Every finding on record at WellBridge of Pinckney

This citation pertains to intake 3065557Based on interview and record review the facility failed to send accompaniment to an outside dermatology (medical specialty related to the skin) office appointment for a resident with severe cognitive impairment and failed to ensure they were sent with the required documents to be seen at the dermatology appointment for one resident (R800) of one reviewed for attendance for outside appointments resulting in a delay of being seen by a dermatologist. Findings include.Clinical record review revealed R800 was admitted to the facility on [DATE], had advanced dementia that affected their decision-making ability and on 2/25/25 was deemed unable to participate in medical treatment decisions. A Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6/15 that indicated R800 had severe cognitive impairment.Clinical record review of the Provider Progress note dated 6/9/26 at 12:46 PM, authored by Nurse Practitioner (NP) B documented .Patient noted to have nonhealing skin lesion on right lateral cheek. Concern for skin CA (Cancer).Record review documented NP B placed an order on 6/9/26 at 1:29 PM, .Consult to dermatology for lesion on right lateral face.On 8/19/26 at 12:05 PM, Receptionist D (receptionist at dermatology office) was interviewed and confirmed on 6/11/26, R800 arrived at the dermatology office and was being seen as a new patient for a dermatology consult. R800 was brought to the dermatologist by a transportation courier and dropped off alone. R800 was unable to answer basic questions, could not provide their history or reason for being seen. Based on their cognitive function, the Dermatologist (Medical Doctor) was not comfortable seeing R800 and cancelled the initial consult. Receptionist D explained they contacted the facility and explained R800 needed an advocate with them or would not be able to be seen, and the facility rescheduled the dermatology consultation for 6/30/26. Continued interview with receptionist D indicated on 6/30/26, R800 arrived at the appointment accompanied with facility staff, but they still were sent without the required documentation (valid identification, insurance cards, or patient advocate information) which was against their dermatology office policy and R800 was not seen by the Dermatologist.On 8/19/26 at 12:52 PM, Social Work Assistant (SWA) C was interviewed and confirmed they arranged outside medical appointments and consultations for the long-term residents. SWA C recalled being contacted by the dermatology office and was informed R800 was unable to be seen on 6/11/26 because they were not their own person and incapable of answering questions. SWA C confirmed R800 was sent on 6/11/26 with the transportation courier and no other person was present. SWA C confirmed R800 had advanced dementia and a low BIMS (6/15) and had severe cognitive impairment. When questioned if it was appropriate for R800 to attend an initial physician consult alone with cognitive impairment, SWA C replied it probably was not appropriate.On 8/19/26 at approximately 1:10 PM, during the interview with SWA C (who attended the appointment on 6/30/26) SWA C said the dermatology office would not see R800 at the rescheduled consultation because R800 was sent without needed documentation. SWA C returned to the facility with R800 and informed the Director of Nursing (DON) they were not seen. When questioned if R800's Durable Power of Attorney (DPOA) was contacted about R800 not being seen by dermatology, SWA C said they had tried calling but never spoke to the DPOA (Durable Power of Attorney). When asked if there was any documentation of these phone call attempts, SWA C stated there were none. When asked if they normally document phone call attempts, they said they do but for R800's dermatology appointments, they did not.During the interview, with SWA C the DON was present and said once they were informed, the dermatologist would not see R800, they personally contacted the office. Per the DON, they spoke with an office manager, but not the office manager for that specific office, who stated they would investigate the situation and call them back. Per the DON, they never heard back from the person they spoke with. The DON also had no documentation of when or who they spoke with at the dermatology office. Per SWA C and the DON they said they were going to reschedule R800 to be seen by another dermatology office. When asked when the next scheduled appointment was and what dermatology office was contacted, SWA C was unable to provide knowledge or documentation of the new dermatologist, date or time of the next appointment.On 8/19/26 at 1:28 PM, a telephone interview was conducted with NP B who vaguely acknowledged the dermatology consult order. Their progress notes from 6/9/26 were read to them .Patient noted to have nonhealing skin lesion on right lateral cheek. Concern for skin CA (Cancer). Consult to dermatology for lesion on right lateral face. and they remarked they see so many people, they couldn't recall any specifics of R800 and their concern for skin cancer.On 8/19/26 at 1:33 PM, a telephone interview was conducted with R800's DPOA and confirmed they had no knowledge there was an order for a dermatology consult related to skin cancer. Per the DPOA, they had never been notified by the facility of R800 needing a dermatology consult, nor were they aware that R800 had gone to see a dermatologist on 6/11/26 or 6/30/26. Per the DPOA, this was the first they had heard of these incidents regarding R800 and the concern to follow up with a dermatologist.On 8/19/26 at 2:14 PM, a request was made to the Nursing Home Administrator (NHA) and DON to provide policy and or procedures regarding Scheduling and Attending Medical Appointments/Consults and Resident Guardian Notifications. Per the DON, the facility had no guidelines or policies regarding such areas.On 8/19/26 at 3:04 PM, during an interview with the NHA, DON, and clinical corporate representative F, the DON remarked they had identified there were some, areas for improvement regarding the concerns for R800 dermatology consultation appointment. No further documents or information was provided by the end of this survey.

This citation pertains to intake #2691527Based on interview and record review the facility failed to prevent an avoidable fall as well as conduct a thorough root-cause analysis investigation into a fall for one resident (R801), of three residents reviewed for falls resulting in fractures of their clavicle and thoracic vertebra number four. Findings include:A complaint received by the State Agency alleged R801's bed was not in the lowest position when they sustained a fall resulting in injury.On [DATE] at 10:22 AM, a review of R801's closed clinical record revealed they admitted to the facility on [DATE], elected Hospice Services on [DATE] and expired in the facility on [DATE]. R801's diagnoses included: repeated falls, stroke, heart disease, vascular dementia with behaviors, and adjustment disorder.Continued review of R801's record revealed an Incident Note entered into the record on [DATE] at 12:04 PM by Nurse 'A' that read, Writer was notified that resident had fallen on the floor. When writer went to assess resident, resident was on the side if [sic] the bed lying on her side. Resident was unable to explain who [sic] she fell onto the floor or what happened at all. When writer was assessing resident, writer found a skin tear to her right knee, a large known [sic] (knot) on the left side of her forehead and a large knot on the right side of her neck.Writer contacted hospice and daughter who wanted her to be sent to (Hospital Name) .A review of a late entry eINTERACT SBAR (Situation, Background, Assessment, Recommendation)Summary for Providers entered into R801's record on [DATE] for the fall that occurred on [DATE] was conducted and read, Late Entry: Situation: The Change In Condition/s reported.are/were: Falls.-Mental Status Evaluation: No Changes observed.Behavioral Status Evaluation: (Blank). - Pain Status Evaluation: Does the resident/patient have pain? Yes.- Neurological Status Evaluation: No changes observed. A. Recommendations: Hospice and family notified. Due to pain and visible knot on guest. Send to Ed (Emergency Department) for further evaluation per hospice.Further review of R801's progress notes revealed an Incident Note entered into the record by Nurse 'A' on [DATE] at 5:05 PM that read, .Resident returned from the hospital from being sent there earlier due to fall. Resident had imaging done in ER (emergency room) and it came back that she has a T4 (thoracic vertebra) compression fracture and a right clavicle fracture. Due to resident being on hospice and also not being a good candidate for surgery, the ER did not treat the fracture.Upon arrival, resident stated that she was in pain. Writer administered PRN (as needed) Morphine.On [DATE] at 11:45 AM, an interview was conducted with Nurse 'A' regarding R801's fall on [DATE]. They were asked to describe what they remembered about the incident and said they were charting when they heard CNA (Certified Nurse Aide) 'C' call for their help in R801's room. They said R801 was observed on the floor next to their bed with a knot on their head and a knot on their right clavicle. Nurse 'A' said R801 cried out in pain when they tried to move her. Nurse 'A' went on to say when they entered the room they noticed, The bed was higher than it was supposed to be. They were asked to demonstrate an approximation of the bed height and Nurse 'A' (who reported their height at 5'10) gestured to their waist level. Nurse 'A' said, It was not normal for R801's bed to be at that height. They were asked if they knew how R801's bed could have been raised from its previously observed low level and said, I think I know what happened. When queried further, Nurse 'A' did not provide any additional details. Nurse 'A' continued to say after they assessed R801 they were sent to the hospital to return later in their shift with a broken clavicle and T4 vertebra. Nurse 'A' was then asked about the last time they observed R801 prior to the fall and said they gave R801 a breathing treatment and when they left the room the bed was in the lowest position. They were then asked if they observed anyone else entering R801's room after they gave the breathing treatment and said they knew CNA 'C' had gone in there after them for a check and change. They were further queried if they observed anyone else entering the room after CNA 'C' and before the fall and they offered no response.On [DATE] at 12:02 PM, an interview was conducted with CNA 'C', R801's assigned CNA on [DATE]. They were asked to describe what they remembered from the incident and said they were working with a resident one room away when they heard R801 yelling for help. CNA 'C' said they went to the room and observed R801 on the floor next to their bed. They said they called for Nurse 'A' and another CNA and they put R801 back in bed. They were asked if they observed anything unusual about the bed and said, When I walked in the bed was high. CNA 'C' then said, We all know (R801), and her bed is supposed to be low. CNA 'C' said they performed a check and change before R801 fell and reported the bed was in the lowest position when they left the room. CNA 'C' was then asked if they knew how the bed got raised after they provided care and before the fall. They said they heard a housekeeper was in the room, raised the bed to clean under it and didn't return it to the lowest level. Finally, CNA 'C' was asked if they observed a housekeeper enter the room after they provided care and before R801 fell and said they did not, but someone (CNA 'C' did not know who) said they saw a housekeeper in the room prior to the fall.On [DATE] at 1:30 PM, the facility's Administrator provided an investigation file that contained an incident report prepared by Nurse 'A', a typed statement from Housekeeper 'E' (taken and signed by Environmental Services Director 'G'), and fall assessment dated [DATE]. At that time, they were asked if they had any additional documents to provide regarding their investigation into the fall and they confirmed what they provided was all they had. On [DATE] at 1:37 PM, a review of the investigation documents and the facility provided incident report prepared by Nurse 'A' on [DATE] at 10:55 AM was conducted and read, .Nursing Description: Nurse observed resident lying on her side on the floor next to the bed. Non-skid socks were on. Brief clean and dry. Residents [sic] bed was at standard transfer height.Continued review of the incident report included a typed statement from Nurse 'A' that read, The CENA (CNA) came and told me (R801) was on the floor. I went to the room and observed (R801) on the floor next to the bed.bed was at standard transfer height. Last seen by nurse when given a neb (nebulizer) tx (treatment) at approx [sic] 0930. The incident report further documented a typed statement from CNA 'C' that read, I checked on (R801) after breakfast, around 10:15 AM, brief check and change done, she wanted to stay in bed instead of coming out to common area because she had a cold.Around 10:50 AM when I was giving a shower to another resident, I heard (R801) yelling for help, I went in and saw her laying on the floor next to the bed.A review of the typed statement dated [DATE] prepared and signed by Environmental Services Director 'G' from Houskeeper 'E' was conducted and read, Upon interviewing my staff member (Houskeeper 'E') VIA PHONE on 12/8 about the fall that occurred on 12/6 in (room number). She entered (room number) to clean it and at no time did she raise the bed.When (Housekeeper 'E') entered the room the bed was at the lowest position, and when she exited the bed was still at the lowest position. She can't remember exact time she was in there; however, it was after the incident.It was noted none of the documents provided attempted to identify a root cause of R801's fall.On [DATE] at 1:56 PM, a second interview was conducted with Nurse 'A' regarding R801's fall. They were asked if they thought R801 could have raised the bed on their own and said they were not sure, but if they did it would have been by accident. They were then asked if they knew if there were surveillance cameras in the hallways and said they were aware of cameras in the hallways.On [DATE] at 2:20 PM, an interview was conducted with the facility's Administrator and Corporate Nurse 'H' regarding R801's fall. They were asked if Nurse 'A' and CNA 'C' attested to the bed being in the lowest position, and Houskeeper 'E's statement that indicated they weren't in the room prior to the fall, how the bed got raised from it's low level to waist height. Corporate Nurse 'H' said R801, must have messed with the bed control and raised the bed on their own. Corporate Nurse 'H' continued to say R801 was, restless because a few days earlier they were running a fever, showed signs and symptoms of a respiratory infection and had been started on antibiotics.It was noted, nowhere in the facility's investigation was there documented evidence of R801 exhibiting restless behavior, nor did the investigation reveal Corporate Nurse 'H's reported explanation of R801 raising their own bed. At the conclusion of the interview, the Administrator and Corporate Nurse 'H' were asked if there were security cameras in the hallways and they confirmed there were. They were asked if they revealed any of the footage to determine the timeline and the validity of the staff statements or whether they viewed them for evidence of someone else entering the room who could have possibly raised the bed, and they reported they did not review any camera footage.On [DATE] at 2:35 PM, a second review of R801's clinical record was conducted. R801's care plan was reviewed and did not indicate R801 had any behaviors of manipulating their bed controls. Further review of the record revealed the following:An eINTERACT SBAR Summary for Providers dated [DATE] at 5:24 AM that read, .The Change In Condition(CIC)/s reported on this CIC Evaluation are/were: Fever Tired, Weak, Confused, or Drowsy.Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were:- Mental Status Evaluation: Increased confusion(e.g. disorientation)- Functional Status Evaluation: General weakness- Behavioral Status Evaluation: (Blank).A progress note dated [DATE] at 5:49 PM that read, .Resident was resting comfortable in bed entire day.There was no obvious documented evidence in R801's chart between [DATE] and R801's fall on [DATE] that indicated they were exhibiting restless behaviors.On [DATE] at 2:52 PM, a follow-up interview was conducted with CNA 'C'. They were asked to describe R801's presentation on [DATE] prior to the fall. CNA 'C' reported R801 had been sick and sleeping a lot for a few days prior to the fall. They said they were having to wake R801 to eat and provide one-to-one feeding assistance. They were asked if she usually required one-on-one assistance with eating and said no. CNA 'C' was asked if R801 had exhibited any behaviors of restlessness or agitation on [DATE] when they performed their check and change prior to the fall and said no, further saying R801 didn't even wake up while their brief was checked. CNA 'C' was then asked if they thought R801 knew how to use the bed controls and if they would raise their own bed beyond the low level it was last observed at and said they didn't think so.A review of a facility provided policy titled, Falls Reduction Program revised 4/2025 was conducted and read, .Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury. All residents who are admitted are at risk for falls.3.3 IDT (Interdisciplinary Team) to review each incident to complete root cause analysis.3.4.2 Complete/review Fall Assessment.Summarize IDT analysis.

This citation pertains to Intake#1201757.Based on observation, interview and record review the facility failed to prevent a fall for one (R701) of three residents reviewed for falls, resulting in R701 falling out of bed and sustaining multiple fractures, bruising to their face, eyes, arms and legs that required hospitalization. Findings include: A complaint was filed with the State Agency (SA) that alleged during care R701, who was bedridden, was turned too far to the right and fell out of bed, landed face down resulting in fractures to their nose, right ankle and multiple bruising on their face, arms, legs requiring hospitalization.On 7/9/25 at approximately 8:50AM, R701 was observed lying in bed. The bed was in a high position and did not have enablers bars. The resident had bruising under both the left and right eye. Their left arm was bruised from their wrist up to above their elbow. R701 was queried as to what caused the bruises. R701 reported that a Certified Nursing Assistant (CNA) was changing their brief and asked them to turn over to the right and hold the mattress with their left hand. They did what the CNA asked them to do, but felt the CNA pushed them one more time to assist with the roll over. They could not hold the mattress and fell out of bed and landed on their face. R701 noted that following the fall they were in so much pain, and it took almost an hour to get to the hospital. R701 further reported that their right foot was completely wrapped up as it was fractured following the fall. R701 could not provide the name of the CNA but was able to give a description. R701 was asked how nursing staff generally changes their brief and R701 noted that generally two people assist. They did note that the CNA has changed them by themselves in the past, usually on the midnight shift.A review of R701's clinical record revealed the resident had an original admission date of 12/29/16 with diagnoses that included: cerebrovascular accident (CVA)/stroke, difficulty walking depressive disorder. A view of the resident's Minimum Data Set (MDS) with a date of 6/20/25 noted that the resident had a Brief Interview for Mental Status (BIMS) score of 13/15 (cognitively intact). The MDS noted the resident was incontinent of bowl.Continued review of R701's clinical record revealed, in part, the following:3/17/25: Order: Transfer and ambulation; 2 PA (person assist) with mechanical lift.No ambulation.6/24/25 (1:15 AM): Nurses Note: .Writer was called into resident room by staff stating that resident fell on the floor during his brief change. Upon entering the room, resident was found on the floor face down, resident bed always in a high position.resident stated his neck was hurting, staff assisted writer with turning guest on his back to be further assessed, writer noted a spot of blood on the carpet and blood clot on guest nose, vs (vitals) taken and documented, guest also had a small tear on his L (left) knee and toe. Authored by Nurse D.6/24/25: Prehospital Care Report Summary: .Call received 1:01 AM .Name: R701 .Medical Need: unable to get out of bed .Severe pain: Yes.Mechanism of Injury.Fall.Height of fall: 3 (feet).Events leading up to the call.Prior to EMS (Emergency Medical Services) arrival crews were informed that around 12:45 AM.R701 was being changed in bed.bed was elevated 3-4 (feet) off the ground.Guard Rails to the bed were not in place.Staff states that as the rolled PT(patient) onto his side to facilitate changing pt he continued to roll off the bed falling to the floor below and striking his head. Patient suffered from multiple injuries to the head.Head to toe assessment reveals a contusion to the orbital bone region just superior to PT's left eye.laceration to the medial anterior portion of pts nose. takes anticoagulants.PT states he can't sign because he is right-handed and suffers from hemiplegia to the right side following a CVA (stroke).6/24/25: Hospital Record: .Nose Fracture.Chief Complaint: Patient transported from (name redacted) facility.Patient had a fall. Patient hit his head.Patient has a c-collar in place.Hemiplegia on right side due to a stroke.6/25/25: Hospital Record: .per chart.presented to our emergency department yesterday after a fall. Staff were completing a bed change, and they did not have the rails up, and patient fell out of bed. He did hit his head .displaced nasal bone fracture on both sides.today, patient presents to the emergency department.appears patient complaining of occipital headache.confusion this morning.x-ray of the right lower extremity revealed an acute impacted fracture of the distal tibia .extending into the medial malleolus with associated moderate swelling.Care Plan: Focus: ADL(activities of daily living)/Mobility deficit r/t (due to) R(right) sided hemiplegia following CVA (12/20/16).Interventions: .Transferring 2 PA with mechanical lift Hoyer (extra-large sling)- Initiated 7/3/25.Focus: Risk for falls r/t R sided hemiplegia(date initiated: 9/28/22.Revision 7/9/2025.Interventions:.Transfer & Ambulation: 2 PA with mechanical lift.Non-Ambulatory.1 PA for bed mobility (date initiated 7/9/25).Enabler bar on Right side of bed (7/9/25).Floor mat to Right side of bed. *It should be noted that changes/interventions were made to R701's care plan during the Survey (7/9/25). An enabler bar was not observed in the resident's room during the observation on 7/9/25 at 8:50 AM. Further, there was no indication in R701's care plan that noted the resident should be left in a high position, per their preference, during brief changes.A request for all Investigation/Accident (IA) reports was made, including all accompanying documents was made on 7/9/25 at approximately 10:36 AM. The following IA was provided: Fall.Date: 6/24/25- 1:10 AM.Resident: R701.Incident location: Resident's Room.Person Preparing Report: Nurse D.Incident Description: writer was called into resident room by staff stating that resident fell on the floor during brief change. Upon entering the room, resident was found on the floor face down. Resident stated his neck was hurting.Resident unable to give Description.Resident Taken to Hospital: Y (yes).Injuries Observed at Time of Incident:.Abrasion: right elbow.left elbow.right hand (back).left knee (front).right lower leg (front).Right ankle (outer).left toes.Face.Mobility: Bedridden.Multiple bruising and abrasion to leg, hands, toes, elbow and knees. Both eyes are black and purple in color. *It should be noted that the only documents attached with the IA included the note written by Nurse D as shown above and the IA form. There were no interviews/statements from staff, including CNA E. Nor, a statement from R701.On 7/9/25 at approximately 12:19 PM, a phone interview was conducted with Nurse D. Nurse D was asked about the fall incident involving R701 that occurred on or about 6/24/25. Nurse D reported that they worked the evening shift starting 6/23/25 and both her and CNA E were assigned to R701. Nurse D reported that CNA E told them they needed assistance as R701 fell out of bed and was on the floor. Nurse D further reported that to their knowledge R701 required two people for brief changes and CNA E did not have another person with them during the brief change. Nurse D reported that they obtained a statement from CNA E and noted that it should have been attached with the IA.On 7/9/25 at approximately 12:41PM, a phone interview was conducted with CNA E. CNA E was queried as to R701's fall incident that occurred on the 6/23/25 midnight schedule. CNA E reported that they were assigned to R701 and had worked with him several times. CNA E reported that in the past they had worked out a plan with R701 with respect to brief changes while in bed. They noted that they go in on their own and help R701 roll to the right side of the bed and grab their mattress with their left hand. While they are on their right side, CNA E stated that they change their brief. They stated on the night of the incident, R701 must have jerked and let go of the mattresses and then they rolled out of the bed. CNA E was asked how they determined residents, including R701's bed mobility status. CNA E reported that they thought R701 was a one person assist but found out after the accident that he really was a two-person assist. CNA E reported that he received education as to R701's bed mobility status as a two-person assist but stated that generally on the midnight shift it is hard to find other staff to assist. CNA E was asked as to R701's bed being left high while being changed. CNA E reported that he likes his bed left up high. *It should be noted that there was no documentation noted in R701's clinical record that indicated R701 refused to have their bed lowered during brief changes.On 7/9/25 at approximately 1:38 PM an interview was conducted with the Director of Nursing (DON). A corporate nurse staff was present during the interview. The DON was asked how nursing staff, including CNAs, can determine a resident's bed mobility and transfer status. The DON reported that staff can review the residents' Kardex that stems from their care plan to determine the proper way to care for a resident. The DON was asked about R701's fall and what the facility determined was the root cause. The DON reported that CNA E should not have changed the resident's brief on their own and in the manner they used. They reported they were educated following the incident. They also determined that mobility status was not placed in the Kardex but after reviewing the resident's care plan, it was updated. A review of the R701's care plan along with the DON showed new interventions were placed in on 7/9/25.On 7/9/25 at approximately 2:14 PM, an interview and record review were conducted with CNA G. CNA G reported that they were currently assigned to R701 and familiar with his care needs. When asked as to their bed mobility status, CNA G reported that R701 required two people during brief changes and noted that at times they often asked for a third person as the resident was a large person and bedbound. CNA G was asked how they were aware of the resident's status, and they noted they look to the resident's Kardex. CNA G was asked to pull up R701's Kardex and verify R701's status. CNA G needed some assistance from another staff person but was able to do so and pointed to the area that noted: Transfer & Ambulation: 2 PA with mechanical lift. CNA G then stated that was how they new how to provide care. CNA G continued to look at the Kardex and then noted that a new intervention had just been place that stated 1 PA for bed mobility. CNA G noted that that was new and stated that they would not feel comfortable with a 1 PA due to R701's status. On 7/9/25 at approximately 3:20 PM, an interview was conducted with Physical Therapist Director (PTD) H. PTD H was asked as to R701's bed mobility and transfer status. PTD H reported that R701 was MAX (maximin) assist and was uncertain as to his prior mobility status. PTDH did note that recently R701 was changed to a 1 PA assist. When queried as to the fall that occurred, PTD H stated that R701 was a two person assist for transfers and noted that it may have been possible to change R701 with one person if they were strong but noted that CNA E never should have rolled R701 away from him while attempting to change him.An Employee Corrective Action document provided by the facility was reviewed and read, in part: .Date: 6/25/25.Employee Name: CNA E.Supervisor: Director of Nursing (DON).Briefly describe the incident(s) and work rule(s) violated:.Failure to perform job duties satisfactorily and according to job.On Monday 6/23/25, CNA E was changing a resident that has paralysis to the right side of his body. He stated his routine is he goes in and rolls the resident to his Right side of the bed with his left hand he (R701) holds onto the mattress and then gives him a little roll while he is changed. On this night CNA E did roll resident onto his Right side only this time the resident fell off the right side onto his face. The resident prefers his bed to be higher than normal up in the air and the bed was left up high while being changed.EMS was called to help assist him off the floor onto the stretcher and take him to the ED (emergency department). When the resident returned, he did sustain a nasal fracture and tibial fracture. The resident who is bed bound, a 2 PA (person assist) with a Hoyer lift.Resolution: Education on turning and changing a resident, along with having CNA E show me how to read a Kardex to check residents transfer status and discussing the need to have 2 people with brief changes for 2PA residents, Hoyer lift, larger residents and new admissions.A review of the document provided to CNA E titled How to Reposition a Bedbound Patient (1/21/21) was reviewed and documented, in part, the following: .announce your intention to move them.remove any items that might be damaged or get in the way.move to one side of the bed while you move to the side that will roll toward.have them roll towards you.If.can't move on their own, their position should be adjusted every two hours.if possible have someone help you.When you are ready to turn.have one person stand on each side of the bed. Make sure.hands and feet are comfortable position.each person should gather up their side of the draw sheet and make sure it will comfortably support.slowly pull the drawsheet towards you, gently rolling.over as you do.The facility policy titled, The (facility) Group-Transfer-Policy (1/1/20) was reviewed and documented, in part: The facility will determine the guest's transfer status by utilizing an IDT (interdisciplinary team) approach.The facility will honor these approaches by care planning the guest's status in their care plan. The CNAs and licensed nurses will be responsible to ensure they are following the care plan/Kardex .

This citation pertains to intake #1201662.Based on interview and record review, the facility failed to ensure appropriate documentation of administration and accountability of controlled substances for one (R702) of one resident reviewed for medication administration. Findings include:Review of a complaint reported to the State Agency included an allegation the facility failed to prescribe controlled substances according to standards of practice.Clinical record review revealed R702 was admitted to the facility on [DATE] for physical therapy and back pain management related to a compression fracture to the lumbar spine (lower back). Record review did not reveal a calculated Brief Interview of Mental Status (BIMS) score, however Provider Progress notes documented R702 was alert, orientated, and able to make their needs known.Review of the Medication Administration Record (MAR) and the corresponding Control Substance Proof of Use Records (CS) revealed multiple discrepancies in which Oxycodone (an opioid pain medication) was documented as administered on the MAR but not reflected on the CS record.On 7/9/25 at 2:30 PM, an interview and record review with the Director of Nursing (DON) and Regional Clinical (RC) C confirmed documentation of controlled substances must be on the CS form and documented on the electronic MAR. The DON and RC C reviewed CS Record #12273520 and R702's April 2025 electronic MAR and acknowledged Nursing did not document the administration correctly based on the following discrepancies:On 4/26/25, R702 was ordered Oxycodone (an opioid pain medication) 15 milligram (mg) give 0.5 tablet (7.5 mg) by mouth every six hours as needed for pain.The CS Record for Prescription number #12273520 documented administration of the medication on:4/27/25 8:00 4/27/25 20:46 4/28/25 18:454/29/25 2:20 4/29/25 20:00 The April 2025 Electronic MAR only documented administration on Wednesday 4/30/2025 at 4:19 and 19:39. None of the documented administrations listed above were reflected on the MAR.Record review of R702's Oxycodone orders revealed the following:On 4/28/25 at 18:38 Oxycodone 15 mg give 0.5 tablet by mouth every six hours as needed for pain. Quantity 60On 5/1/25 11:17 Oxycodone 15 mg give 0.5 tablet four times a day. Quantity 56On 5/2/25 at 8:48 Oxycodone 15 mg give 1 tablet by mouth four times a day. Quantity 52The DON confirmed when the orders indicate give 0.5 tablet, the Pharmacy scores the tablets in half, so when documentation shows amount given as 1 that is a half tablet and, in this order, would be 7.5 mg of Oxycodone.Record Review of the CS record for prescription number #12273922 documented administration as:5/2/25 20:17- One Tablet5/3/25 02:20-One Tablet5/3/25 07:50-One Tablet5/3/25 13:12-One Tablet5/7/25 08:30-One Tablet5/7/25 02:40-One Tablet5/7/25 20:10-One Tablet5/8/25 02:10-One Tablet5/8/25 08:23-One Tablet5/8/25 13:03-One TabletOn 7/9/25 at 2:30 PM, The DON and RC C reviewed the above orders and confirmed that on 5/2/25 at 11:17AM, R702's pain medication was increased from 7.5mg to 15 mg of Oxycodone and administration of the dose increase would be reflected as giving 2 tablets. The DON and RC C acknowledged Nursing did not administer the medication as ordered.Further record review of the CS record for prescription number #12273922 documented on Line One on 4/30/25 Delivery 60 Tablets. The last entry line of the page was dated 5/9/25 at 8:33AM amount remaining 15 Tablets. The DON and RC C were asked if there was another CS form that continued this medication count, at which time a CS form was reviewed only documenting on 5/9/25 amount remaining was 13 and on 5/12/25 zero remained. The DON and RC C said this must be the continuation sheet, however, there was no pharmacy label on the sheet indicating the resident and the medication. The DON acknowledged there was no patient identifier and could not confirm what was the medication and or who the CS form belonged to.The complainant was concerned regarding multiple prescriptions for Oxycodone were filled within a very short time frame from the same Provider, Nurse Practitioner (NP) B and same Resident, R702 and provided the State Agency with a NarxCare Report (a report that reviews a patients-controlled substance data from government-managed and regulated prescription drug monitoring programs). The report was generated on 5/19/25 for R702 and revealed the following prescriptions were all ordered by NP B, filled and delivered to the facility:4/29/25 Oxycodone 15 mg Quantity 305/01/25 Oxycodone 15 mg Quantity 305/02/25 Oxycodone 15 mg Quantity 52On 7/9/25 around 2:45 PM, RC C further reviewed the Oxycodone orders written by NP B and confirmed they were discontinued correctly by NP B, but the Pharmacy still refilled each order and sent to the facility. RC C remarked the Pharmacy should have caught this and not have delivered.Further record review of the CS record for prescription number #12274320 documented on 5/11/25 that 59 tablets of Oxycodone remained. Administration documented on 5/12/25 at 2:00 AM one tablet was given and a heavily scratched area within the amount remaining box documented 57 tablets remained. The DON reviewed the document and confirmed this was in error and should have been calculated at 58 tablets, not 57 tablets.The CS record for prescription number #12274455 documented on 5/4/25, 51 tablets remained, and medications were recorded as administered on 5/10, 5/11, 5/13, 5/14, and 5/15. When the DON reviewed, it was apparent Nursing was interchanging administration documentation between two different CS Records and retrieving from separate bottles of Oxycodone. Further record review of CS record #12274455 revealed two administrations were documented as 3/13 at 20:09 and 3/14 at 02:00. The DON recognized the documentation error reflected the month of March and not May. When inquired about the timeframe narcotic medications are disposed of after residents are transferred or discharged , the DON replied within a day. The DON was provided and confirmed their signature, with CS record for prescription number #12274455 documenting on 6/6/25, 40 pills were disposed of and the CS record for prescription number #12274320 documenting on 6/6/25, 46 pills were disposed of. The DON was informed that R702 was discharged to the hospital on 5/16/25. The DON did not comment why the Oxcodone was not disposed for weeks later.The DON replied they were very disappointed and education on all that was reviewed on R702, was top priority and thanked for brining to their attention.

Based on observations, interviews and record reviews the facility failed to consistently ensure the required Physician visits at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter and/or failed to ensure the first initial comprehensive visit was conducted by the Physician for six (R's 89, 62, 3, 67, 34 and 11) of six residents reviewed for Physician visits. Findings include: R89 On 4/1/25 at 11:30 AM, R89 was observed sitting in their wheelchair in the dining area with their daughter. A brief interview was conducted with the resident and the resident's daughter at that time. A review of the medical record revealed R89 was admitted to the facility on [DATE] with diagnoses that included: dementia, intracerebral hemorrhage intraventricular, chronic kidney disease, dysphagia, and diastolic congestive hear failure. A review of the medical record revealed Physician D consulted with the resident in July 2024 and failed to conduct a physician visit once every 30 days for the first 90 days. Review of the medical record revealed the next documented Physician D visit was dated 10/14/24. There was no other documented consultations by Physician D. Further review of the medical record revealed R89 was seen by the Nurse Practitioner (NP) on 11/12/24, 1/22/25 and 3/13/25. The facility failed to ensure the frequency and timeliness of the required Physician visits. R62 On 4/1/25 at 1:12 PM, R62 was observed in their room in bed. R62's husband was observed sitting by the bedside. An interview was conducted with R62 at that time. A review of the medical record revealed R62 was admitted to the facility on [DATE] with diagnoses that included: acute and chronic respiratory failure with hypoxia, Guillain-Barre syndrome and hypertension. Further review of the medical record revealed R62's first initial visit was conducted by a Nurse Practitioner (NP) C and not by the assigned Physician D. The facility failed to ensure the initial comprehensive visit was conducted by the Physician. R67 On 4/1/25 at 11:07 AM, R67 was observed sleeping in their room. R67's wife was observed at the bedside, a brief interview was conducted with R67's wife at that time. A review of the medical record revealed R67 was admitted to the facility on [DATE] with a primary diagnosis of acute on chronic systolic congestive heart failure. Further review of the medical record revealed R67's first initial visit was conducted by NP C on 3/17/25. Physician D completed a consultation on 3/19/25. The facility failed to ensure the initial comprehensive visit was conducted by the Physician. On 4/2/25 at 11:58 AM, the Director of Nursing (DON) was interviewed and asked the protocol on Physician D and NP C consultations with the facility residents. The DON stated the Physician D does the initial visit for all of the residents. Physician D then informs NP C what to monitor and watch for thereafter. The DON was then asked why R89 had not been seen by Physician D at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The DON was asked about R62 and R67's first initial comprehensive visit being conducted by NP C and not Physician D as required. The DON stated they would look into it and follow back up. On 4/3/25 at approximately 2:53 PM, the DON accompanied by Nurse Consultant (NC) A asked what the concern was with the Physician visits for R89. The concern of the frequency of Physician D visits to meet the requirements was discussed regarding R89, R62 and R67, both the DON and NC A acknowledged the concern. No further explanation or documentation was provided by the end of the survey. 34275 R#34 On 4/1/24 at approximately 9:51 AM, R34 was observed lying in bed. The resident was alert and able to answer all questions asked. R34 reported that they had been a resident at the facility for about two years. When asked about the care provided at the facility, R34 responded that while most of the staff are very nice and most care is provided, they were upset that they are never seen by their doctor. R34 noted that they reported their concern to some of the staff members but could not specifically recall their names. A review of R34's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, COPD (chronic obstructive pulmonary disease) and rheumatoid arthritis. A review of the resident's MDS noted that R34 had a BIMS score of 14/15 (cognitively intact cognition). The last physician notes in R34's chart was dated 1/24/25 (late entry) and authored by Physician D. Prior to the visit on 1/24/25, R34 was seen by Physician D as seen on a progress note dated 10/23/24 (late entry). On 4/3/25 at approximately 12:34 PM, R34 reported to the Surveyor that Physician D came to their room yesterday (4/2/25) walked in the door, looked around the room and left. R34 noted that the physician did not perform a full examination and/or talk with the resident. *It should be noted that on 4/3/25 at approximately 1:30 PM, a review of R34's clinical record showed no indication that Physician D had seen the resident. On 4/3/25 at approximately 3:02 PM, an interview was conducted with Unit Manager Nurse F. UM F was queried as to Physician D care visits. UM F reported that they believed the facility policy/protocol was that the Physician was to see residents every three months, unless it is made none to them that the resident needs to be seen or that they and/or a family member requests a visit. With respect to R34, UM F reported that they recalled that R34 wanted to be seen in February for reasons associated with their diabetes. UM F could not recall if they noted the concern in the resident's clinical record, but did explain how physician forms can be filled out by staff. 47283 R3 Record review revealed R3 was long-term care resident of the facility, originally admitted on [DATE]. R3's admitting diagnoses included left wrist fracture, respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), urinary retention, neuromuscular dysfunction of bladder, dementia and heart failure. Based on Minimum Data Set assessment dated [DATE], R3 had Brief Interview for Mental Status (BIMS) score of 14/15, indicative of intact cognition. Review of R3's Electronic Medical Record (EMR) revealed a physician/NP (Nurse Practitioner) progress notes dated 6/21/24; 10/2/24; and (late entry note dated) 1/15/25. There were no other physician visits completed during this period. The physician or NP visits were not completed at least once every 60 days. The facility failed to ensure the frequency and timeliness of the required Physician visits. R11 Record review revealed R11 was a long-term resident of the facility. They were admitted to the facility on [DATE]. R11's admitting diagnoses Chronic Obstructive Pulmonary Disease (COPD), atrial fibrillation, cancer of the breast and respiratory failure. Review of R11's EMR revealed that they were receiving hospice services. Review of R11's progress notes revealed an initial physician note dated 4/3/24. Further review reveled Physician/NP notes dated 4/29/24; 7/24/24 (approximately 3 months); 8/9/24; 10/2/24 and 3/26/25 (approximately over 5 months after the previous visit). There were no other physician/NP visits in between during this period. The facility failed to ensure the frequency and timeliness of the required Physician visits. An interview with the Nurse Practitioner (NP) C was completed on 4/3/25 at approximately 3:05 PM. They were queried how often they were seeing the residents. They reported that they worked with Physician D and they were at the facility Monday through Friday. They were seeing long-term residents if they had any issues or needed any labs or other diagnostic tests etc. and did not have any schedule to see the long-term care residents. An interview with Director of Nursing (DON) was completed on 4/3/25 at approximately 3:10 PM. They were notified of the concerns with frequency of physician visits for R3 and R11. DON reported that they understood the concern and their corporate vice president was aware of the concern and they were following up with Physician D. An attempt was made to contact Physician D via phone on 4/3/25 at approximately 4:01 PM. There was no answer and it went to their voicemail, and the mail box was full; unable to leave any message.

Based on observation, interviews, and record reviews the facility failed to prevent a significant medication error for one (R67) of one resident reviewed for a significant medication error. Findings include: On 4/1/25 at 11:07 AM, R67 was observed sleeping in bed. R67's wife was at the bedside. When asked if they had any concerns with R67's care at the facility R67's wife stated there was a problem with the resident's Lasix medication when they were first admitted . R67's wife stated R67 had congestive heart failure in the hospital and was prescribed Lasix medication. R67's wife said the nurses was not giving the medication to R67 and they had questioned the nurses about it and they did not listen until they informed the facility's Director of Nursing (DON) of the issue. R67's wife stated the DON did fix their concern but R67's wife stated .What if I wasn't here? I am always by his side because I don't know what could happen . A review of the medical record revealed R67 was admitted to the facility on [DATE] with a primary diagnosis of acute on chronic systolic congestive heart failure. Review of the hospital discharge documents provided to the facility upon R67's admission documented the following in part, . Acute decompensated heart failure . furosemide 20 mg (milligram) tablet, commonly known as: LASIX. Take 1 tablet (20 mg) by mouth once daily. Please take 40mg (2 tablets) for weight gain over 2 lbs (pounds) in 24hrs and reach out to cardiologist. Last Given: March 14, 2025 6:04 AM . A review of the March 2025 Medication Administration Record revealed the following: Lasix Oral Tablet 20 MG, Give 1 tablet by mouth in the morning. Start Date: 3/16/25. The first administration for this order was given on 3/17/25, two days after admission to the facility and three days after their last dose of Lasix. A review of the medical record revealed no documentation on why the Lasix administrations were omitted and no documentation of the Physician to have been notified for further directive. A Physician note dated 3/17/25 at 9:45 AM, revealed no documentation of the Lasix medication. Review of the Physician notes revealed the following: On 3/19/25 at 10:40 AM, . Daily weights ordered . On 3/21/25 at 12:52 PM, . c/w (continue with) daily weights . On 3/27/25 at 9:02 AM, . c/w daily weights . A review of the documented weights for R67 revealed the facility failed to obtain a daily weight on the following days: 3/18/25, 3/19/25, 3/20/25 and 3/23/25. Despite the continuous documentation from the Physician to conduct weekly weights, an order was placed on 3/14/25 for Weekly weights. A review of the medical record revealed no clarification of the discrepancy regarding how often the staff were to obtain R67's weight. There was no admission weight noted for 3/15/25, however the weight documented on 3/16/25 was recorded at 188.8 lbs (pounds). A review of a Nursing note dated 3/20/25 at 2:50 PM, documented in part . Resident presents with some SOB (shortness of breath), 2-3+ pitting edema to bilateral feet/ankles. Lungs assessed and there is some crackles in the lower bases. (Nurse Practitioner Name) notified and we will give extra Lasix doses NOW and then increase to 40mg BID (twice per day) and (NP) will reevaluate . Review of a Nursing note dated 3/20/25 at 9:22 PM, documented in part . Took all meds including increased 40mg . Extra fluids given per request. Some crackles still noted as earlier this day. 02 (supplemental oxygen) on with no further respiratory distress noted . Review of a Physician note dated 3/21/25 at 12:02 PM, documented in part . Patient was admitted for fluid overload. Patient was diuresed <sic> . Patient was seen today as a follow up to diuretic management. Wife at bedside and had concerns regarding an increase in Lasix. States his BP (blood pressure) was low in the hospital and felt his Lasix dose was too high. Patient's BP at the facility ranges from stable to elevated. Wife is adamant that Lasix dose be reduced despite discussion of risks and benefits. Patient's weight was noted to be uptrending <sic>. Education provided . CHF (congestive heart failure)- Lasix decreased per wife. Provider recommends maintaining BID (twice a day) Patient and family decline. c/w daily weights . On 3/25/25 R67's weight was recorded at 191.0 lbs. On 3/26/25 the resident's weight gain was recorded at 191.8 lbs. A Physician note dated 3/27/25 at 9:02 AM, documented in part . Patient was admitted for fluid overload. Patient was diuresed <sic> . Patient was seen today as a follow up to diuretic management. Weight reviewed and are down trending . CHF- Lasix decreased to maintenance- c/w daily weights . This Physician note is not accurate, R67's weight was not down trending. As noted above R67's weight was noted to have a weight gain. The Physician and/or NP failed to identify the weight gain. On 4/1/25 and 4/2/25 the resident's weight gain was recorded at 192.2 lbs. This is a 3.4 lb weight gain from the admission weight. Review of the record revealed no documentation of the additional weight gain to have been identified and no documentation of the Cardiologist to have been notified as instructed by the transferring hospital. Further review of the record revealed no notification to the Physician of the weight gain. On 4/3/25 at 11:54 AM, the DON was interviewed and asked why R67's Lasix was not implemented and administered timely, considering their primary diagnosis to have been congestive heart failure. The DON was asked why daily weights were not obtained as noted by the Physician and asked about the weekly weights order implemented instead of the daily weights noted in the Physicians plan of care. The DON was asked about the missing weights and the weight gain with no identification by the facility staff and no notification to the Cardiologist. The DON stated they would look into it and follow back up. At 2:48 PM, the DON was accompanied by Nurse Consultant (NC) A and stated they reviewed the concern and acknowledged the missed doses of the Lasix and the lack of follow-up with the Physician regarding the missed Lasix dose on the 15th. NC A stated it could have possibly been missed due to the late admission to the facility. NC A was asked would they have expected the admitting nurse to clarify with the Physician when they are reconciling the medications and NC A acknowledged that would have been the expectation. NC A and the DON both acknowledged the discrepancies with the weekly weight order, physician plan of care to obtain daily weights and the weights that were not obtained and the DON stated they would complete education with the nursing staff to prevent further incidents. On 4/3/25 at 4:01 PM, an attempt was made to contact Physician D, however Physician D did not answer their phone and a voice message could not be left due to the mailbox being full. No further explanation or documentation was provided by the end of the survey.

Based on observations, interviews and record reviews, the facility failed to ensure the implementation of accurate assessments, appropriate and effective care plans/interventions and adequate supervision for the safety of R89 (elopement) and R's 69, 3 and 16 (falls), five of seven residents reviewed for accidents. Findings include: R89 On 4/1/25 at 11:30 AM, R89 was observed sitting in their wheelchair in the dining area with their daughter. A brief interview was conducted with the resident and the resident's daughter at that time. R89's daughter stated they had no concerns with the care provided at the facility. R89's daughter stated the facility staff has kept them and their siblings informed of everything, . like the other day he (R89) was found in the parking lot thinking he was going home . R89's daughter stated the staff called them and because of the incident an ankle bracelet was placed on the resident. A review of the medical record revealed R89 was admitted to the facility on [DATE] with diagnoses that included dementia. The medical record revealed the resident was deemed incompetent and R89's children shared Power of Attorney. A review of a Nursing note dated 3/30/25 at 11:18 AM, documented in part . Resident is exit seeking multiple times today. He states, I'm going home today A wander guard to his Right ankle has been applied (wander guard number) EXP (expiration): 7/27 . This note was documented by the facility's Director of Nursing (DON). A review of R89's medical record revealed no documentation of the resident to have been found outside of the facility. On 4/2/25 at 11:59 AM, the DON was interviewed and asked about the elopement incident with R89. The DON replied they had . just found out about that on Sunday . (Sunday 3/30/25). The DON stated the incident occurred one early morning and one of the night shift aides was leaving and observed R89 outside under the facility's awning. The DON stated the aide brought the resident back into the facility. The DON stated the aides came and told them about it on Sunday when they came to the facility. The DON identified two of the dayshift aides that informed them of the incident. The DON was asked the name of the CNA that found the resident outside and the DON provided the name of Certified Nursing Assistant (CNA) H. On 4/2/25 at 12:06 PM, a telephone interview was conducted with CNA H. CNA H was asked about the elopement incident with R89. CNA H stated they were driving leaving work to go home and saw (R89) outside by themselves under the awning in front of the facility. R89 stated they pulled over their car and brought the resident back into the facility and told CNA I and CNA J that the resident was found outside by themselves. When asked, CNA H stated they could not recall the exact times of last seeing R89 nor the exact time of finding R89 outside of the facility. CNA H was asked if any of the Administration, Corporate or any other staff have followed up with them regarding this incident and CNA H stated no one had contacted them to question them about the incident. CNA H stated since the incident they had not been back to work and had been off for a few days and will return to work tomorrow (4/3/25 night shift). On 4/2/25 at 12:16 PM, the Administrator was interviewed and asked about the elopement incident with R89. The Administrator was asked the date and time that the facility identified for the elopement incident for R89. The Administrator stated they would have to review their investigation report. The Administrator was asked what they had identified regarding the incident and the Administrator stated it was their understanding (R89) was found outside in front of the facility. The Administrator was asked what interventions were implemented to ensure the safety of R89 after the alleged incident and the Administrator replied that LPN G put a wander guard on the resident. The Administrator was asked when they were informed of the incident and by whom, the Administrator stated the DON had informed them but they did not recall the date and time that they were informed. On 4/2/25 at approximately 3:20 PM, the Nurse Consultant (NC) A provided the facility's investigation. An Incident and Accident report was not provided. On 4/3/25 at 8:54 AM, the investigation file was reviewed. Review of the investigation file included the following: An Employee Corrective Action documented for CNA H that noted the resident (R89) to have been found by CNA H outside and the failure to report the incident per the facility's protocol. This Corrective Action was back dated to 3/31/25. A telephone statement from CNA H that documented on the last day that they worked (3/28/25) they found (R89) outside in their wheelchair. CNA H was driving home and stopped their car to bring R89 back into the facility. CNA H informed the interviewer that they gave R89 to CNA I and CNA J who both stated they would inform the nurse. This statement had the date of 3/31/25. The investigation file failed to identify the lack of supervision for R89. A review of the medical record revealed a Wandering assessment dated [DATE] and 3/31/25, documented the resident to be Low Risk for Wandering. The facility failed to complete the 3/31/25 assessment accurately after the identified elopement. Review of the 3/31/25 wandering assessment failed to note any checks or documentation for the following sections- B. Behavior/Mood, C. Recent Experiences, D. Mobility and G. History of wandering. All sections were left blank. Review of R89's care plans including a care plan titled Resident at risk for wandering or elopement r/t (related to) altered mental state and expressing need to leave building Initiated on 3/30/25, revealed no documentation of the resident elopement incident. On 4/3/25 at 12:00 PM, the DON was interviewed and asked about R89 to have been exit seeking, the implemented wandering/elopement care plan/interventions and the inaccurate 3/31/25 wandering assessment. The DON stated they would look into the concerns and follow back up. No further explanation or documentation was provided by the end of the survey. Review of a facility policy titled Wandering, Unsafe Resident revised December 2008, documented in part . The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) . The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering . The resident's care plan will indicate the resident is at risk for elopement or other safety issues . Nursing staff will document circumstances related to unsafe actions . FALLS R16 On 4/1/25 at 10:06 AM, R16 was observed sitting in their wheelchair eating a cookie and drinking water. The resident was not able to appropriately respond to interview questions. A review of the medical record revealed R16 was admitted to the facility on [DATE], with diagnoses that included Parkinson's, Lupus, history of falls and repeated falls. R16 required staff assistance for all Activities of daily living. A review of the hospital documents provided to the facility upon R16's admission noted the following in part, . Reason for hospitalization . apparently attempted to stand on his own which led to him falling . hit his head . EMS (Emergency Medical Services) was called following the fall and patient brought . for further evaluation . Patient admitted . for recurrent falls and failure to thrive . Over this last month, the patient has fallen about 5 times . Recurrent falls, gait instability . Concern the patient requires higher level of care and assistance . Review of an Admission fall risk assessment dated [DATE], revealed to be inaccurate. The assessment categorized R16 as Moderate Risk for falls. Section 4. Medication Use was noted to be blank and failed to identify the medications the resident was currently taking that included gabapentin. A review of R16's medical record revealed a care plan titled Risk for falls r/t Hx (history) of falls, non-verbal, Impaired balance/poor coordination, unsteady gait, Parkinsonism . initiated 1/1/25, documented the following interventions: Administer medications as ordered by physician, evaluate lab tests & xray PRN (as needed), Neuro checks per protocol, Reinforce need to call for assistance and Transfers and Gait: 1 PA (person assistance) with U-step walker: WBAT (Weight Bearing as Tolerated) . The form also failed to identify the resident's unsteady gait in section 11. Gait Analysis. This care plan was not adequate or individualized to prevent further falls for R16, a resident with a known history of falls and current hospitalization due to a fall. Review of the medical record revealed the following falls: January 2025 - 13th, 20th, 21st. February 2025- 10th & 12th. On 4/2/25 at 2:21 PM, the Administrator was asked to provide all of R16's Incident and Accident (I&A) reports for falls. The facility provided an I&A for every fall except for the 1/21/25 fall. Review of the medical record revealed no Interdisciplinary meeting or documentation to identify the root cause of the 1/21/25 fall. Review of R16's care plan revealed no additional interventions implemented for the 1/21/25 fall. On 4/3/25 at 11:47 AM, the Director of Nursing (DON) was interviewed and asked about the inaccurate admission fall assessment and the inadequate fall interventions to prevent further falls for a resident identified with a known history of falls and who should have been identified as a high fall risk. The DON stated they would look into the concern and follow back up. At 3:31 PM, the DON returned and stated they identified concerns of the staff to have inaccurately completed the assessments and apologized for not documenting the follow up of R16's 1/21/25 fall into their medical record. At this time, the DON provided and investigation summary. Review of the investigation report documented the following in part . Root cause was determined to be that Guest is a 1 PA using U-step walker for transfer . was self-transferring from bed without calling for assistance. His call light was closed to reach and not activated . Intervention: Physician to review medication, therapy to work on strengthening and transfer mechanism. IDT reviewed and cp (care plan) updated . The care plan was not updated as documented. Review of a facility policy titled Falls Reduction Program dated 9/25/16, documented in part . PURPOSE: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury . Identify/analyze resident risk for falls . Implement and indicate individualized interventions on Care Plan . If fall occurs Charge Nurse to complete . Immediate interventions as identified by physical assessment and environmental observation . Identify any additional interventions in the Care Plan . No further explanation or documentation was provided by the end of the survey. 47283 R3 Record review revealed R3 was a long-term care resident of the facility, originally admitted on [DATE]. R3 was recently sent to the emergency room (ER) on 3/23/25 due to complaints of pain in the left forearm. R3's admitting diagnoses included left wrist fracture due to a fall at the facility, respiratory failure, dementia, Chronic Obstructive Pulmonary Disease (COPD), urinary retention, neuromuscular dysfunction of bladder, dementia and heart failure. Based on Minimum Data Set assessment dated [DATE], R3 had a Brief Interview for Mental Status (BIMS) score of 14/15, indicative of intact cognition. An initial observation was completed on 4/1/25 at approximately 9:05 AM. R3 was observed in their bed. They were dressed and observed wearing a night top. R3 had a brace on their left forearm due to a recent fall at the facility and they were diagnosed with a left wrist fracture. R3 was queried about the cast, they reported that they fell in the bathroom a few days ago and they went to the hospital. When queried further on how they fell , R3 stated that they fell right here and pointed to the bathroom; added that somebody put something on the floor that shouldn't be there and I stumbled and fell . They added that they were not able to use their left hand. Review on R3's hospital discharge summary dated 3/23/25 read in part, Presents with wrist injury. Patient came via EMS (Emergency Medical Services) from nursing facility for left wrist injury with obvious deformity. Facility denies patient fell but is unsure how the injury occurred. Wrist has been injured x few days per EMS . Discharge summary from the hospital revealed closed fracture of the left distal radius. Review of R3's nursing progress note revealed that R3 had a fall on 4/1/25 at 2 PM, slipped from wheelchair. Review of R3's progress notes revealed no nursing progress notes between 3/16/25 to 3/23/25, the day R3 was transferred to the ER due to complaints of left arm pain and swelling. A Progress note dated 3/23/25 at 10:23, read, patient complaints of left arm pain to touch, swelling observed, on call MD (Medical Doctor) notified, stat (urgent) 2-view x-ray ordered'. R3 returned from hospital on 3/24/25 and the progress note dated 3/24/25 at 00:05 read, .patient stated she was tired and little confused of her surroundings. Patient left arm is in a cast and a sling. Writer put bed to lowest position .patient was re-educated on safety and importance of using call light and waiting for assistance. Received report from EMS, who stated she had received oxycodone and morphine at the hospital. Review of R3's fall risk assessment dated [DATE] deemed R3 as low risk for falls with a score of 5.0., when the nursing assessment upon re-admission revealed increased confusion. Review of fall risk assessment scores from 1/15/24 revealed the following scores that did not correlate with the rest of the nursing/interdisciplinary findings/assessments: 1/15/24 - 9.0 ->Moderate Risk 1/22/24 - 11.0 ->Moderate Risk (no fall risk assessments between 1/22/24 and 12/23/24 - approximately 11 months) and had a significant change Minimum Data Set (MDS) assessment dated [DATE]. 12/23/24 - 11.0 -> Moderate Risk 3/24/25 - 5.0 ->Low Risk (after they had a fall at the facility with wrist fracture and was transferred to ER) R3 was transferred to hospital on 3/23 and they were receiving diuretics and narcotics and a fall risk assessment dated [DATE] did not reflect R3 receiving the medications. 4/1/25 - 7.0 ' Moderate Risk A request was sent via e-mail to provide all Incident & Accident reports for R3 from 12/1/24 to 4/2/25 on 4/3/25 at 9:22 AM. Two incident reports were received for 3/23/25 and 4/1/25. Review of investigation report for the incident dated 3/22/25 revealed a summary of meeting note that read, reviewed environment - ability to get up unassisted, self-reported .therapy agrees - could get up unassisted, suspect fall related to clutter, not tubing. MDS assessment dated [DATE] and R3's care plan revealed that they needed moderate assistance with toileting needs (less than 50% help from staff) and needed substantial/maximal assistance (more than 50% help from the staff) with bed to wheelchair transfers and toilet transfers. There was no other objective clinical assessment on R3's Electronic Medical Record (EMR) that revealed that they were able to perform transfers (including floor transfers) unassisted other than the statement written on the investigation report. Review of a rehabilitation screen dated 3/24/25 revealed a Physical Therapy (PT) evaluation was recommended to address the recent fall on 3/22/25, PT evaluation was completed on 4/1/25 (7 days) after another fall. An interview with Unit Manager (UM) N was completed on 4/3/25 at approximately 9:30 AM. They reported that they had worked as the on call nurse manager on 3/22/25 and 3/23/25 and had also worked on the unit when R3 was sent out emergency room (ER) for further evaluation. They reported that R3 was not able to provide any information on fall. They were queried about the fall risk assessment from 3/24/25 after the fall with left wrist fracture and how R3's fall risk changed from moderate to low risk after their fall? They reviewed the assessment on EMR and reported they did not complete the assessment, when queried who did, they reported that it was completed by their corporate nurses. An interview with the Director to Rehab (DOR) O was completed on 4/3/25 at approximately 12 PM. They were asked about the rehab screen that was ordered and completed on 3/24/25 and why the PT evaluation was completed on 4/1/25 (approximately a week later) after R3 had another fall. DOR O reported that their team was unable to do the evaluation. They reported that R3 was scheduled for a Physical Therapy (PT) evaluation on 3/27/24 (reviewed the schedule on their computer) but the Physical Therapist was unable to complete the evaluation as they had too many admissions and they had to prioritize the new admission evaluations. An interview with the Director of Nursing (DON) was completed on 4/3/25 at approximately 10:25 AM. The DON was queried about R3's unwitnessed fall and transfer to the ER with a fracture to the left wrist. The DON reported that they spoke with the resident and R3 reported that they fell and got themselves up and did not tell anyone until the next morning when their wrist started hurting. When queried about their ability to transfer and the fall risk assessment dated [DATE] that deemed R3 was a low risk, the DON reported that they would check and report later. Later that day, the DON came back and reported that change in score was related to history of falls and an error in incontinence score. No additional documentation or explanation was provided prior to survey exit. 48680 R69 On 4/1/25 at 11:13 AM, an observation was made of R69 in their room in the wheelchair with a neck brace on getting their hair combed by a staff member. R69 was convinced they were going to the hospital to get surgery; an interview attempt was made but R69 was not able to have an appropriate conversation. A review of the record revealed that R69 had a fall on 3/19/25 and was sent to the hospital in case they hit their head. R69 also had a fall on 3/21/25. A further review of the record revealed that R69's care plans were not updated from the fall that took place on the 19th and there were no neurological checks completed. On 4/3/25 4:34 PM, the Director of Nursing (DON) and the regional Nurse was interviewed and asked after a fall what was the facility's process. The DON reported, they assess the resident, call the doctor and family, imitate a neurological assessment and they will send the resident to a higher care setting if needed. The DON was asked to provide the neurological assessment for R69 for the unwitnessed fall on 3/19/25. The DON presented a handwritten neurological sheet that was filled out entirely, however, there were times recorded with vital signs and other data while the resident was in the emergency room and not at the facility. The DON was asked how was that possible to get information such as vitals for a resident that was not in the facility. The DON had no answer. On 4/4/25 at approximately 10 AM, this writer received a call from the Administrator stating that their team discussed the neurological assessment that was submitted was deemed false documentation and that it should not be used. No additional information was provided by exit of survey. 34275

Based on observation, interviews and record reviews the facility failed to thoroughly investigate an elopement incident for one Resident of one resident reviewed for elopements. Findings include: On 4/1/25 at 11:30 AM, R89 was observed sitting in their wheelchair in the dining area with their daughter. A brief interview was conducted with the resident and the resident's daughter at that time. R89's daughter stated they had no concerns with the care provided at the facility. R89's daughter stated the facility staff keep them and their siblings informed of everything, . like the other day he (R89) was found in the parking lot thinking he was going home . R89's daughter stated the staff called them and because of the incident an ankle bracelet was placed on the resident. A review of the medical record revealed R89 was admitted to the facility on [DATE] with diagnoses including dementia. The medical record revealed the resident was deemed unable to make medical treatment decisions and had an activated power of attorney. A review of medical record revealed no documentation of the R89 being found outside of the facility. A review of a Nursing note dated 3/30/25 at 11:18 AM, documented in part . Resident is exit seeking multiple times today. He states, I'm going home today A wander guard to his Right ankle has been applied (wander guard number) EXP (expiration): 7/27 . This note was documented by the facility's Director of Nursing (DON). A review of the Medication Administration Record (MAR) revealed Licensed Practical Nurse (LPN) G was the assigned nurse for R89 on day shift for 3/30/25. On 4/2/25 at 11:08 AM, R89 was observed in their wheelchair propelling themselves through the dining room towards the hallway where their room was located on. A wander guard was observed on the resident's right ankle. On 4/2/25 at 11:47 AM, LPN G was interviewed and asked about the incident of R89 being found outside of the facility. LPN G stated the incident did not happen on their shift. LPN G stated they were informed of the incident by the off going nurse on 3/30/25. LPN G stated they were informed the resident was found outside in the early morning hours. LPN G stated usually there is a person sitting at the front desk to monitor the elopement risk residents, however at the time of the incident there was no personnel at the front desk. LPN G stated usually R89 was not . exit seeking, but he actually got out. LPN G stated they placed a wander guard on R89 during their shift the day of 3/30/25. LPN G opened their cell phone pictures and stated, see I took a picture of the wander guard before I put it on him. The picture was reviewed and confirmed. On 4/2/25 at 11:59 AM, the DON was interviewed and asked about the elopement incident with R89. The DON replied they had . just found out about that on Sunday . (3/30/25). The DON stated the incident occurred in the early morning and one of the night shift aides was leaving who observed R89 outside under the facility's awning. The DON stated the aide brought the resident back into the facility. The DON stated the aides came and told them about it on Sunday when they came to the facility. The DON identified two of the day shift aides that informed them of the incident. The DON was asked the name of the CNA that found the resident outside and provided the name of Certified Nursing Assistant (CNA) H. The DON stated they would have expected staff to notify them of the incident so that they could notify the Administrator. The DON was asked if they notified the Administrator when they were informed of the incident and the DON stated they did. This confirmed the DON and Administrator was informed of the incident on 3/30/25. On 4/2/25 at 12:05 PM, the Administrator was asked to provide CNA H time punches for the last two weeks. On 4/2/25 at 12:06 PM, a telephone interview was conducted with CNA H, who was asked about the elopement incident with R89. CNA H stated they were driving, leaving work to go home and saw R89 outside by themselves under the awning in front of the facility. R89 stated they pulled over their car and brought the resident back into the facility and told CNA I and CNA J the resident was found outside by themselves. When asked, CNA H stated they could not recall the exact times of last seeing R89 or the exact time R89 was found outside of the facility. CNA H was asked if any of the Administration, Corporate or any other staff have followed up with them regarding this incident and CNA H stated no one had contacted them to question them about the incident. CNA H stated since the incident they had not been back to work and had been off for a few days and will return to work tomorrow (4/3/25 night shift). A review of the time punch detail for CNA H revealed the last day worked was noted as 3/28/2025 the 7 PM to 7 AM shift. Review of the facility assignment sheets for 3/28/25 revealed CNA H was on duty for the midnight shift and confirmed CNA I and CNA J were the oncoming day shift CNA's. On 4/2/25 at 12:16 PM, the Administrator was interviewed and asked about the elopement incident with R89. The Administrator was asked the date and time that the facility identified for the elopement incident for R89. The Administrator stated they would have to review their investigation report. The Administrator was asked what they had identified regarding the incident and stated it was their understanding (R89) was found outside in front of the facility. The Administrator was asked who they identified as the staff who found R89 outside and stated they would have to refer to their investigation report. The Administrator was asked what interventions were implemented to ensure the safety of R89 after the incident and replied, LPN G put a wander guard on the resident. The Administrator was asked when they were informed of the incident and by whom, the Administrator stated the DON had informed them but they did not recall the date and time that they were informed. The Administrator was asked to provide their investigation thus far and to provide the facility's incident and accident report of the elopement incident for review. On 4/2/25 at 1:32 PM, a second request was made to the Administrator to provide the facility's investigation and Incident and Accident report regarding R89's elopement incident. On 4/2/25 at approximately 2:03 PM, the Administrator accompanied by Nurse Consultant (NC) A explained, the DON was just informed of the elopement incident this Sunday (4/30/25). The Administrator was asked why they failed to report the allegation of R89 to have eloped from the facility, without staffs knowledge and stated they were still investigating the allegation. The Administrator stated they informed NC A about the incident yesterday (4/1/25) to help them complete the investigation. NC A stated they started in-servicing the staff today and explained they were interviewing staff now regarding the incident. The Administrator was asked why the investigation did not start before when they were first made aware of the incident by the DON on 3/30/25 and NC A explained the staff stories were all over the place and they were still interviewing the staff. The Administrator and NC A were asked a third time to provide the investigation and the Incident and Accident report for R89's elopement. On 4/2/25 at approximately 3:20 PM, NC A provided the facility's investigation. An Incident and Accident report was not provided. Shortly after the Administrator and corporate staff were asked for the facility's camera footage of the front foyer area at the time of the incident. NC A informed the survey team that the facility footage was only kept for 24 hours and no longer had the camera footage for review. On 4/3/25 at 8:54 AM, the investigation file was reviewed. Review of the investigation file contained the following: A Employee Corrective Action documented for CNA H which noted R89 was found by CNA H outside and failed to report the incident per the facility's protocol. This 'Corrective Action' was back dated to 3/31/25. A statement from CNA I and CNA J who denied being informed of R89 being found outside by CNA H. A telephone statement from CNA H which documented they found R89 outside in their wheelchair on the last day that they worked (3/28/25). CNA H was driving home and stopped their car to bring R89 back into the facility. CNA H informed the interviewer that they gave R89 to CNA I and CNA J who both stated they would inform the nurse. This statement had the date of 3/31/25. The file did not contain a narrative of the incident, investigation findings, identification of the root cause, and failed to identify if there was lack of accountability and/or lack of supervision from any of the facility staff assigned to R89. A review of R89's medical record revealed no information documented regarding the incident. Further review of the medical record revealed a Wandering assessment dated [DATE] and 3/31/25, which documented the resident as Low Risk for Wandering. The facility failed to complete the 3/31/25 assessment accurately after the identified elopement. A review of a facility policy titled Elopements revised December 2008, documented in part . Staff shall investigate and report all cases of missing residents . Staff shall promptly report any resident who tries to leave the premises . to the Charge Nurse or Director of Nursing . The Director of Nursing or Charge Nurse shall . complete and file Report of Incident/Accident; and . Document the event in the resident's medical record . The facility staff failed to follow the facility policy. As of 4/3/25, the last day of the facility's survey, the Administrator and Corporate staff had not provided a thorough and full investigation to the surveyors for review, despite CNA H having to stop their car to bring R89 back into the facility on [DATE], six days prior. No further explanation or documentation was provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure a physician's order, assessment and specify the times to be used while in wheelchair for a seatbelt device per plan of care for one (R7) resident reviewed for physical restraints. Findings include: On 4/1/25 at 10:00 AM, R7 was observed in their room sitting in wheelchair positioned in a slouched manner over a bedside table. R7 was also observed with a seatbelt device on and clasped together. R7 was asked how they were doing but the conversation was intangible. A review of the Electronic Medical Record (EMR) revealed R7 was admitted to the facility on [DATE] with the diagnoses of falls, difficulty in walking and cerebral palsy. The Minimum Data Set (MDS) assessment completed on 12/27/24 indicated R7 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) Score of 7/15. On 4/2/25 at 11:00 AM, the assigned Nurse was asked if R7 could release the seatbelt device by themselves. The nurse attempted asking several times for R7 to release the seat belt independently without success. The Nurse then went on to get the Certified Nursing Assistant (CNA) for the unit. The CNA asked R7 if they could release their seat belt device. The CNA went on to cue R7 and placed the seatbelt device in the hand of R7 who then demonstrated ability to unsnap the safety belt device. A review of the record revealed R7 had not been assessed for the seat belt device since 10/12/21. There was no physician order for the safety belt, no consent, and the 'fall' care plan stated it was for safety. There were no indicators for restraint use noted on any of the MDS assessments. On 4/2/25 at 12:20 PM, the Director of Nursing (DON) was asked, how often assessments were supposed to be done for restraints. The DON reported the facility was a restraint free facility, so they did not have assessments. The DON was then informed R7 had a seatbelt on that took several cues and direct placement of the seatbelt device clasp into R7's hands before R7 could remove seatbelt. The DON stated, the seat belt used for R7 was not a restraint because they were able to remove the device by themselves. The DON was then asked how often the use of this device should be reassessed, and the DON reported at least quarterly. On 4/2/25 at 12:23 PM, the Occupational Therapist was observed completing an assessment for the seat belt in the dining room while R7 was eating lunch. On 4/3/25 12:28 PM, an interview with the Family Member of R7 stated, the seat belt was for pleasure since R7 worked a General Motors for so long making their seat belts so it was a comfort thing. Family Member reported, that R7 should be able to take it off but they rarely paid it any attention when they visited. On 4/3/25 at 3:30 PM, in an interview with the DON and the Regional Nurse, they were asked why the seat belt was care planned under falls if it was for pleasure or activities, and why the progress note stated that it was for trunk support and positioning. The DON and Regional Nurse reported the seat belt was not a restraint. No additional information was provided by the exit of survey.

Based on observation, interview and record review the facility failed to administer medication according to professional standards of practice for one Resident (R12) of one resident reviewed for medications. Findings include: On 4/1/25 at approximately 10:03 AM, R12 was observed sitting in their wheelchair watching television. The resident had a full breakfast tray in front of them. On the tray was a small cup filled with approximately 10 pills. The resident was asked about the pills sitting on the breakfast tray. While alert, R12 was not able to provide an answer as to what pills were in the cup and why they were left on their tray. On 4/1/25 at approximately 10:11 AM, Nurse E who was assigned to R12, was asked about the pills left on R12's breakfast tray. Nurse 'E entered the room and viewed the pills and noted they thought the resident took the medication and then noted they should not have left the pills on the tray. Nurse E lifted the cup and asked R12 to take the medication. Nurse E did not provide the names of the medication to the resident. R12 swallowed the all the pills at approximately 10:12 AM. A review of R12's clinical record revealed the resident was initially admitted [DATE] with diagnoses including: delusional disorders, type II diabetes, vascular dementia and chronic kidney disease. The resident had a court appointed guardian assigned, effective 3/12/25. A review of the resident's Minimum Data Set (MDS) assessment R12 had a recent Brief Interview for Mental Status (BIMS) score of 14/15 (intact cognition). There was no order in the clinical record indicating R12 could self-administer medication. Continued review of R12's clinical record revealed Nurse E recorded in the Medication Administration Record (MAR) dated 4/1/15 that at 8:36 AM the following medications were administered to R12: 1. Jardiance (used for diabetic neuropathy) 10 MG (milligrams), 2. Duloxetine (used for depression/anxiety) 60 MG, 3. Metoprolol (used for high blood pressure), 4. Zyrtec (used for seasonal allergies) 10 MG, 5. Atorvastatin (used for high cholesterol), 6. Glipizide (used to treat diabetes) 10 MG, 7. Ferrous Sulfate (used to treat anemia), 8. Depakote (used to treat bipolar patients and for seizures)125 MG. On 4/2/25 at approximately 10:46 AM, an interview was conducted with the Director of Nursing (DON) who noted, Nurse E reported they were aware of the pills that were left on R12's breakfast tray. Nurse E stated to the DON, they believed the pills may have been spit out by the resident. It should be noted, the pills viewed on 4/1/24 at approximately 10:03 AM appeared untouched, dry and remained in the cup. The DON was informed, Nurse E documented in the MAR, all medications were administered at 8:36 AM. The DON acknowledged Nurse E should not have left the medications with the resident and should not record they were administered if Nurse E did not view they were taken.

Based on observation, interview, and record review facility failed to ensure an indwelling foley catheter was secured appropriately for one Resident (R3) of two residents reviewed for catheter care resulting in the potential for catheter dislodgement, urethral trauma, and Urinary Tract Infection (UTI). Findings include: R3 A review of the medical record for R3 revealed admission to the facility on [DATE] with diagnoses including urinary retention, neuromuscular dysfunction of bladder, and dementia. The Minimum Data Set (MDS) assessment dated [DATE], revealed R3 had Brief Interview for Mental Status (BIMS) score of 14/15, indicative of intact cognition. On 4/1/25 at approximately 9:05 AM, R3 was observed in their bed and a foley catheter collection bag was connected to the wheelchair. A velcro catheter securement device was observed laying on the floor of the bathroom on the right side of the toilet. During this observation an interview was completed. When asked how long the catheter was place, R3 reported they had the catheter for a while. When queried about the catheter securement strap and if they had taken it off, R3 was unaware. When queried about how they were transferring in/out of bed and going to the bathroom, R3 reported staff had been helping them after their fall. At approximately 9:20 AM, Licensed Practical Nurse (LPN) L who was assigned to care for R3 came into R3's room. LPN L was queried about the catheter securement device observed on the bathroom floor and confirmed it was a foley securement device. They picked up the device from the floor and disposed it. They were queried on how the device ended up on the bathroom floor and what was securing the foley. LPN L checked for a foley securement device on R3, while this Surveyor waited outside the room. At approximately 9:22 AM, LPN L came to the door and replied, R3 did not have any securement device and they were unsure how it came off. LPN L stated they were going to get a new catheter securement device. When asked how long the catheter securement device was off, LPN L stated they were unsure. At approximately 9:23 AM, LPN L notified Certified Nursing Assistant (CNA) M to get a catheter securement device for R3. CNA M brought a catheter securement device and gave it to the nurse. At approximately 9:40 AM, LPN L was in R3's room when the Director of Nursing (DON) came by R3's room. LPN L reported to the DON, the surveyor observations and the new catheter securement device they had put on R3, while the surveyor was standing in the hallway, outside R3's room. Review of E3's progress note revealed a nursing note dated 4/1/25 at 10:52 AM (after the securement strap was observed on the floor and brought to the staff's attention), that read, Patient (R3) is noncompliant with foley strap (catheter securement device). Staff notified nurse manager. Care plan will be updated. There was no further documentation of the resident's noncompliance. Review of R3's physician order revealed an order dated 1/26/25 that read in part, Foley cath. care Q (every) shift. Assess catheter placement, tubing, and anchor . Review of nursing Q-Shift follow-up for this order from 3/1/25 to 4/3/25 revealed 10 blank entries on Treatment Administration Record. Review of R3's foley catheter care plan revealed an updated intervention dated 4/1/25 (after the concern was brought to the attention of the facility) that read, ensure that foley is properly anchored to leg. Resident frequently removes Cath secure . An interview with CNA M was completed on 4/1/25 at approximately 9:25 AM in the hallway. CNA M reported being regularly assigned to the unit and they knew R3 well. They were queried about R3's functional status and their ability to transfer. CNA M reported R3 needed help with their transfers because of their cast and they were assisting them with getting in and out of bed with their toilet transfers. CNA M was queried if they assisted R3 with toileting during their shift and they reported that they assisted the resident in the morning. When queried about the catheter securement device found on the floor of the bathroom, CNA M was unsure and did not provide any further explanation. An interview with Unit Manager (UM) N was completed on 4/3/25, at approximately 9:30 AM. UM N' was queried about their staff expectations for foley catheter care. UM N explained, nurses and CNA's had specific orders to follow depending on the type of catheter. They were notified of the observations of R3 and the catheter securement device observed on the floor in an area of the bathroom which could not be reached from the area where R3's was (in her bed). UM N was also made aware of the interviews with staff and acknowledged the concern of staff not ensuring a catheter securement device was in place for R3 to prevent accidental dislodgement. On 4/2/25 at approximately 10:55 AM, during an interview, the DON was queried about the facility standards for foley care and expectations from their staff. The DON reported there was an order for nurses to do foley care every shift which included checking the anchor. The DON was notified of the observations for R3 and the location where the catheter securement device was observed while R3 was observed in their bed under their blankets. The DON reported R3 was non-complaint and had a care plan. The DOB was asked why the care plan and documentation was not entered into the medical record until after this Surveyor brought the concern to facility's attention. The DON was also asked why there was no prior evidence of R3's non-compliance with removing the catheter securement device in the medical record. The DON reported they had sent the resident out to replace foley after they had started. They added that they would look for additional documentation. No further documentation was provided prior to survey exit. Review of facility provided document titled CATHETER CARE (INDWELLING CATHETER AND SUPRAPUBIC) with a revision date of 8/17/17 read in part, PROCEDURE FOR INDWELLING CATHETER: . 7. Properly secure tubing to leg using a catheter strap to reduce risk of trauma .

Based on observation, interview and record review, the facility failed to timely report an allegation of an elopement to the State Agency (SA), for one Resident (R89) of one resident reviewed for elopements. Findings include: On 4/1/25 at 11:30 AM, R89 was observed sitting in their wheelchair in the dining area with their daughter. A brief interview was conducted with the resident and the resident's daughter at that time. R89's daughter stated they had no concerns with the care provided at the facility. R89's daughter stated the facility staff has kept them and their siblings informed of everything, . like the other day he (R89) was found in the parking lot thinking he was going home . R89's daughter stated the staff called them and stated because of the incident an ankle bracelet was placed on the resident. A review of the medical record revealed R89 was admitted to the facility on [DATE] with diagnoses that included dementia. The medical record revealed R89 was deemed unable to make medical treatment decisions and had an activated power of attorney. A review of R89's medical record revealed no documentation of the resident being found outside of the facility. Review of the SA Facility Reported Incident (FRI) system database revealed no submission from the facility regarding the alleged elopement. A review of a Nursing note dated 3/30/25 at 11:18 AM, documented in part . Resident is exit seeking multiple times today. He states, I'm going home today A wander guard to his Right ankle has been applied (wander guard number) EXP (expiration): 7/27 . This note was documented by the facility's Director of Nursing (DON). On 4/2/25 at 11:08 AM, R89 was observed in their wheelchair propelling themselves through the dining room towards the hallway their room was located on. A wander guard was observed on the resident's right ankle. On 4/2/25 at 11:59 AM, the DON was interviewed and was asked about the elopement incident with R89. The DON replied they had . just found out about that on Sunday . (Sunday 3/30/25). The DON stated the incident occurred early in the morning. The DON indicated one of the night shift aides was leaving and observed R89 outside under the facility's awning and brought the R89 back into the facility. The DON stated the aides came and told them about it on Sunday when they came to the facility. The DON identified two of the day shift aides that informed them of the incident. The DON was asked the name of the CNA that found the resident outside and the DON provided the name of Certified Nursing Assistant (CNA) H. The DON stated they would have expected staff to notify them of the incident so that they could notify the Administrator. The DON was asked if they notified the Administrator when they were informed of the incident and the DON stated they did. This confirmed the DON and Administrator was aware of the incident on 3/30/25. On 4/2/25 at 12:05 PM, the Administrator was asked to provide CNA H time punches for the last two weeks. On 4/2/25 at 12:06 PM, a telephone interview was conducted with CNA H, who was asked about the elopement incident with R89. CNA H stated they were driving leaving work to go home and saw (R89) outside by themselves under the awning in front of the facility. R89 stated they pulled over their car and brought the resident back into the facility and told CNA I and CNA J that the resident was found outside by themselves. When asked, CNA H stated they could not recall the exact times of last seeing R89, or finding R89 outside of the facility. A review of CNA H's time punch documented CNA H last day worked was noted as 3/28/2025 on the 7 PM to 7 AM shift. Review of the facility assignment sheets revealed CNA H on duty for the midnight shift and confirmed CNA I and CNA J as the day shift CNA's. On 4/2/25 at 12:16 PM, the Administrator was interviewed and asked about the elopement incident with R89. The Administrator was asked the date and time that the facility identified for the elopement incident for R89. The Administrator stated they would have to review their investigation report. The Administrator was asked what they had identified regarding the incident and the Administrator stated it was their understanding (R89) was found outside in front of the facility. The Administrator was asked the name of the staff member the facility identified to have found R89 outside the facility and the Administrator stated they would have to refer to their investigation report. The Administrator was asked when they were informed of the incident and by whom, the Administrator stated the DON had informed them but they did not recall the date and time that they were informed. The Administrator was asked why they failed to report the incident to the SA and the Administrator stated they were still investigating the incident. The Administrator was asked to provide their investigation thus far and to provide the facility's incident and accident report of the elopement incident for review. On 4/2/25 at 1:32 PM, a second request was made to the Administrator to provide the facility's investigation and Incident and Accident report regarding R89's elopement incident. On 4/2/25 at approximately 2:03 PM, the Administrator accompanied by Nurse Consultant (NC) A, explained the DON was just informed of the elopement incident this Sunday (3/30/25). The Administrator was asked why they failed to report the allegation of R89 eloping from the facility and the Administrator stated they were still investigating the allegation. The Administrator stated they informed NC A about the incident yesterday (4/1/25) to help them complete the investigation. The Administrator and NC A was asked third time to provide the investigation and the Incident and Accident report for R89's elopement. On 4/2/25 at approximately 3:20 PM, NC A provided the facility's investigation. An Incident and Accident report was not provided. On 4/3/25 at 8:54 AM, the investigation file was reviewed. Review of the investigation file contained the following: A Employee Corrective Action documented for CNA H which noted the resident was found by CNA H outside and failed to report the incident per the facility's protocol. This Corrective Action was back dated to 3/31/25. (As of 4/2/25 when interviewed, CNA H denied having been contacted by anyone regarding follow up from finding R89 outside of the facility and having to bring them back in to safety.) A statement from CNA I and CNA J who denied being informed by CNA H about R89 being found outside. A telephone statement from CNA H which documented they found (R89) outside in their wheelchair on the last day they worked (3/28/25). CNA H was driving home and stopped their car to bring R89 back into the facility. CNA H informed the interviewer that they gave R89 to CNA I and CNA J who both stated they would inform the nurse. This statement was dated 3/31/25. Review of a report submitted to the SA on 4/3/25 documented in part . year the incident occurred-3/28/2025 . During the annual survey the surveyors are alleging the guest was at the front doors and brought in by a staff member. Investigation has been put in place, POA, and physician contacted. I acknowledge that the information provided is true to the best of my knowledge- Yes . On 4/3/25 at 1:23 PM, the Administrator and NC A were interviewed and asked about the submission to the SA on 4/3/25 regarding the incident with R89. The Administrator and NC A were asked why they documented on the report that the surveyors are alleging the guest was at the front doors and brought in by a staff member . when they were fully aware of CNA H verbalizing the allegation, and the facility obtained a statement from CNA H that documented the incident as described. The Administrator stated that was documented in error and apologized for the mistake. The Administrator stated the report was not supposed to say that. The facility also completed an Employee Corrective Action documenting CNA H's failure to report the incident. The Administrator and NC A were then asked about the Employee Corrective Action for CNA H and how it was dated 3/31/25 when CNA H had already verbalized no follow up was conducted with them by anyone regarding the incident. The Administrator and NC A acknowledged the concern and left the conference room. A short time later, the Administrator and NC A returned and stated the Employee Corrective Action for CNA H was not accurate and was not obtained on the date of 3/31/25. No further explanation was provided. The facility failed to timely submit and provide an accurate report to the SA. A review of a facility policy titled Elopements revised December 2008, documented in part . Staff shall investigate and report all cases of missing residents . Staff shall promptly report any resident who tries to leave the premises . to the Charge Nurse or Director of Nursing . The Director of Nursing or Charge Nurse shall . complete and file Report of Incident/Accident; and . Document the event in the resident's medical record . The facility staff failed to follow the facility policy. No further explanation or documentation was provided by the end of the survey.

This citation pertains to intake MI00145465, MI00145510 Based on interview and record review, the facility failed to permit one resident (R901) of two reviewed for discharge, to return to the facility and failed to provide the required facility-initiated discharge documentation. Findings include: On 7/3/24 and 7/8/24 two complaints were received by the State Agency (SA) alleging the facility failed to readmit R901 once medically cleared from the hospital and did not provide facility-initiated discharge paperwork. A clinical record review revealed R901 was admitted to the facility on [DATE] with medical diagnoses which included history of traumatic brain injury, hypertension, asthma, dysphagia (difficulty speaking and swallowing) and seizures. R901 required maximum assistance for all Activities of Daily Living (ADL) and had mass cognitive and communication loss related to the traumatic brain injury. Review of a Medical Progress note dated 7/1/24 documented the Facility Physician, Doctor (Dr.) A was notified R901's blood pressure 200/114 and pulse 80. Dr A indicated the blood pressure was too high for R901, ordered to administer Catapres (medication to lower blood pressure) and send to the Emergency Department. Further review of Intake MI00145510, alleged on Wednesday, July 3, they received a telephone call from the Nursing Home Administrator (NHA) stating R901 could not return to the facility. Complainant replied that it didn't sound legal and the NHA responded, that's what we are doing. On 6/17/24 at 9:35 AM, The NHA and Director of Nursing (DON) confirmed the facility could meet all needs for R901. However, R901 was not accepted back to the facility related to the relationship between the facility and R901's Guardian. The NHA and DON confirmed the Guardian would intimidate and threaten the staff, and repeatedly interfered with R901's care. When asked if any grievances were documented, the NHA and DON indicated many attempts were made to the Guardian to provide opportunity to file formal grievances, however, the Guardian would never submit, and filed all concerns directly to the SA. The NHA acknowledged a phone call was made to the Guardian indicating R901 would not be returning to the facility. The NHA further confirmed the required documentation of a facility-initiated discharge was not provided.

Based on interview and record review, the facility failed to establish a comprehensive infection control program that identified resident infections, utilized laboratory and pharmaceutical data and ensured departmental surveillance and staff education on infection control. This deficient practice had the potential to effect all 75 residents (including R61 and R286) who resided in the facility. Findings include: On 3/13/24 at 10:11 AM, Registered Nurse (RN) C, who served as the Infection Preventionist was interviewed and asked about the facility' s infection surveillance. RN C explained she had started at the facility in late January 2024, so February was the first month she had personally done surveillance at the facility. RN C was asked if she also provided education to staff. RN C explained she was going to start doing staff development as she had noticed several issues with staff education. During the review of the infection surveillance, it was discovered R61, who had been admitted multiple times for rehabilitation since 4/3/23 was currently on Macrobid 100 mg (milligrams) one time a day, and had been on Macrobid since 6/15/23, almost nine months. When asked why R61 was on indefinite Macrobid, RN C explained R61's Infectious Disease (ID) doctor had put them on it. RN C was asked if R61 had ever followed-up with ID or Urology to ensure Macrobid was still needed nine months later. RN C was not able to find any documentation of a follow-up. Also discovered during the review, R286 had been given Ciprofloxacin 500 mg two times a day for 10 days for a urinary tract infection (UTI) with Gross hematuria . RN C was asked if gross hematuria was a symptom of a UTI. RN C explained it was not. R61 Review of the clinical record revealed R61 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: wedge compression fracture of vertebra, diabetes and heart disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R61 was cognitively intact. Review of R61's progress notes revealed: A physician note by Dr. G dated 2/26/24 at 10:15 AM read in part, .AP (action plan): . 6 Asymptomatic bacteruria/ Recurrent UTI- On chronic Macrobid; The benefits outweigh the risks . No mention in the progress note of education to resident and/or family of risks of long term antibiotic use, and no description of what benefits outweighed what risks. A physician note by Nurse Practitioner (NP) F dated 2/27/24 at 11:13 AM that read in part, .6 Asymptomatic bacteruria/ Recurrent UTI- On chronic Macrobid; The benefits outweigh the risks . It should be noted that the majority of the note including all ten points of the AP section were identical to Dr. G's progress note. A late entry physician note by NP F dated 3/6/24 at 9:35 AM read almost the same as the previous two notes including all ten AP points including 6 Asymptomatic bacteruria/ Recurrent UTI- On chronic Macrobid; The benefits outweigh the risks . On 3/13/24 at 11:25 AM, NP F was interviewed and asked why R61 had been on Macrobid since 6/15/24 with no documented follow-up with ID or Urology. NP F did not offer an explanation. NP F was asked why the progress notes did not say what benefits outweighed what risks. NP F did not offer an explanation. On 3/13/24 at approximately 12:45 PM, the Director of Nursing (DON) brought hospital paperwork to show ID had ordered the Macrobid. The paperwork shown documented R61's family had requested R61 be on Macrobid to prevent UTI's. When informed of what the paperwork documented, the DON gathered up the hospital paperwork and explained she would find the notes about the ID doctor and left with the paperwork. No documentation was provided by the end of the survey. On 3/13/24 at 1:09 PM, Dr. G was interviewed by phone and asked why R61 had been on Macrobid since 6/15/24. Dr. G explained R61 had been in and out of the facility for rehabilitation, and the resident wanted to stay on Macrobid as ID had put her on it. Dr. G was asked why the very similar progress notes by himself and NP F did not say what benefits outweighed what risks. Dr. G agreed the wording did not convey what the risks were. Dr. G was asked if R61 had been educated on the risks of long term antibiotic use, as there was no documentation of any education to R61. Dr. G had no answer. R286 Review of the clinical record revealed R286 was admitted into the facility on [DATE] with diagnoses that included: cellulitis of right toe, diabetes and heart disease. According to the MDS assessment dated [DATE], R286 was cognitively intact. Review of R286 ' s progress notes revealed a nursing note by Licensed Practical Nurse (LPN) L dated 1/25/24 at 6:34 PM that read, Guest reports that his urine is pink tinged. He states he has chronic prostatitis and this happens sometimes. Practitioner notified with request to see guest. On 3/13/24 at approximately 12:30 PM, LPN L was interviewed and asked about R286's urine. LPN L explained she remembered very well, R286 told her his urine was a little pink and his Primary Care Doctor (PCP) would always give him antibiotics when this happened for his prostatitis. When asked if that was why antibiotics were ordered for R286, LPN L agreed. Review of a facility policy titled, Infection Prevention and Control Program dated 11/21/17 read in part, .Surveillance is interdisciplinary, prospective and proactive, and utilizes both process and outcome data for prevention, early detection, and control of infections and communicable disease in the facility . Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made . A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner .

Based on observation, interview and record review, the facility failed to ensure nail care was provided to a resident (R10) of three residents reviewed for activities of daily living (ADL's). Findings include: On 3/11/24 at 10:42 AM, R10 was observed lying in bed. R10 was asked about care at the facility. R10 explained they had been asking for their fingernails and toenails to be cut, but no one had cut them since they had been there. Observation of R10's toenails revealed long, broken toenails. R10 explained they had been told they were on an imaginary list to be seen by Podiatry. Observation of R10's fingernails revealed broken nails on R10's right hand and long (approximately 1/4 to 1/2 inch) fingernails on R10's left hand including R10's left thumbnail that was wrapped over the top of the thumb and going down the inside of the thumb. R10 explained they did not have use of their left arm, only their right arm so their nails would get broken on their right hand as they used it for everything. Review of the clinical record revealed R10 was admitted into the facility on [DATE] with diagnoses that included: hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side, diabetes and depression. According to the Minimum Data Set assessment dated [DATE], R10 was cognitively intact and required assistance of staff for ADL's. Review of R10's skin integrity care plan revealed an intervention initiated 4/3/23 that read, Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. On 3/12/24 at 10:20 AM, Upon knocking and opening the door, R10 was not observed in the room, and the shower could be heard running in the bathroom. On 3/12/24 at 10:55 AM, R10 was observed sitting in a wheelchair in the room. R10's fingernails on their left hand still appeared to be long with the thumbnail wrapped around around the top of the thumb. On 3/12/24 at 11:20 AM, Certified Nursing Assistant (CNA) H was interviewed and asked about nail care at the facility. CNA H explained the Podiatrist would cut toenails, but fingernails were cut by CNA's. When asked how often fingernails were cut, CNA H explained they were cut when needed. On 3/12/24 at 11:55 AM, the Social Services Director (SSD) was interviewed and asked if R10 had ever been seen by the Podiatrist. The SSD explained she would find the information. On 3/12/24 at 12:13 PM, the SSD R10 had been put on the list for the Podiatrist in November 2023, but had not been seen by the Podiatrist. When asked why R10 had not been seen by the Podiatrist since November, the SSD had no explanation. On 3/12/24 at 12:30 PM, the Director of Nursing (DON) was interviewed and asked about R10's long fingernails. The DON explained R10 had not complained about their long nails. The DON was asked if R10 had to complain about their nails to get them cut, or if staff should be cutting fingernails before they started to wrap around a thumb. The DON explained staff should be cutting nails if they were long. Review of a facility policy titled, Assisting the Nurse in Examining and Assessing the Resident revised October 2010 read in part, .Activities of daily living (ADL) include the resident's physical, psychological, social and spiritual activities . As you provide the resident with personal care needs, you should note: . b. Assistance needed with bathing, hair and nail care, dressing and undressing, mouth care; and c. Any changes in the resident's grooming or dressing habits .

Based on observation, interview, and record review, the facility failed to secure medications and administer medications/treatments according to accepted standards of clinical practice for three residents (R63, R56, R6) of three reviewed for standards of practice, resulting in the potential of medications not being administered correctly and for medications to be unsecured. Findings include: Resident #6 Clinical record review revealed R6 was admitted to this facility on 7/17/22 with primary medical diagnosis of nontraumatic brain dysfunction, heart failure, thyroid disease, and urinary dysfunction. Review of the Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of nine, indicating moderate cognitive impairment. On 3/12/24 at 8:26 AM, medication administration was observed by Licensed Practical Nurse (LPN) A for R6. Prepackaged medications were handed to this surveyor for identification. As LPN A was retrieving additional ordered medications, it was identified that one ordered medication was not in R6's medication cabinet. LPN A stated she needed to go elsewhere to retrieve it and proceeded to leave the room with the medication cabinet open and previously pulled medications were left on top of this surveyor's computer. This surveyor stopped LPN A as she passed by and inquired if leaving R6's medications on my computer is standard practice. LPN A stated no, retrieved medications and returned to the medication cabinet. The Director of Nursing (DON) was informed that LPN A left medications unattended and attempted to leave the room with an unlocked medication cabinet. The DON replied LPN A must have been nervous being observed by the surveyor and indicated that she would further discuss and acknowledged medications should not be left unattended. Review of the facility Medication Administration Policy dated 01/21 stated .During administration of medications, the medication cart is kept closed and locked when out of site of the nurse. No medications are kept on top of the cart . 39592 R63 On 3/11/24 at 11:02 AM, R63 was observed sitting in their room. A medicine cup containing a pinkish liquid was observed on R63's over-bed table. R63 was asked about the pinkish liquid in the medicine cup. R63 explained it was Carafate (anti-ulcer medication), the nurse had brought it for them, but they did not want to take it at that time, so the nurse had left it on their table so they could take it later. Review of the clinical record revealed R63 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: multiple sclerosis, fibromyalgia and gastro-esophageal reflux disease (GERD). According to the MDS assessment dated [DATE], R63 was cognitively intact. Review of R63's March 2024 Medication Administration Record (MAR) revealed an order for, Sucralfate (Carafate) Oral Suspension 1 GM (gram)/10ML (milliliters), Give 10 ml by mouth four times a day for ulcer . Further review of the clinical record revealed no documentation of R63 having been assessed for self-administration of medications. On 3/12/24 at 10:02 AM, Registered Nurse (RN) D, R63's assigned nurse, was interviewed and asked about the Carafate left on R63's over-bed table on 3/11/24. RN D explained she had not left any medication with R63 as she was not a good candidate for self-administration of medications. When asked how the Carafate got on R63's table, RN D explained R63 received Carafate four times a day, and could have been left by the midnight nurse. On 3/13/24 at 9:21 AM, the DON was interviewed and asked if Carafate could be left on an over-bed table for a resident not assessed for self-administration of medications. The DON explained medications should never be left at the bedside. 47283 R56 A record review revealed R56 was a long-term resident originally admitted to the facility on [DATE], was recently hospitalized and readmitted on [DATE]. R56's admitting diagnoses included Peripheral Vascular Disease, recent vascular surgery in lower extremities due to limb ischemia (lack of blood supply), and Diabetes Mellitus. Based on the Minimum Data Set (MDS) assessment dated [DATE], R56 had a Brief Interview for Mental Status score of 15/15, indicative of intact cognition. An initial observation was completed on 3/11/23, at approximately 11:25 AM. R56 was observed sitting on their bed. An interview was completed during this observation. R56 had multiple deep red lesions on their right arm. The skin appeared dry, scaly and had multiple scabbed areas. When queried R56 on how they were doing, R56 reported that the have had itching and pain on their right arm and pointed to all the lesions. R56 also reported it started a couple of weeks ago; they had one lesion in their mouth and one on their left ear. When queried if they were getting any treatment, R56 reported they were getting treatment before and they reported that the nurse practioner was there to see her earlier today. When queried further about the treatment, R56 pulled a cream that was sealed in a bag with a pharmacy label that read Clobetasol 0.5% cream - Dr. Issue date: 2/29/24 - apply cream topically to rash twice daily for 5 days and reported that was cream that was ordered by their doctor. When queried if they were keeping the cream and applying on their own, R56 reported that they were supposed to be locked in their medication cabinet. R56 added that they had reported increased itching to their day shift nurse on 3/10/23 and the nurse had pulled out this cream that was ordered before (for 5 days from 2/29/24) and had told them that they could apply the cream on their own. R56 stated, I don't think it was smart idea. This surveyor asked R56 if they had used the cream on their own. R56 reported that they were not comfortable applying the cream on their own. When queried why, R56 reported that it needed to be applied specifically on the rashes/reddened areas and they were not comfortable applying the cream on their own. R56 added that they had not used the cream since the nurse had left it at the bedside on 3/10/23. During a follow-up observation that was completed on 3/11/23, at approximately 11:50 AM, this surveyor was in the room speaking with R56's roommate. R56 was sitting up on their bed, a facility staff member was observed applying the cream for R56 and had left the room. This surveyor queried R56 and they reported that the staff member who applied the cream was their nurse would lock the cream. At approximately 12:05 PM, RN K who was assigned to care for R56 that shift was in the 400 hall. This surveyor queried RN K about the medication. RN K reported that they had locked up the medication and confirmed that R56 was not comfortable applying the cream. Review of R56's Electronic Medical Record (EMR) on 3/11/23, revealed a discontinued order with a start date of 2/29/24 that read, Clobetasol propionate external cream 0.5%. Apply to rash topically two times a day for dermatitis for 5 days. A review of Treatment Administration Record revealed that R56 had received above medication 2/29/24, 21:00 through 3/5/24, 9:00. The above medication was discontinued as of 3/5/24. A last practioner note dated 3/4/23 at 14:30 read in part, The rash is worsening with intense itch per patient .shingles-Valacyclovir ordered. The benefits outweigh risks. DC clobetasol. Further review of R56's EMR did not reveal any assessment or care plan for self-administration of medications/treatments. Review of R56's EMR on 3/12/24 revealed no new orders. A late entry practitioner note dated for 3/11/24, completed on 3/12/24 at 11:25 read, AP (Assessment - Plan): Shingles - improving, continue Benadryl for itching. R56 had an ongoing order for Benadryl Allergy Oral Tablet 25 MG (Diphenhydramine HCl) Give 1 tablet by mouth every 8 hours as needed for itching since 02/29/2024. There were no other orders. A nursing progress note dated 3/12/24 completed at 11:07 AM (after the concerns were brought to the facility's attention on 3/11/24) read, called and spoke to NP (Nurse Practitioner) regarding visit on 3/11. NP visiting again today a new order to start cream that was previously used for duration 5 days. An order dated 3/12/24 revealed that Clobetasol propionate external cream 0.5%. was reordered for 5 days from 3/12/24 through 3/17/24. R56 did not have an order for the medication on 3/10/24, when the medication was given to the resident to self-administer, without an assessment for self-administration. During an interview with the unit manager A on 3/12/24, at approximately 12:00 PM, unit manager A was queried on the self-administration of medication process. Unit manager A reported that they would complete a self-administration assessment and if residents were able to complete it based on the assessment, a care plan would be in initiated. When queried on R56 and the clobetasol topical cream, unit manager A reviewed the EMR and confirmed that R56 did not have a self-administration assessment, care plan and no active order for the medication (clobetasol cream). An interview was completed with the Director of Nursing (DON) on 3/12/23, at approximately 3:05 PM. The DON was queried on concerns with the discontinued medication that was left at bedside for R56, when the resident clearly expressed that they were not comfortable administering the medication. The DON reported that R56 had a verbal order to apply the cream from the practitioner on 3/11/24, despite no evidence on R56's EMR, medication was reordered on 3/12/24. The DON reported that they understood the concern about medication that was left at the bedside for R56 and that the nurse did not follow the facility's process; they would follow-up and re-educate the nurse. A review of facility provided document titled Job description for RN (registered nurse) Supervisor read in part, The RN Supervisor is responsible for ensure standards of care for the area, manages the environment to ensure safety standards are maintained. Ensures their unit maintains compliance with federal, state, and local regulations. The employee must follow [facility] policy and procedures. Supervise the patients in their group and the performance of the nursing assistants. The employee would perform duties as defined by state and federal regulations. Essential Functions: Gives nursing report at the beginning and end of their shift. Makes frequent rounds to assess their group of patients. Takes vital signs as needed. Completes assigned charted each shift. Updates MD, families, and Wellness Director of changes in condition Ensures work area is maintained in a clean and sanitary manner. Updates care plans as needed to ensure care is being delivered as ordered & attends care plan meetings as scheduled. Keeps medication rooms and medication drawers locked & orderly. Counts narcotics each shift with the oncoming nurse. Completes the required form upon admission, transfer and/or d/c. Receives and transcribes MD orders as received .

Based on interview and record review, the facility failed to maintain an effective Antibiotic Stewardship program that included consistent implementation of protocols for appropriate antibiotic administration and ensured that infection criteria were met for three residents (R47, R61 and R286) resulting in the potential for unnecessary antibiotic usage and the development of multiple drug resistant organisms. Findings include: On 3/12/24 at 10:11 AM, Review of the facility's infection control program with Registered Nurse (RN) C, who served as the Infection Control Nurse revealed the following: R61 was documented in February 2024 as having a urinary tract infection (UTI), was Asymptomatic, no organism was identified, and was on indefinite Macrobid 100 mg (milligrams) one time a day since 6/15/23. R61 was also documented in December 2023 as having a UTI for Functional decline, the organism was documented as UNKNOWN, criteria not met, was on Macrobid 100 mg. RN C explained R61 had been placed on Macrobid by an Infectious Disease (ID) doctor and had been on Macrobid since 6/15/23. RN C was asked if R61 had any follow-up with ID or Urology to see if the Macrobid was still needed after almost nine months. RN C explained she would look for documentation. No documentation of follow-up with ID or Urology was provided by the end of the survey. R47 was documented in January 2024 as having a UTI, had Altered mental status, the organism was documented as N/A (not applicable), criteria not met, was on Macrobid 100 mg two times a day from 1/31/24-2/5/24. RN C was asked if a culture and sensitivity (C&S) were done of R47. RN C explained only a urinalysis (UA) was documented as done. When asked how was it determined which antibiotic to use when the organism was not identified by a C&S, RN C explained she did not know. R286 was documented in January 2024 as having a UTI, had Gross hematuria , the organism was not documented, criteria not met, was on Ciprofloxacin 500 mg two times a day. RN C was asked if gross hematuria was an indicator of infection. RN C explained no, it was not. Review of a facility policy titled, Antibiotic Stewardship Policy and Program Protocol Requirements undated read in part, .Protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made .

Based on interview, and record review, the facility failed to abide to the resident's advance directives for one (R42) of one resident revieweded for code status. Finding include: R42 was initially admitted to this facility on [DATE] with obstructive uropathy (blockage of urine flow), diabetes, colon cancer, chronic kidney disease, behavioral disturbance and unspecified dementia. A Brief Interview for Mental Status (BIMS) summary score of five, indicated a severely impaired cognition. On [DATE] at 1:30 PM, a record review revealed R42 consented on [DATE] .in the event my heart and breathing should stop, no person shall attempt to resuscitate. Being of sound mind, I voluntarily execute this order, and I understand its full import . The do-not-resuscitate order was issued by Physician G and the attestation of witnesses signed by Social Service Department B and J stated .The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence . Further record review identified on [DATE], a social services care transition note indicated .guest will remain a Cardiopulmonary Resuscitation (CPR) by default until Power of Attorney (POA) is on file and competency is evaluated by two physicians . On [DATE] at 3:04 PM, an interview was conducted with Social Services B who stated R42 was assessed on [DATE], and based on change in cognition, the facilities interdisciplinary team felt it was in the best interest of R42 to be defaulted to a full code until a Power of Attorney (POA) was confirmed. Social Services B further stated that when R42 signed the do not resuscitate order the BIMS score was five and further acknowledged that she and colleague J signed the witness attestation indicating R42 was of sound mind to change his code status. On [DATE] at 3:35 PM, The facilities administrator was notified of the facilities interdisciplinary team changed the R42's code status to full resuscitation without his knowledge and contraindicated original wishes made by R42 on [DATE]. When requested the facilities Advance Directive Policy, the facility forwarded an Advance Directive pamphlet that is provided to the residents upon admission.

This citation pertains to intake #MI00141606. Based on interview and record review, the facility failed to identify a change in condition and ensure timely care and treatment for one resident (R705) of one resident reviewed for a change in condition, resulting in delayed hospitalization and treatment, and the worsening of overall health. Findings include: A review of a complaint submitted to State Agency(SA) documented concerns of failure to assess and properly treat, lack of rehabilitation, fall with injury and notify a change in condition. On 12/27/23 at 9:30 AM, Family A(the complainant) was interviewed regarding R705's stay at the facility. Family A stated, .On 10/18/23 my mother was transferred to the facility and as soon as she was released from the stretcher her independence was stripped away. My mother was placed in her room they took vital signs and put her in a brief. My mother and I both told the facility that she did not wear briefs because she was able to walk to the bathroom, and that when the nurse told us that they are not allowed to get her up until therapy assessed for safety reasons, which I understood that. We had a three week discharge date and she was not progressing. I talked to the therapy department on why wasn't she walking because she had been doing so at the hospital. I later found out that she was getting therapy but at 6 am and doing in room therapy, the therapist would place her in a wheel chair and then she would remain in her wheel chair until it was time for her to lay back down for bed. This of course caused her to be incontinent on accident because it was no one would take her to bath room once she was in the chair and she still needed some assistance with transfers. At this point I noted that my mothers progress from the hospital had regressed and I spoke to administration about this matter and asked could she be placed on a bathroom schedule and they told me that they were short staffed .My mother's discharge was approaching and she had made no progress to be able to live in a assisted living facility and I brought that to the administration attention and they stated she could stay another week but I told them with the exception of her doing therapy outside of her room and that they actually take her to the bathroom instead of putting three briefs on her, they agreed so we stayed. On a Monday 11/13/23 at 8:30 PM, I received a phone call from a male nurse (later identified as Nurse E) who told me my mother had fallen .I asked the nurse was it bad and he replied, 'Yep its bad.' I then asked Nurse E was she (R705) going to the hospital, Nurse E replied, 'Nope, but the Nurse Practitioner (NP) (later identified as NPF) would see her' and that they had started neuro checks on her .On 11/14/23 I arrived to the facility at 6 AM .a nurse told me that the Certified Nursing Assistant (CNA) (later identified as CNA G) had gotten my mother up to walk her to the bathroom and walked away to move her bedside table and my mother fell and hit the back of her head, Nurse E also told me that she (R705) was vomiting all night (which she was still vomiting the time that I arrived). After they finished the neuro checks on my mother no one came in to take my mother's vitals (blood pressure, pulse, respirations and temperature) and I stayed there all day and night after my mother's fall. I asked Nurse B should vitals be done and she replied our CNAs don't have time for that they are too busy and short staffed. On 11/15/23, the NPF finally came to assess my mother at this time my mother had stopped vomiting because they had gave her medication to stop it (the vomiting) she asked my mother what happened and how did she fall, my mother responded and told her,'I did not fall', and I explained to her (NP F) that she fell and hit her head, there was a knot on the back of her head and she was on a blood thinner, I also let NPF know that my mother's mental status was a little off she was reverting back to childlike tendencies and that was never my mother. I also let NP F know that my mother was more tired than usual and NP F told me she would be back and see my mother the next day but would order labs. The NP F never came back to see to see my mother. At this point I asked Nurse B could they send my mother to the hospital and she replied to me, 'Why would we do that?' .Nurse B told me that the facility wouldn't send her out because there NPs at the facility would assess her and treat her as necessary .The facility kept telling me that my mother is old and its probably dementia however my mother has never had dementia .The Saturday (11/18/23) after the fall .I told the nurse I want to send my mom to the hospital the nurse .came to my mother's room and asked my mother, 'Do you want to go to the emergency room and be waiting for hours not to be seen?' .I asked Nurse B to call the doctor .the on call NP answered and I told her what happened to my mother, that her sodium level was low and how she had been presenting for almost a week, she told the facility to send her out (to the hospital) .We arrived to the hospital, my mom had a concussion, and aspiration pneumonia from vomiting . My mother stayed in the hospital 10 days receiving antibiotics and ended up being septic (severe bacterial infection) . A Record review revealed that R705 was admitted to the facility on [DATE] with the diagnoses of displaced intertrochanteric facture of the left femur, weakness and dizziness and giddiness with a Brief Interview for Mental Status(BIMs) score of 14 (indicating an intact cognition). A further review of the record revealed that on 10/18/23 an admission note was put in stating, Resident states she's had multiple falls in the past month. A further review of the record revealed that R705 fell on [DATE]. According to the accident and incident report, R705 was walked to the bathroom by CNA G and CNA G reached over to move a bedside table out of their walking path and R705 lost balance and fell . It stated that the daughter was notified and the provider was contacted and no new orders were given and to continue with the neuro check/fall protocol. A record review of a progress note created by Nurse E stated that after falling, R705 complained of being hot, and generalized aching when getting up after being transferred to the bed. There was no mention of the the resident's nausea and vomiting all night and into the morning when family a had arrived that morning at 6AM on 11/14/23. A review of the medical record revealed no documentation by the nursing staff reflecting the change of condition, nausea, vomiting and dizziness with the resident or why they contacted the physician for Ondansetron 4mg (milligrams) (a medication used for nausea and vomiting) started on 11/14/23 at 10:45AM and Meclizine 25mg (a medication used for dizziness and giddiness) on 11/16/23 at 8:45 AM. A review of the medical record revealed that NP F created a late entry progress note time stamped for 11/20/23 at 7:04 AM back dated for 11/15/23. The note revealed that when she went to assess resident on 11/15/23 (two days after the fall) that R705 was feeling better and that the nausea and vomiting had subsided and complained of dizziness while in bed and turning or turning with ambulation. NP F prescribed Meclizine for dizziness and giddiness. On 12/27/23 at 10:13 AM, the Director of Nursing (DON) was interviewed and asked what the protocol was for a resident that falls and hit their head, the DON replied, We do neuro checks. The DON was asked what the facility's process is for a resident with a visible knot on their head and the new development of nausea and vomiting, the DON replied, Yes, we would report the knot and vomiting to the doctor and if they want them sent out or if they are on a blood thinner we will send them out to the hosptial (for evaluation). On 12/27/23 at 11:04 AM, an attempt to call Nurse E was completed, however there was no answer and the voicemail box was not set up to leave a message for a call back. On 12/27/23 at 11:15 AM, an attempt to call CNA G was made but their was no answer. CNA G did not call this surveyor back by the end of the survey process. On 12/27/2023 at 1:00 PM, Doctor C (R705's attending physician) was contacted via telephone and interviewed briefly. Dr. C was asked if he was familiar with R705, the replied, Yes and explained she was discharged from the facility about a month ago, and she was not a resident for that long. He was further asked was he aware that R705 had fallen at the facility, hit the back of her head, had a knot on their head and was experiencing nausea and vomiting, Doctor C stated, No, I was not aware of that but I am on vacation if you want to discuss it further you can call me back after the first of the new year. Doctor C was asked if NP F was available to talk and stated, No, she is on vacation as well . No addition information was provided at the exit of survey.

Based on interview and record, the facility failed to transfer one resident (R705) per the care plan, of one resident reviewed for falling, resulting in a fall with injury to the back of head. Findings include: A review of a complaint submitted to the State Agency(SA) documented concerns of failure to assess and properly treat, lack of rehabilitation, fall with injury and notify a change in condition. A record review revealed that R705 was admitted to the facility on [DATE] with the diagnoses of displaced intertrochanteric facture of the left femur, weakness and dizziness and giddiness with a Brief Interview for Mental Status (BIMs) score of 14 (indicating an intact cognition). A further review of the record revealed that on 10/18/23, an admission note was put in stating that Resident states she's had multiple falls in the past month. A further review of the record revealed that upon admission on 10/19/23, R705's transfer status was a two persons assist with a two wheeled walker and weight bearing as tolerated and to only ambulate with therapy was discontinued on 11/4/23. On 11/4/23 a new transfer status was put in for one person assist with a two wheeled walker weight bearing as tolerated and to ambulate with therapy only was discontinued 11/13/23. A further review of the record revealed that R705 fell on [DATE] at 8:00PM, according to the accident and incident report R705 was being walked to the bathroom by CNA(certified Nurse Assistant) G and CNA G reached over to move a bedside table out of their walking path and R705 lost their balance and fell . It stated that the daughter was notified, and the provider was contacted, and no new orders were given and to continue with the neuro check/fall protocol. On 12/27/23 at around 2:00PM, Therapist D was interviewed and asked what was R705's transfer status upon discharge to from the facility, Therapist D explained that R705 was a one person assist with rolling walker but to only ambulate with the therapy department. Therapist D was then asked how is the frontline staffed notified of these changes, Therapist D stated, We put it in an order and it would usually show up on the Kardex (care plan for CNA) for CNAs. Therapist D was asked should CNAs have been walking R705 to the rest room, Therapist D stated, No and explained that the CNA's can help R705 stand and pivot to a wheelchair and then get R705 up when at the bathroom to pivot her to toilet but therapy is the only department that should ambulate R705 according to the orders. Therapist D was asked do CNAs use transfer belts (a belt that ties around the waist of the resident to allow an area to grab/hold on to the resident during transfers), Therapist D replied, No not to my knowledge. On 12/27/23 at 2:10 an attempt to call CNAG was made but no answer. There was no return phone call back by the end of the survey. On 12/27/23 at the Director of nursing (DON) was interviewed and asked what the transfer status of R705 was, the DON explaineded R705 was a one person assist with the walker and was to ambulate with staff. The DON was asked if the facility uses gait belts to transfer residents, the DON replied, No, we do not use gait belts at the facility this is a no lift facility so if a resident cannot push up on their own staff would then let nursing or therapy know about the extra needed assistance.The DON was further asked since the facility doesn't use gait belts how do they assist residents with standing, DON replied, that the CNA would stand in front of resident and assist them by either grabbing their paints or under their arms. The DON also stated there was no correlation with the prevention of falls if gait belts are used. The DON was then asked how should staff transfer a person who is a 1 person assist and should they be unassisted for any moment during the transfer process. The DON replied, No, they should not be unassisted at any time during the transfer. The staff member would assist the resident up and then guide them to wherever they were going. The DON was asked if staff should have made sure the paths were clear prior to transfers and replied, You should (clear a path prior to attempting to transfer a resident). No additional information was provided by the exit of survey.

This citation pertains to Intake #MI00138141. Based on observation, interview and record review, the facility failed to timely assess, monitor and appropriately treat a resident with a history of respiratory distress for one (R702) out of three residents reviewed for change in condition/oxygen levels, resulting in in the development of respiratory distress (O2 level at 66%) requiring emergency hospital treatment and admission. Findings include: A Complaint was filed with the State Agency (SA) that alleged EMS (emergency medical service) was told by a nurse caring for R702 that their oxygen levels remained at 66% on room air for over an hour before they called EMS causing the resident to decompensate due to an inability to breath and hypoxia. A review of the (name redacted) County EMS report documented, in part: .Date: 7/3/23 .call received (22:31:13) .On Scene (22:52:29) .Patient Name (R702) .Events leading up to the call: .female sick for a few days with shortness of breath, tonight staff notes 1 hour PTA (prior to arrival) PT (patient) rapidly deteriorated and she is now having extreme distress .Onset: 1 hour PTA .Provocation (what makes it better or worse): nothing .Quality .Impending Respiratory Failure .Severity .Acute .Time .PT condition is deteriorating .Additional Assessment Findings: PT .found lying on her left side in bed, AO (alert and oriented) 1-2 with diminished LOC (level of conscious) per staff. Skin pale, cool, diaphoretic. Breathing >30BPM (breaths per minute) with diminished lung fields and accessory muscle use. PT (patient) is hypotensive (low blood pressure). SPO2 (oxygen saturation-normal is >90%) 60% on room air, 94% on 6 LPM (liters per minute) Nasal Cannula . A review of R702's hospital records documented, in part: .R702 .admitted to the Medicine Faculty Hospitalists service for Respiratory failure .Arrival Date/Time: 7/3/23 -11:42 PM .Brief Hospital Course .R702 .history of pulmonary sarcoid, COPD (chronic obstructive pulmonary disease) .presenting acute hypoxic and hypercapnic respiratory failure .Patient was at (Facility) after recent admission at (name redacted) Hospital (4/18-4/23) for respiratory failure of unclear etiology. She reports that she had been doing well at (Facility) until 2 nights prior to her current presentation. She says that in the evening two nights ago, she started developing increasing difficulty with her breathing, feeling short of breath and with a lot of mucus/phlegm production in the back of her throat. She says they treated her with nebulizers (breathing treatments), oxygen and Mucinex (anti congestant), and her symptoms did improve. The next day she was feeling better. They kept her on oxygen, but she says she was feeling better, so she kept turning the oxygen off herself. That evening she reports feeing worse again, with recurrent shortness of breath. She remembers asking a nurse to help her get into bed around 7 PM. That is the last thing she remembers. Per ED (emergency department) . patient became increasingly dyspneic (difficulty breathing) that evening, prompting EMS to be called. EMS reportedly found her saturating 60% on room air. She was placed on NRB (non rebreather mask) and treated with nebulizers and solumedrol .ED initiated aggressive treatment with BiPAP, continuous albuterol, ipratropium, magnesium, terbutaline, epinephrine, ceftriaxone, azithromycin and IV (intravenous) Lasix .RPAN (respiratory test) resulted positive for parainfluenza (virus that can cause upper and lower respiratory infections) . MFH (Medicine Faculty Hospitalist )COURSE: She initially had increased work of breathing after leaving ICU (intensive care unit), but with supportive oxygen up to 10 liters of nasal cannula .She was intermittently delirious requiring restraints which improved by discharge . On 7/21/23 at approximately 9:20 AM, R702 was observed lying in bed. The resident had 02 (oxygen) running at 2 liters. The resident was alert and noted that they had some hearing and vision problems. R702 reported that they had been at the facility since April 2023 and was admitted due to respiratory issues. When asked how long they have been on 02, they reported since they returned from the hospital. When asked about why they were sent via EMS to the hospital with their most recent hospital stay (7/3/23-7/13/23), R702 stated that they remembered being in the hospital and coming back to the facility, but not much more than that. A review of R702's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: COPD, acute and chronic respiratory failure, sarcoidosis (disease caused by growth of inflammatory cells) and anxiety. A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact) and required extensive one person assist for most activities of daily living (ADLs). Continued review of R702's clinical record documented, in part, the following: Care Plan: Focus: Potential/actual alteration in oxygen exchange R/t (due too) COPD, sarcoidosis, SOB (shortness of breath), Asthma (Revision on 5/30/23) .Interventions:Monitor of s/sx (signs and symptoms) of respiratory distress and report to MD PRN: Respirations, Pulse Oximetry, increased heart rate .Restlessness, Diaphoresis, headaches, Lethargy . Review of the R702's orders, showed no order for 02 since admission. Medical Administration Record (MAR) noted R702 received Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/ML-milligrams/liters) 3 ml inhale orally via nebulizer every 6 hours as needed for wheezing: Given 7/2/23 @ 11:11 AM, 7/3/23 @ 8:56 AM and 7/3/23 @ 4:12 PM (last dose of Albuterol Sulfate provided through the nebulizer marked as administered). 7/3/23 (8:23 PM): Medication Administration Note: Albuterol Sulfate Inhalation Nebulization Solution (2.5 MG/3 ML) .3 ml inhale orally via nebulizer every 6 hours as needed for wheezing PRN Administration was: ineffective . clearly still has wheezing (emphasis added). Skilled Charting (Effective Date: 7/3/23 at 11:00 PM and Created Date: 7/4/23 at 1:02 AM): guest sent to ER per her request, due to respiratory distress, guest having unstable vitals low oxygen 69%; labored breathing, pulse as low as 33. On call (name redacted) approve order. Writer received call from (name redacted) hospital ER where she was sent and spoke with social worker and ER physician. (Authored by Nurse A) 7/3/23 (11:00 PM): SBAR Summery for Providers: Situation: The Change in Condition/s reported on this .Evaluation are/were: Abnormal vital signs (low/high BP (blood pressure), heart rate, respiratory rate, weight change) Shortness of breath .At the time of evaluation resident/patient vital signs, weight and blood sugar were: Blood Pressure (BP): 168/80 (7/3/23 @10:00 PM) .Pulse (P): 60 (7/3/23 @ 10:00 PM) .Respiratory Rate (RR): 36 (7/3/23 @ 10 PM) .Temp (T): 97.1 (6/30/23 @ 5:22 AM), Weight(W): 196.8 lb. (6/1/23 @ 9:07 AM) .Pulse Oximetry : O2 97.0% (6/30/23 @5:22 AM - Method: Room Air *It should be noted that 6/30/23 was the last 02 Stat Summary noted in the resident's clinical record ) .Primary Diagnosis is: SARCOIDOSIS, UNSPECIFIED SHORTNESS OF BREATH .Nursing observations are: recommend to send to ER for respiratory distress per guest request .C. New Intervention Orders: Oxygen (if available). On 7/21/23 at 11:03 AM Nurse A was contacted via phone. A voice message was left. A second attempt to contact Nurse A was made via phone on 7/21/23 at 4:06 PM. No return call was made by Nurse A prior to the end of the Survey. On 7/21/23 at approximately 2:02 PM an interview and record review were conducted with the Director of Nursing (DON). The DON was asked as to the facility policy pertaining to 02 orders as well as vitals. The DON reported that residents need an order from the physician for 02. When asked why R702, who was currently observed with 02 running at 2liters did not have a physician order. The DON reported that there should have been an order. With respect to obtaining vitals, the DON noted that vitals are taken upon admission and then daily for approximately one month, unless a different order is provided. With respect to long term residents, vitals, including 02 stats, the DON stated that they are not taken daily as residents are treated as if they were living at home. When asked about R702 and the decline in 02 status leading to respiratory distress and a hospitalization , the DON reported that she was aware that the resident was having respiratory issues as they had shortness of breath and recalled personally giving the resident albuterol treatments on 7/2/23. When asked as to why the document created by Nurse A (7/3/23) noted that R702 guest sent to ER per their request, the DON reported that was the facilities way of confirming hospitalization with their residents. When asked as to the why the resident was not being continuously assessed and when was it determined the resident's 02 level was 66% on room air, the DON reported they would look at the resident's record to determine if 02 stats and necessary observations were made. *It should be noted that following the interview as noted above, the DON provided a copy of the July MAR and noted that R702 vitals were noted under Resident was actively assessed for symptoms of COVID-19 (fever, cough, sore throat, chills/shaking, loss of taste .). On 7/1/23 no temps or 02 states were documented. On 7/2/23 a temp of 97.1 and O2 Stat of 97 was documented. On 7/3/23, again no vitals were noted (including 02 Stat) in the MAR. No further documentation was provided by the end of the Survey. On 7/21/23 at approximately 3:30 PM a phone interview was conducted with Physician Extender (PE)B. PE B was queried as to R702 hospitalization on [DATE]. PE B reported they were aware the resident was having respiratory issues. When asked if nursing staff should have continued to monitor the resident who was having respiratory issues, PE B noted that it may have helped prevent the respiratory decline and hospitalization . The facility policy titled, Acute Condition changes- Clinical Protocol was reviewed and documented, in part: During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay; .The Physician and nursing staff will identify any complications and/or problems that occurred during a recent hospital stay, which may indicate the risk of additional complications or instability; . The facility policy titled, Pulse Oximetry (Assessing Oxygen Saturation) was reviewed and documented, in part: .The pulse oximeter is a probe with light emitting diodes (LEDs) connected to an oximeter .The oximeter .calculates the pulse oxygen saturation (Sp02), which is a reliable measure of Sp02 .Normal Sp02 is between 90 and 100 percent; Sp02 below 70 percent is life threatening .

Based on interview and record review, the facility failed to ensure accurate medication reconciliation upon admission to the facility from the hospital for one (R809) of two residents reviewed for quality of care, resulting in a hospitalization due to metabolic [CONDITION(S)] (alterations in brain chemistry) secondary to severe [CONDITION(S)] (underactive [CONDITION(S)]) progressing to myxedema (a life threatening condition caused when the level of [CONDITION(S)] hormones become very low) after the resident did not receive their [CONDITION(S)] medication for three months. Findings include: Review of R809's clinical record revealed R809 was originally admitted into the facility on [DATE], readmitted on [DATE], and expired in the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R809's cognition was not assessed, and they required extensive assistance for transfers and bed mobility. Review of R809's progress notes revealed R809 was transferred to the hospital on [DATE] after a fall. Review of a progress note dated [DATE], written by Physician B revealed, in part, the following: Patient .was sent out after a fall with metabolic [CONDITION(S)]. Head CT (Computerized Tomography) and MRI (magnetic Resonance Imaging) were normal. It was felt that [CONDITION(S)] was likely due to [CONDITION(S)]. [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) was increased to 300 mcg (micrograms) .AP (Assessment/Plan) .metabolic [CONDITION(S)] - likely due to [CONDITION(S)] .[CONDITION(S)] disease s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue with [MEDICATION(S)] . Review of R809's hospital History and Physical (H&P) dated [DATE] revealed, in part, the following: (R809) is .presenting with fall .In chart review it was found that pt (patient) had TSH of 99 (normal reference range is 0.5 to 5.0 milli-international units per liter - mIU/L - of blood. High TSH levels indicate [CONDITION(S)]) at last hospitalization in ,d+[DATE] and was discharged on [MEDICATION(S)] but patient never started [MEDICATION(S)]. Her med list upon arrival today did not include [MEDICATION(S)] .ED (emergency department) Course: .TSH 233 with Free T4 <0.25 (normal reference range is 0.8 to 1.8 nanograms per deciliter - ng/dl of blood) .Assessment/Plan .Acute metabolic [CONDITION(S)] progressing towards myxedema .Last hospitalization ,d+[DATE] TSH 99 - discharged on [MEDICATION(S)] but was not on current med list or in dispense history, current TSH 233 with free T4 <0.25, acute metabolic [CONDITION(S)] secondary to severe [CONDITION(S)] .[CONDITION(S)] (abnormal low heart rate) - Likely secondary to above, uncontrolled [CONDITION(S)] . Review of R809's Discharge Summary provided to the facility when discharged from the hospital and admitted into the facility on [DATE] revealed, in part, the following: .Active Issues Requiring Follow-Up .[CONDITION(S)]: Patient was not taking her meds prior to hospitalization . Needs follow up TSH .Discharge Medication List: .CONTINUE taking these medications .[MEDICATION(S)] ORAL Take by mouth .DETAILS OF HOSPITAL STAY .[CONDITION(S)] .TSH 99.58, likely due to Pt's medication non-compliance. Continuing home [MEDICATION(S)] ([MEDICATION(S)]). Needs follow up with her PCP (primary care physician) for TSH recheck . Review of R809's Physician's Orders in the facility's electronic medical record revealed an order dated [DATE] for [MEDICATION(S)] Sodium Tablet Give 300 mg (milligrams) by mouth one time a day related to [CONDITION(S)] . Note that the dosage for [MEDICATION(S)] is measured in mcg and not mg. There were no Physician's Orders for [MEDICATION(S)] ([MEDICATION(S)]) for R809 prior to [DATE]. Further review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note dated [DATE], written by Physician B, documented, .[CONDITION(S)] - Continue with [MEDICATION(S)] . Progress notes dated [DATE], [DATE], and [DATE], written by Nurse Practitioner (NP) G, documented, .[CONDITION(S)] - Continue with [MEDICATION(S)] . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of laboratory results revealed R809's TSH was not rechecked between their admission into the facility on [DATE] and they hospital admission on [DATE]. On [DATE] at 2:25 PM, an interview was conducted with Physician B via the telephone. When queried about how medications were reviewed and reconciled when a resident was admitted into the facility, Physician B reported nurses reviewed the medications with the physician and entered the orders into the electronic medical record. When queried about how medications were evaluated by the physician during physician visits, Physician B reported they read resident's medication lists and tried to reconcile any high risk medications. When queried about whether they were aware that R809's [MEDICATION(S)] was not ordered when they were admitted into the facility on [DATE], they reported they were not aware. When queried about whether [MEDICATION(S)]/[MEDICATION(S)] should have been ordered for R809 at that time, Physician B reported if someone had [CONDITION(S)], [MEDICATION(S)]/[MEDICATION(S)] was the typical medication used to treat it typically, [MEDICATION(S)] is used. When queried about any monitoring of R809's TSH levels between [DATE] and [DATE], Physician B reported it was not monitored in the facility until right before the resident signed on to hospice in February 2022. Physician B reported it was not monitored in the facility prior to that. On [DATE] at 3:24 PM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's admission process in regard to medication reconciliation, the DON reported there was an admission checklist that the nurses referred to, the nurse entered/transcribed the medications into the electronic medical record, sent a list to the provider, and the provider reconciled the medications and told the nurse if anything needed to be added or changed. When queried about R809 and why the [MEDICATION(S)] was not ordered upon their admission into the facility on [DATE], the DON reported she would look into it. On [DATE] at 5:02 PM, Nurse E, the admitting nurse for R809 on [DATE], was contacted via the telephone for an interview. Nurse E was not available for an interview prior to the end of the survey. On [DATE] at 5:47 PM, any additional information that the facility wished to provide was requested from the Administrator and DON. No additional information was provided prior to the end of the survey. Review of a facility policy titled, Admission Assessment and Follow Up: Role of the Nurse revised [DATE], revealed, in part, the following: .Reconcile the list of medication from the medication history, admitting orders, the previous MAR (Medication Administration Record) (if available), and the discharge summary from the previous institution, according to established procedures .Contact the Attending Physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .The following information should be recorded in the resident's medical record: .Orders obtained by the physician .

This citation pertains to Intake Number(s): MI 547 Based on observation, interview, and record review, the facility failed to review the total program of care including medications and laboratory results during physician (provider) visits for two (R804 and R809) of two residents reviewed for physician visits, resulting in hospitalization for a urinary tract infection ([CONDITION(S)]) after a delay in review of R804's urinalysis results and R809 being hospitalized due to metabolic [CONDITION(S)] (alterations in brain chemistry) secondary to severe [CONDITION(S)] (underactive [CONDITION(S)]) progressing to myxedema (a life threatening condition caused when the level of [CONDITION(S)] hormones become very low) after the resident did not receive their [CONDITION(S)] medication for three months. Findings include: R809 Review of R809's clinical record revealed R809 was originally admitted into the facility on [DATE], readmitted on [DATE] and [DATE], and expired in the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R809's cognition was not assessed, and they required extensive assistance for transfers and bed mobility. Review of R809's progress notes revealed R809 was transferred to the hospital on [DATE] after a fall. Review of a progress note dated [DATE], written by Physician B revealed, in part, the following: Patient .was sent out after a fall with metabolic [CONDITION(S)]. Head CT (Computerized Tomography) and MRI (magnetic Resonance Imaging) were normal. It was felt that [CONDITION(S)] was likely due to [CONDITION(S)]. [MEDICATION(S)] (a medication used to treat [CONDITION(S)]) was increased to 300 mcg (micrograms) .AP (Assessment/Plan) .metabolic [CONDITION(S)] - likely due to [CONDITION(S)] .[CONDITION(S)] disease s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Continue with [MEDICATION(S)] . Review of R809's hospital History and Physical (H&P) dated [DATE] revealed, in part, the following: (R809) is .presenting with fall .In chart review it was found that pt (patient) had TSH of 99 (normal reference range is 0.5 to 5.0 milli-international units per liter - mIU/L - of blood. High TSH levels indicate [CONDITION(S)]) at last hospitalization in ,d+[DATE] and was discharged on [MEDICATION(S)] but patient never started [MEDICATION(S)]. Her med list upon arrival today did not include [MEDICATION(S)] .ED (emergency department) Course: .TSH 233 with Free T4 <0.25 (normal reference range is 0.8 to 1.8 nanograms per deciliter - ng/dl of blood) . Review of R809's Discharge Summary provided to the facility when discharged from the hospital and admitted into the facility on [DATE] revealed, in part, the following: .Active Issues Requiring Follow-Up .[CONDITION(S)]: Patient was not taking her meds prior to hospitalization . Needs follow up TSH .Discharge Medication List: .CONTINUE taking these medications .[MEDICATION(S)] ORAL Take by mouth .DETAILS OF HOSPITAL STAY .[CONDITION(S)] .TSH 99.58, likely due to Pt's medication non-compliance. Continuing home [MEDICATION(S)] ([MEDICATION(S)]). Needs follow up with her PCP (primary care physician) for TSH recheck . Review of R809's Physician's Orders in the facility's electronic medical record revealed an order dated [DATE] for [MEDICATION(S)] Sodium Tablet Give 300 mg (milligrams) by mouth one time a day related to [CONDITION(S)] . There were no Physician's Orders for [MEDICATION(S)] ([MEDICATION(S)]) for R809 prior to [DATE]. Further review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] A progress note dated [DATE], written by Physician B, documented, .[CONDITION(S)] - Continue with [MEDICATION(S)] . Progress notes dated [DATE], [DATE], and [DATE], written by Nurse Practitioner (NP) G, documented, .[CONDITION(S)] - Continue with [MEDICATION(S)] . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of laboratory results revealed R809's TSH was not rechecked between their admission into the facility on [DATE] and they hospital admission on [DATE]. On [DATE] at 2:25 PM, an interview was conducted with Physician B, who was R809's attending physician and the facility's medical director, via the telephone. When queried about how medications were evaluated by the physician during physician visits, Physician B reported they read resident's medication lists and tried to reconcile any high risk medications. When queried about whether they were aware that R809's [MEDICATION(S)] was not ordered when they were admitted into the facility on [DATE], they reported they were not aware. When queried about whether [MEDICATION(S)]/[MEDICATION(S)] should have been ordered for R809 at that time, Physician B reported if someone had [CONDITION(S)], [MEDICATION(S)]/[MEDICATION(S)] was the typical medication used to treat it. When queried about monitoring of R809's TSH levels between [DATE] and [DATE], Physician B reported it was not monitored in the facility until right before the resident signed on to hospice in February 2022. Physician B reported it was not monitored in the facility prior to that. Review of a facility policy titled, Physician Visits (revised [DATE]) revealed, in part, the following: .The resident's Attending Physician is responsible for prescribing new therapy, ordering a transfer to the hospital, conducting required routine visits, delegating and supervising follow-up visits from Nurse Practitioners or Physician Assistants, etc .to ensure that the resident receives quality care and medical treatments . R804 A Complaint was filed with the State Agency (SA) that alleged R704 was diagnosed with a Urinary Tract Infection ([CONDITION(S)]) provided the wrong antibiotic, had an increase in confusion, decrease in intake and was transferred to the hospital and was admitted for five days. Admission records from (name of hospital) dated [DATE] documented, in part, the following: .Patient was left overnight in her wheelchair about a week ago. Since then, she has been more fatigued .she resided at a SNF (Skilled Nursing Facility) who obtained a urinalysis last week and reports .a [CONDITION(S)] .after taking antibiotics her daughter did not notice significant improvement in patient's mental status and energy .Assessment and Plan: [CONDITION(S)] .One week of worsening fatigue and decreased p.o. (ora;) intake .Do not have records of when urinalysis was collected what antibiotic she was recently on however patient did not have significant improvement .with that treatment. Infectious workup notable for urine with leukocyte esterase and 89 wbc (white blood cells), concern for inadequately treated urinary tract infection . Continued Hospital records ([DATE]) . Urine cultures; inadvertently not sent on presentation .report from facility noted>100,000 [CONDITION(S)]- sensitive to [MEDICATION(S)]- to which she was transitioned today . A review of R804 clinical record documented the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] (severely cognitively impaired) and required one-person extensive assist for most ADLs Continued review of R804's clinical record documented, in part, the following: [DATE] Skilled Charting: .CNA noticed blood during brief change. A urine sample was obtained to be sent to lab and the guest has a current temp of 102.5. Tylenol give at this time for fever. [DATE]: physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .A UA was ordered and revealed a [CONDITION(S)] for which the patient was started on [MEDICATION(S)] (an antibiotic) . [DATE]: Skilled Charting: .Received order from (name redacted) Physician B to send R803 out to (name redacted) Hospital ER for eval and tx (treatment) of continued weakness, loss of appetite and increased confusion since recent [CONDITION(S)] . An order dated [DATE] documented, Send urine for culture one time only related to Urinary Tract Infection . An order dated [DATE] documented, [MEDICATION(S)] Capsule 100 MG ([MEDICATION(S)]) Give 1 capsule by mouth two times a day related to urinary tract infection .for 5 days. A review of R804's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . on [DATE] (9:00PM), [DATE](9:00AM and 9:00PM). [DATE](9:00AM and 9:00PM), [DATE](9:00AM and 9:00PM), [DATE](9:00AM and 9:00PM) and [DATE](9:00AM). Laboratory Results documented, in part: Urinalysis/Urine Culture/ Document - Reviewed by (name redacted) Physician B on [DATE] Collection Date: [DATE], Received Date: [DATE], Reported Date: [DATE] .Urinalysis .Organism 1 >100,000 CFU/ML [CONDITION(S)] Pneumoniae (cultures greater than 100,000 colony forming units indicate infection and are not drug resistant and can be treated with certain antibiotics) .Sensitivity (a test used to help choose the antibiotic most effective against the specific types of bacteria) .[MEDICATION(S)] (also none as [MEDICATION(S)]) was noted as R (resistant to the bacteria resulting in possible continued growth of the bacteria). On [DATE] at approximately 2:23 PM, an interview was conducted with Physician B regarding R804's [CONDITION(S)]. Physician B was asked as to why a prescription for [MEDICATION(S)] 100 mg was initially ordered and not discontinued after the laboratory results with a Report Date of [DATE] noted that [MEDICATION(S)]/[MEDICATION(S)] was resistant to the bacteria. Physician B stated that they would have changed the antibiotic if they had read the lab results and noted that they may have been out of town at the time the labs were reported. Physician B noted on a return phone call on [DATE] at approximately 3:05 PM that they did see R804 clinically on [DATE] and noted that they appeared to have improved. Physician B again noted that they had not reviewed the laboratory results prior to the resident's hospitalization and recalled ordering the resident to the hospital on [DATE]. On [DATE] at approximately 3:25 PM, an interview was conducted with the Director of Nursing (DON). The DON was queried as to coordination nursing staff and physicians regarding laboratory results and reported that lab results are entered into a resident's electronic record for review and the physician has access. Review of the facility policy titled, Test Results (revised [DATE]) documented, in part: The resident's Attending Physician will be notified of the results of diagnostic tests .Policy Interpretation and Implementation .1. Results of laboratory tests shall be reported in writing to the resident's Attending Physician or to the facility .2. Should the test results be provided to the facility, the Attending Physician shall be promptly notified of the results. 3. The Director of Nursing, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician .

Based on interview and record review, the facility failed to prevent significant medication errors involving four residents (R#'s 73, 3, 46, and 229) of four residents reviewed for significant medication errors resulting in R73 receiving R3's medications, R73 being transferred to the hospital, and R46 receiving R229's narcotic pain medication. Findings include: A review of a facility provided policy titled, Medication Administration dated ,d+[DATE] was conducted and read, POLICY Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so .3. Prior to administration, review and confirm MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents are identified before medication is administered using at least two resident identifiers . On [DATE] at 10:00 AM a review of R46's clinical record was conducted and revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's Minimum Data Set assessment dated [DATE] revealed R46 had severely impaired cognition, was non-ambulatory, and required extensive to total assistance from one to two staff members for all activities of daily living. A review of R46's progress notes was conducted and revealed a note entered into the record by Licensed Practical Nurse (LPN) 'D' on [DATE] at 1:19 AM that read, Writer was alerted by Nurse (LPN 'F') that a medication error had occurred. Nurse had administered a [MEDICATION(S)] ,d+[DATE] (narcotic pain medication) intended for resident (R229) .to this resident (R46) .Medication was pulled from back-up stock by fell ow nurse (LPN 'E') as (LPN 'F) does not have access to pyxis being an agency nurse. A review of R46's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 4:20 PM, an interview was conducted with LPN 'E' regarding their knowledge of the medication error involving R46. LPN 'E' explained LPN 'F' did not have access to the facility's back up medication supply so LPN 'F' asked LPN 'E' to pull a narcotic pain medication for administration to R229. LPN 'E' said they pulled the medication and gave it to LPN 'F' who was in R46's room at the time. LPN 'E' said they heard LPN 'F' administered the medication to R46, not R229, who it was intended for. On [DATE] at 5:05 PM, an interview was conducted with LPN 'D' regarding their knowledge of any medication errors that had recently occurred in the facility. LPN 'D' reported they were aware of two recent incidences of medication errors, one involving R46 receiving R229's narcotic pain medication and another incident where R73 received several of R3's medications. LPN 'D' was further interviewed regarding the medication error involving R73 and R3 and reported that R73 suffered from low blood pressure as a result of receiving the wrong medications and they had to be transferred to the hospital. On [DATE] at 10:10 AM, a review of R73's closed clinical record revealed an admitted [DATE], a re-admitted [DATE] and a discharge date of [DATE] after they expired in the facility. R73's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of R73's progress notes was conducted and revealed the following: A note entered into the record by Nurse Practitioner (NP) 'J' on [DATE] at 12:35 AM, that read, Notified by nurse at <sic> patient's blood pressure was ,d+[DATE] orders given to sent patients <sic> to ED (emergency department) . A note entered into the record by LPN 'G' on [DATE] at 3:22 AM that read, .at 11 pm on Thursday [DATE]th, this writer was finishing up med pass and was called to this room for meds. At the time this writer was getting meds for another room (R3) and then shifted to getting meds for the room which was calling (R73). When pulling the meds this writer in error placed them in with the meds already started for the other room (R3). After giving the meds, this writer noticed the error .Vitals taken for baseline and every 15 minutes .As Blood <sic> pressure got lower this writer was instructed by on call and shift leader to send resident out .At this time guest is hypotensive at Hospital <sic> and being monitored . A note entered into the record by LPN 'D' on [DATE] at 4:54 AM that read, Writer was alerted by Nurse (LPN 'G') that writer was needed in guest's room immediately to assist with an incident. On they <sic> way to the room with fell ow nurse, writer was informed that a medication error had occurred with the guest. Writer was further informed that guest (R73) had been given medications accidentally that were meant for (R3) .and that these medications included narcotics and a blood pressure medication .On call care provider was notified .At approx. 0030 (12:30 AM) on [DATE], writer received information that guests (R73) BP (blood pressure) had dropped to ,d+[DATE]. Writer reported back to room to attempt and confirm guest's BP. The vitals cart was having difficulty picking up the guest's BP, so writer instructed Nurse (LPN 'G') to call the on call care provider directly to update him .Writer also spoke to on-call directly and informed him that the guest's BP had dropped below 70 systolic (top blood pressure number). Writer received orders to send guest to hospital for further evaluation . A review of R73's History and Physical from the hospital dated [DATE] was reviewed and read, .Chief Complaint: [CONDITION(S)] due to drugs. History of Present Illness: .presents with [CONDITION(S)] after an accidental overdose .As per patients nurse .at (Facility Name) .medication were given at 11 PM. patient received her own medications which included [MEDICATION(S)] (anti-anxiety) 0.5 mg (milligrams), [MEDICATION(S)] (anti-depressant) 10 mg, [MEDICATION(S)] (supplement for sleep) 3 mg, [MEDICATION(S)] (supplement) 20 mEq (milliequivalent), [MEDICATION(S)] (blood thinner) 20 mg, [MEDICATION(S)] (narcotic pain medication) 5 mg, and [MEDICATION(S)] (muscle relaxant) 6 mg. patient also received his <sic> second patient's medication which included [MEDICATION(S)] (stool softener) 100 mg, [MEDICATION(S)] (anti-convulsant) 300 mg, [MEDICATION(S)] (blood pressure medication) 12.5 mg, [MEDICATION(S)] (cholesterol medication) 40 mg, 2 [MEDICATION(S)] ([MEDICATION(S)]), Trazadone (anti-depressant), and [MEDICATION(S)] XR 25 mg (for bladder spasm). Patient found to be pale, hypotensive hypoxic and lethargic at EMS arrival .Assessment & Plan: The Patient .who is bedbound and presents with [CONDITION(S)] after an accidental overdose. [CONDITION(S)], lethargy due to accidental medication overdose at the long-term care facility .Blood pressure noted to be 64 systolic and [CONDITION(S)] (low heart rate) with a heart rate in 50s <sic> .Poison control was notified .Acute hypercarbic (excessive [MEDICATION(S)] in the bloodstream, typically caused by inadequate respiration) [CONDITION(S)] likely due to medication overdose. Currently requiring [CONDITION(S)] (a device used to assist with breathing) . Continued Review of R73's hospital clinical records was conducted and revealed R73 discharged back to the facility on [DATE]. On [DATE] at 12:00 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding the medication errors. The DON said the nurses who had medication the errors had been re-educated and medications should be administered per the five rights of medication administration.