0 to 15). A score of 15 indicated no cognitive deficits. A score below 7 indicated severe cognitive impairment. On 5/20/15 at 1:25 p.m., during an interview in the Director of Nurse's (DON) office at SNF 3, Resident 5 sat in a wheelchair. Resident 5 stated she had been at (SNF 3) for a long time. Resident 5 stated she did not know why she was there, how she got there or where she was. On 5/21/15 at 2:35 p.m., during a telephone interview, Resident 5's Geriatric Psychiatry Consultant (GPC) stated he had met with Resident 5 on April 8, 2015. The GPC stated he would not consider Resident 5 able to make good decisions regarding her own healthcare. On 5/8/15 at 2:25 p.m., during an interview in the SNF 1 conference room, the Facility Medical Director (FMD) stated he had not been made aware seven long term care residents had transferred out of SNF 1 in March 2015. The FMD stated the transfers had not been discussed at the Quality Assurance Committee Meetings (committee of facility personnel that identify problems and seek solutions). On 5/19/15 at 3:25 p.m., during a telephone interview, Medical Doctor (MD) 1 stated he had been the physician for Residents 1, 3, 4 and 7. MD 1 stated SNF 1 had sent a request for those residents to be transferred to another facility. MD 1 stated he had not attended any discharge planning meetings for Resident 1, 3, 4, or 7. MD 1 stated it was the responsibility of the facility to determine if a transfer was in the resident's best interest. MD 1 stated Residents 1, 3, 4 and 7 had been stable. MD 1 stated he had not been aware of any reason to deny the request to transfer. On 5/22/15 at 12 p.m., during an interview in the SNF 1 conference room, Adm 1 stated none of the residents (Resident 1, 2, 3, 4, 5, 6, or 7) had requested to transfer to another SNF. Adm 1 stated she had received a call in March 2015 from the Regional Director of Operations who had stated there were open long term care beds at another facility and if any resident wanted to transfer there were beds available. Adm 1 stated she had contacted the SNF 1 social services department to interview residents at SNF 1 to determine if any resident was interested in a transfer. Adm 1 stated there was no SSD employed at SNF 1 in March 2015. Adm 1 stated she had instructed two SSAs (SSA 1 and SSA 3) to speak with residents who were alert and oriented and could make their own decisions to determine if they were interested in a transfer. Adm 1 stated none of the residents (Residents 1, 2, 3, 4, 5, 6, or 7) had any condition that required transfer. Adm 1 stated, We offered the transfers. Adm 1 stated there had not been any care conferences or discharge planning meetings to determine if the transfers would meet the needs of Residents 1, 2, 3, 4, 5, 6 or 7. Adm 1 stated the two SSAs who arranged the transfers for the residents had not received adequate training to transfer residents appropriately. Adm 1 stated she should have provided oversight and supervised the SSAs in the absence of a Social Services Director.

Based on observation, interview, clinical record and administrative document review, the facility failed to ensure it was free of significant medication errors for three of seven sampled residents (Resident 1, Resident 2 and Resident 4), when multiple medications were not available and administered for multiple days and times as ordered by the physician; and seven of seven sampled Residents missed one or more doses of medications ordered. These failures had the potential to result in decreased therapeutic effect of medications and serious harm or death for Residents 1, 2 and 3 and potential medical complications [REDACTED]. Findings: 1. Review of Resident 1's clinical record indicated the Resident 1 was admitted to the facility on [DATE] with a medical history that included diffuse (to disburse) non-Hodgkin [MEDICAL CONDITION] of the brain (a type [MEDICAL CONDITION]), left frontal craniotomy (incision into the bones of the skull), [MEDICAL CONDITIONS], [MEDICATION NAME] encephalitis (inflammation of the brain as a result of a [MEDICAL CONDITION] infection) with [MEDICAL CONDITION] (convulsions), pneumonia (inflammation of the lung) with aspiration (food or fluid entering the lungs), [MEDICAL CONDITION] ophthalmicus (a [MEDICAL CONDITION] infection of the eye), gastroesphogeal reflux (return of acids from the stomach to the throat causing heart burn) and [MEDICAL CONDITION] (an irregular heartbeat.) Resident 1's admitting physician orders [REDACTED]. a. [MEDICATION NAME] (medication to treat/control [MEDICAL CONDITION] disorders) 1 milligram (mg) tablet to be administered once daily at bedtime. The order indicated a [DIAGNOSES REDACTED]. b. trifuridine 1% (percent) eye drops (medication to treat [MEDICAL CONDITION] infection), instillation of 1 drop by ophthalmic (eye) route every two hours daily for a [DIAGNOSES REDACTED]. Review of Resident 1's medication administration records (MARs) dated February 2015, March 2015, and April 2015, indicated medications were not given as ordered and contained documentation there was a medication availability issue of the medications as follows: a. [MEDICATION NAME] 1 mg. on 2/28/15 and 3/1/15. b. trifuridine 1% eye drops were not administered on 2/28/15, 3/1/15, and 3/2/15. On 3/18/15, 3/19/15, 4/25/15, 4/26/15, 4/27/15 and 4/28/15; and other multiple doses (39) were missed at varied times. Review of Resident 1's physician order [REDACTED]. Review of Resident 1's MARs dated March 2015 and April 2015 indicated Resident 1 had not received [MEDICATION NAME] as ordered on 3/3, 3/4, 3/5, 3/6, 3/7, 3/8, 3/10, 3/11, 3/12, 3/13, 3/16, 3/17, 3/19, 3/20, 3/21, 3/22, 3/23, 3/24, 3/25, 3/26, 3/27, 3/28, 3/29, 3/30, 3/31, 4/5, 4/6, 4/7, 4/10, and 4/30/15 (30 missed doses). Review of Resident 1's physician orders [REDACTED]. a. [MEDICATION NAME] 10 mg/ml (milliliters) oral solution, 17.5 ml, 175 mg was to be administered through the PEG tube every 12 hours for a [DIAGNOSES REDACTED]. Review of Resident 1's untimed, Nurse's Progress Note and Care Plan, dated, 3/15/15 indicated, Pt (patient) did not receive pm (7 pm) dose of [MEDICATION NAME]. Dtr (daughter) very concerned and wanted med given ASAP. Call to (pharmacy) and asked for stat (immediate) bottle of med. Advised med will arrive by 10-1030 am.(next day). Dtr said that if mother did not get dose by 12 noon she would take her mother to the ER (emergency room ).Dose given to pt at 1140 am. Review of Resident 1's MAR dated March 2015 indicated the resident had not received [MEDICATION NAME] 175 mg on 3/11/15 at 7 p.m., 3/14/15 at 7 p.m., and on 3/15/15 at 7 a.m. b. Review of Resident 1's physician orders [REDACTED]. Review of Resident 1's MAR dated April 2015 indicated [MEDICATION NAME]-quaifenesin 30/600 mg extended release had not been given every 12 hours as ordered on 4/25, 4/26, 4/28, 4/29, or 4/30 (10 missed doses). c. Resident 1's physician orders [REDACTED]. Review of Resident 1's MARs dated April 2015 and May 2015 indicated [MEDICATION NAME] 2.5 mg was not administered on 4/30 and 5/1(2015). On 5/5/15 at 11:40 a.m., during an interview in the hallway while at the medication cart, LN 5 stated medication availability was a problem in the facility. On 5/6/15 at 2 p.m., during a concurrent interview and clinical record review in the facility conference room, licensed nurse (LN) 1 stated she was one of the regular medication administration nurses in the facility. LN 1 reviewed Resident 1's MAR for February, March, April and May 2015. LN 1 identified her initials as documented on Resident 1's MAR for February, March and April 2015. LN 1 stated Resident 1's MAR contained many asterisks (*) printed in the box marked for time of administration for the months of February, March, April and May 2015. LN 1 stated an asterisk in those boxes indicated the medication had not been administered as ordered during that scheduled time. Review of Resident 1's MARs indicated in the upper right hand corner of each page, Legend .* not administered (See last section). LN 1 stated if a medication was not given, nurses should have documented the reason the medication was not given on the last section of the MAR. LN 1 verified Resident 1 had medications including [MEDICATION NAME], [MEDICATION NAME]-quaifenesin, and [MEDICATION NAME] that had not been administered on multiple dates and times as ordered by the physician. LN 1 stated the last section of the MAR indicated the medications had not been given to Resident 1 due to medication availability issues. LN 1 stated medication availability issue meant the medication was not in the medication cart and therefore was not given. LN 1 acknowledged her initials followed by an * on multiple boxes on the MARs for the time of administration for [MEDICATION NAME] in March and April 2015. LN 1 verified many doses of [MEDICATION NAME] had not been administered due to medication availability issues. LN 1 stated she did not know why the medication had not been given for 30 days and not reported to the physician and addressed with the pharmacy. LN 1 stated she should have notified Resident 1's physician the medication had not been administered for each dose that had been missed. On 5/6/15 at 3 p.m., during an interview and concurrent clinical record review in the facility conference room, LN 6 stated she was one of the regular medication nurses in the facility. LN 6 reviewed Resident 1's MAR dated March 2015 and identified her initials as the initials documented on the MAR. LN 6 acknowledged her initials followed by an * for 3/18/15 and 3/19/15 in the time of administration box on the document for [MEDICATION NAME] eye drops. There was no documentation the eye drops had been administered. LN 6 stated the * indicated she had not administered the eye drops on 3/18/15 and 3/19/15. LN 6 stated the last section of the MAR indicated the reason the eye drops were not administered was medication availability issue. LN 6 stated the bottle of eye drops was sometimes empty and staff did not reorder them on time. LN 6 stated she had not notified Resident 1's physician the eye drops had not been given but stated she should have. On 5/6/15 at 3 p.m., during an interview at the nurse's station, LN 6 stated medications were sometimes not available due to staff not reordering on time, especially after a weekend. LN 6 stated, Monday I was missing a lot of my meds and I told the DON. LN 6 stated not any one nurse was responsible for ordering medications; any nurse on any shift could order and reorder medications. LN 6 stated, We do run short (of medications) due to people not reordering. LN 6 stated she was not really sure when medications should be reordered. LN 6 stated she thought medications should be reordered when there was a three day supply left on the medication cart in order to receive the refill on time. LN 6 stated she was not sure how to tell if a medication had been reordered by the previous shift. Review of facility's contracted pharmacy policy titled, On Demand Medication Dispensing System, dated 2013 indicated, 3. Facility should submit reorders for on-demand systems when at least seventy-two (72) hours of supply remain. Review of the facility's contracted pharmacy policy titled, 7.0 Medication Shortages/unavailable Medications, dated 2013 indicated: Procedure:.6. If the medication is unavailable from Pharmacy due to formulary coverage.or other clinical reason, Facility should collaborate with Pharmacy and Physician/Prescriber to determine a suitable therapeutic alternative. 7. If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for orders/direction. 8. When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MAR or TAR (treatment administration record), and in the nurse's notes per Facility policy. Such documentation should include the following information: 8.1 A description of the circumstances of the medication shortage; 8.2 A description of Pharmacy's response upon notification; and 8.3 Action (s) taken. On 5/6/15 at 5:20 p.m., Immediate Jeopardy was called with the facility Administrator, the Director of Nursing and the Regional Director of Clinical Operations present. Resident 1 had not received multiple significant medications on multiple dates and times to treat serious medical conditions due to medications not available for adminisration as prescribed by the physician. Licensed staff had not intervened in Resident 1's behalf to obtain the ordered medications or to obtain further guidance from the physician. The facility failed to implement a process to ensure the medications were available to administer as ordered by the physician. There was a reasonable degree of predictability that a similar situation could occur without corrective action. 2. Review of Resident 2's clinical record titled, Nurses Note dated 4/18/15, indicated, Resident 2 was admitted to the facility from the acute care hospital on [DATE]. Resident 2's face sheet (document with admittance information) indicated a [DIAGNOSES REDACTED]. depression. Resident 2's admission history and physical examination [REDACTED]. Review of Resident 2's inter-facility transfer orders by the physician dated 4/18/15 indicated the following orders: a. [MEDICATION NAME] (an antibiotic to treat infection [MEDICAL CONDITION]) 1 g/50 ml (1 gram diluted in 50 ml of IV fluid) by Intravenous route was to be administered every 4 hours for the [DIAGNOSES REDACTED]. The order indicated the IV [MEDICATION NAME] was to be stopped on 5/13/15. b. [MEDICATION NAME] (medication to treat irregular heartbeat) 200 mg, one tablet was to be taken by mouth twice daily. c. [MEDICATION NAME] CD (Controlled dose)(medication to treat high blood pressure) 120 mg, a 24 hour capsule was to be taken by mouth daily. d. [MEDICATION NAME] Diskus (to treat chronic breathing difficulty) 250 mcg (micrograms)/50 mcg oral inhaler, to be administered by inhalation twice daily. e. beclomethasone (a steroid used to treat asthma) 40 mcg oral inhaler to be administered 1 puff by mouth twice daily. f. [MEDICATION NAME] (medication to treat depression) 15 mg tablet to be given by mouth daily. aa. On 5/6/15 at 6 p.m. during an observation and concurrent interview, Resident 2 was sitting in his room at the side of the bed, fully dressed in street clothes. Resident 2 stated he would rather be at home than in the facility. Review of Resident 2's MAR dated April 2015 indicated the doses of IV administered [MEDICATION NAME] had been administered until 4/22/15 at 2 a.m., and stopped on that date rather than the date as prescribed by the physician (5/13/15). The MAR indicated the [MEDICATION NAME] doses had been restarted on 4/27/15 at 7 p.m. The time period between 4/22/15 and 4/27/15 resulted in multiple missed doses over a six day span for a total of 33 missed doses. On 5/13/15 at 11:35 a.m., during an interview, LN 2 stated she noticed an error on 4/27/15 had been made when the [MEDICATION NAME] had been transcribed from the electronic medical record and the order sent to the pharmacy. LN 2 stated she notified the resident's cardiologist (heart specialist) who had reordered the [MEDICATION NAME] to supply the complete number of doses originally ordered. LN 2 stated the resident was not discharged home on the date as planned because he needed the remaining doses of [MEDICATION NAME] to treat the Bacteremia and would need to reside in the facility additional days to complete the course of IV therapy as ordered by the physician. On 5/14/15 at 11 a.m., during an interview, LN 3 stated she had incorrectly transcribed the [MEDICATION NAME] order from the transfer order to the electronic medical record, and notified the pharmacy. LN 3 stated, I made a mistake. LN 3 was unable to explain how the order had been transcribed to the electronic health record as three days instead of four weeks. On 5/14/15 at 2:25 p.m., during a telephone interview, physician (MD) 2 stated he had been notified Resident 2 had missed some doses of [MEDICATION NAME] but was not aware that it had been as many as 33 doses. MD 2 stated the first ten days to two weeks of antibiotic therapy was a crucial period of time in order to ensure adequate treatment. MD 2 stated the risk of not receiving IV [MEDICATION NAME] could include serious consequences such as blood clots that travel to the heart or lungs and risk of infection. Review of Resident 2's MARs dated April and May 2015 indicated the following additional medications had not been administered as ordered due to the medications not being available: b. [MEDICATION NAME] 200 mg 4/18/15 at 4 p.m., 5/4/15 at 4 p.m., and 5/5/15 at 8 a.m. c. [MEDICATION NAME] CD 120 mg on 5/5/15 at 8 a.m. d. [MEDICATION NAME] Discus 250/50 mcg on 4/18/15 at 6 p.m. e. beclomethasone 40 mcg on 4/18/15 at 8 p.m. f. [MEDICATION NAME] 15 mg on 4/18/15 at 8 p.m. On 5/6/15 during an interview at the nurse's station, LN 2 stated there had been medication availability issues for Resident 2 on 5/4/15 and 5/5/15 because the medications had not been ordered in time to be received with the routine pharmacy delivery time. LN 2 stated Resident 2 had not received the medications as indicated on the April and May MARs. LN 2 stated any licensed nurse could order the medications from pharmacy and no one nurse was specifically responsible. LN 2 stated the physician should have been notified the medications had not been given as ordered. LN 2 stated there was no documentation in Resident 2's clinical record the physician had been notified. 3. Review of Resident 4's clinical record face sheet indicated the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 4's physician orders [REDACTED]. a. [MEDICATION NAME] (medication to prevent and control [MEDICAL CONDITION]) 100 mg tablet was to be given by mouth 2 times per day. Review of Resident 4's MAR dated April 2015, indicated the [MEDICATION NAME] 100 mg tablet had not been given for three consecutive doses on the following days: 4/18/15 - 8 a.m. due to medication availability issue, 4/18/15 - 4 p.m. due to delivery pending, 4/19/15 - 8 a.m. due to called pharmacy to contact MD. Review of Resident 4's clinical record indicated a change of condition form was completed on 4/24/15 at 8:35 a.m. which indicated Resident 4 was transferred to the acute care hospital by ambulance for unresponsiveness, foaming from the mouth. Review of the acute hospital emergency department triage form dated 4/24/15 at 9:13 a.m., indicated Resident 4 was treated in the emergency department for [MEDICAL CONDITION] and transferred back to the facility. 4. Review of Resident 3's clinical record face sheet indicated the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 3's physician orders [REDACTED]. On 5/6/15 at 6 p.m., during a concurrent interview and clinical record review, LN 7 stated Resident 3's MAR dated April 2015 indicated the [MEDICATION NAME]/[MEDICATION NAME] had not been administered to Resident 3 as ordered by the physician on 4/20/15 and 4/21/15 due to medication availability issues. Review of Resident 3's MAR dated April 2015, indicated on the document, [MEDICATION NAME]/[MEDICATION NAME] had not been given on the following days and times due to medication availability issues: 4/20/15 at 12 p.m., 4 p.m., and 8 p.m; and 4/21/15 at 8 a.m., 12 p.m., and 4 p.m. (Six consecutive doses). 5. Review of Resident 5's clinical record face sheet indicated Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 5's physician orders [REDACTED]. Review of Resident 5's MAR dated May 2015 indicated Resident 5 resident had not received the ordered [MEDICATION NAME] on 5/3/15 at 8 p.m. due to medication was not available and the MAR indicated, awaiting pharmacy. On 5/7/15 at 1:40 p.m., during a concurrent observation and interview, Resident 5 was laying on top of the bed, fully dressed in street clothes, wearing a nasal oxygen cannula (pronged tubing placed into the nares for the delivery of supplemental oxygen). Resident 5 was alert and answered questions appropriately. Resident 5 stated she had not received [MEDICATION NAME] on the day she was admitted to the facility. On 5/7/15 at 2:15 p.m., during a concurrent interview and clinical record review at the nurses' station, LN 4 stated Resident 5's MAR dated May 2015 indicated Resident 5 had not received [MEDICATION NAME] on 5/3/15 as ordered. 6. Review of Resident 6's clinical record face sheet indicated Resident 6 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 6's physician orders [REDACTED]. Review of Resident 6's MAR, dated May 2015, indicated [MEDICATION NAME] 25 mg tablet was not available to administer on 5/4/15 at 4 p.m. due to awaiting pharmacy. On 5/7/15 at 10:30 a.m., during an interview at the nurse's station, LN 2 stated the [MEDICATION NAME] order for Resident 6 was written by the physician at 10 a.m. on 5/4/15. LN 2 stated the order was not submitted to the pharmacy until 3:28 p.m. LN 2 stated the order should have been submitted to the pharmacy sooner in order to obtain the 4 p.m. dose of medication for the resident. LN 2 stated the medication nurse should have notified Resident 6's physician the medication was not available in order to determine if the physician wanted the medication to be given later that same day or when the next pharmacy delivery would occur at 8 p.m. 7. Review of Resident 7's clinical record face sheet indicated Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 7's physician orders [REDACTED]. [MEDICATION NAME] (medication to treat nerve pain often caused by high blood sugars as a result of diabetes mellitus) 600 mg tablet, 2 tablets were to be given by mouth 3 times per day. b. [MEDICATION NAME] (medication to treat arthritis pain) 15 mg tablet 1 tablet to be given by mouth once daily. c. [MEDICATION NAME] (medication to control diabetes) 1000 mg tablet, 1 tablet to be given by mouth once daily in the a.m. d. [MEDICATION NAME] 500 mg tablet, 1 tablet to be given by mouth daily at bedtime. e. [MEDICATION NAME] (medication to treat depression) 75 mg tablet, 1 tablet to be given by mouth once daily. Review of Resident 7's MAR dated April 2015, indicated the following medications were not given due to medication availability issues. a. [MEDICATION NAME] 600 mg on 4/4/15 at 8 a.m., and 4 p.m. The medication was also not documented as given on 4/5/15 at 4 p.m. b. [MEDICATION NAME] 15 mg on 4/4/15 at 8 a.m. c. [MEDICATION NAME] 500 mg on 4/30/15. d. [MEDICATION NAME] 1000 mg on 4/4/15. e. [MEDICATION NAME] 75 mg on 4/4/15 at 8 a.m. On 4/29/15 at 2:30 p.m., during an interview, the DON stated The DON stated an electronic report could have been run that would have shown medications had not been administered, but that procedure had not been done in February, March or April 2015. On 5/7/15 at 9:30 a.m., during a telephone interview, Resident 1's Family Member (FM) 1 stated it took over 24 hours after admission to the facility for Resident 1 to get her medications. FM 1 stated the medications for [MEDICAL CONDITION] were supposed to be given at 7 a.m. and 7 p.m. each day, and stated there were family members visiting frequently and had observed the nurses timing of the administration of the medication by staff. FM 1 stated the timing of the medication had often varied and not been given at 7 a.m. and 7 p.m. On 5/7/15 at 2:30 p.m., during an interview at the nurse's station, Resident 1's Medical Doctor (MD) 1 stated she had not been notified of any medication availability issues for the resident and was not aware Resident 1 had not received medications, some for as much as a month. MD 1 stated if she had been aware the facility had been unable to obtain a particular medication she would have developed a plan to obtain or replace that medication. On 5/8/15 at 2:45 p.m., during an interview, the facility Medical Director (FMD) stated he would have expected the nurses to recognize Resident 1 had not received multiple doses of multiple medications. FMD stated the nursing staff should have contacted the pharmacy and the resident's physician. FMD stated he had not been made aware Resident 1 had not received medications due to availability issues and should have been notified as the Medical Director. On 5/7/15 at 10:15 a.m., during an interview in the conference room, the DON stated she was aware there had been medication availability issues. The DON stated, Each missed dose is a medication error. The doctor should be notified of any missed dose of medication. The DON stated the nursing staff had not consistently notified the physician or the DON of medications that were not available and not administered. Review of the facility's contracted pharmacy policy titled, 7.0 Medication Shortages/unavailable Medications dated 2013 indicated:Procedure:1. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy.2. If a medication shortage is discovered during normal Pharmacy hours: 2.1 Facility nurse should call Pharmacy to determine the status of the order. If the medication has not been ordered, the licensed Facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery. 3. If a medication shortage is discovered after normal Pharmacy hours: 3.1 A licensed Facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery; or, 3.2.2 Use of an emergency (back-up) Third Party Pharmacy. 4. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or directions. 5. If the medication is unavailable from Pharmacy or a Third Party Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary. 6. If the medication is unavailable from Pharmacy due to formulary coverage.or other clinical reason, Facility should collaborate with Pharmacy and Physician/Prescriber to determine a suitable therapeutic alternative. 7. If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for orders/direction.8. When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose on the MAR or TAR (treatment administration record) and in the nurse's notes per Facility policy. Such documentation should include the following information: 8.1 A description of the circumstances of the medication shortage; 8.2 A description of Pharmacy's response upon notification; and 8.3 Action (s) taken. On 5/7/15 at 10:15 a.m., during an interview, the DON stated she was aware there had been availability issues with medications. The DON stated licensed nurses had not followed the pharmacy procedures, had not consistently notified physicians of missed medications and did not notify her when there had been medication availability issues. The DON stated there had been no oversight of the medication errors in the past and staff training was needed. On 5/8/15 at 5:10 p.m. the Administrator provided an acceptable plan of action. The Plan of Action included staff training on the pharmacy's policy and procedures on medication dispensing, and included providing information on a 24 hour report to be monitored by the DON and the Executive Director of the availability of all medications twice per shift with an immediate implementation plan in place if medication was not available. As a result of the Plan of Action provided, the Immediate Jeopardy was abated with the Administrator, Director of Nursing and Regional Director of Clinical Operations present.