Every finding on record at Willow Creek Nursing and Rehabilitation Center

Based on record review, and interviews with staff and Physician, the facility failed to ensure a system was in place to check the accuracy of resident care equipment used to check blood pressure readings and temperature readings. Additionally, per interview with a Nurse Practitioner and a Physician, a facility's glucometer reading was difficult to reconcile with other known details regarding a resident's condition and treatment. This affected 1 of 3 sampled residents reviewed for change in condition and had the capability to affect all residents (Resident #2).The findings included:Record review revealed Resident # 2 resided at the facility for four days in April 2026 (4/23/26 to 4/26/26). Review of Resident # 2's hospital Discharge summary, dated [DATE], revealed Resident # 2 had diagnoses including diabetes mellitus.Review of facility blood sugar results on 4/24/26 through 4/26/26 were documented as follows:4/24/26 at 6:00 AM 2914/24/26 at 12:00 PM 2474/24/26 at 6:00 PM 3034/25/26 at 6:00 AM blank4/25/26 at 12:00 PM 2204/25/26 at 6:00 PM 5094/26/26 at 6:00 AM was 233 According to orders and Resident # 2's Medication Administration Record (MAR), Resident # 2 received a scheduled dose of 5 units of Humalog insulin on 4/25/26 at 6:00 PM when her blood sugar registered 509. On 4/25/26 she was documented as only receiving one of two doses of scheduled metformin 1000 mg on 4/25/26. (An 8:30 AM metformin dose was held and an 8:30 PM dose was documented as administered.) These were the last diabetic medications administered prior to Resident # 2's blood sugar then registering 233 on 4/26/26 at 6:00 AM. Review of EMS (Emergency Medical Services) records revealed EMS received a call at 9:18 AM on 4/26/26 to respond for Resident # 2 who was unresponsive. Interview with Nurse # 1 on 6/10/26 at 9:49 AM revealed EMS had been called on 4/26/26 because Resident #2 was unresponsive and her blood sugar was too high to register on the facility glucometer. Review of 4/26/26 Emergency Department (ED) records for Resident # 2 revealed the resident's finger stick blood sugar was greater than 600 upon the first hospital check. Resident's serum blood draw glucose level was 1046 (noted in the timeline ED at 11:34 AM). The resident was admitted to Intensive Care Unit (ICU) with one of the diagnoses listed as diabetic ketoacidosis. (Diabetic ketoacidosis is a life-threatening complication of diabetes that occurs when the body lacks enough insulin to use blood sugar for energy.) The hospital ED Physician, who saw Resident # 2, on 4/26/26, was interviewed on 6/11/26 at 12:30 PM and reported the following information. It was really difficult to reconcile a 6:00 AM blood sugar reading of 233 with a serum blood sugar later the same morning of over a 1000. For some reason, the glucometer machine may not have read correctly and possibly the 233 was not correct. This was especially a possibility considering Resident #2's blood sugar was over 500 the previous evening. A blood sugar change from over 500 to 233 would be a big swing with an insulin dosage of only 5 units of Humalog insulin having been administered. The ED Physician indicated he would advise them to ensure their equipment was calibrated and working correctly. The facility's Nurse Practitioner (NP) was interviewed on 6/10/26 at 1:07 PM and reported the following. It did not make sense to her (the NP) that Resident # 2's finger stick blood sugar came down to 233 on 6/26/26 at 6:00 AM after a result the previous evening of 509 with only an insulin dosage of 5 units of Humalog Insulin. If she had been notified, she would probably have ordered an additional 16 units of Humalog insulin in addition to the regular insulin to get the blood sugar down. It also did not make sense to her (the NP) that on 4/25/26 the resident's blood sugar went from 233 at 6:00 AM to 1046 later that same morning in the emergency department. The Director of Nursing (DON) was interviewed on 6/11/26 at 1:40 PM and reported the following information. Each resident was given a glucometer from the facility upon admission. The glucometers were checked nightly by a nurse with control tests (a quality assurance check that uses a specially formulated liquid with a known glucose concentration). The results were then logged and the logs were not kept after a resident was discharged so she could not check the log data for Resident # 2. She (the DON) had not been made aware of any odd readings from facility glucometers. 1b. A review of the vital signs portion of Resident # 2's medical record revealed on 4/26/26 at 8:55 AM Nurse # 1 documented Resident # 2's blood pressure was 144/69, pulse 129, respirations 18, and temperature 98.8 (taken on forehead by non-contact thermometer). Nurse # 1, who had cared for Resident # 2 on 4/26/26 beginning at 7:00 AM, was interviewed on 6/10/26 at 9:49 AM and reported she had obtained Resident # 2's temperature reading when Resident # 2 was found to be unresponsive by using a temporal thermometer. Nurse # 1 reported the resident did not have a fever. Nurse # 3 was interviewed on 6/10/26 at 10:51 AM and reported the following information. She recalled she was the one to take the resident's blood pressure and heart rate. She (Nurse # 3) had used her own blood pressure monitor. Nurse #3 stated Resident #2's heart rate was elevated but that was the only vital sign she recalled being abnormal. Review of the Emergency Medical Services (EMS) report revealed the following information. EMS received a call at 9:18 AM on 4/26/26 and were at patient at 9:21 AM. Upon arrival the paramedic noted Resident # 2 was unresponsive and tachypneic (elevated respirations). Her skin was hot to the touch and appeared mottled and pale. At 9:27 AM Resident # 2's respirations were 44. At 9:29 AM, the paramedic noted Resident # 2's heart rate was 129, blood pressure 63/35 and respirations 28. At 9:31 AM, the paramedic noted they obtained a manual blood pressure reading of 70/48 and respirations were 31. At 9:34 AM, the paramedic noted they obtained a temperature reading of 105.1 by a no touch infrared thermometer. According to EMS records intravenous fluids and an intravenous antibiotic were administered. There was not a notation regarding any medication for fever. Review of hospital Emergency Department (ED) notes revealed Resident # 2 had a temperature of 102.9 upon admission and her white blood count was elevated (which can indicate infection). The hospital ED Physician, who saw Resident # 2, on 4/26/26, was interviewed on 6/11/26 at 12:30 PM and reported the following information. Given that the facility staff obtained a temperature reading of 98.8 just prior to calling EMS, EMS obtained a temperature reading of 105.1, both the facility staff and EMS assessed the resident to have a high pulse/heartrate combined with the finding in the ED that Resident # 2's white blood count was elevated, indicated that Resident # 2 was probably febrile at the facility before EMS arrived. Given that Resident # 2's blood pressure registered 144/69 by facility staff at 8:55 AM prior to them calling EMS who arrived at 9:21 AM, and who obtained two low blood pressure readings of 63/35 and 70/48, it would appear the facility blood pressure may not have been correct. The ED Physician indicated he would advise them to check the calibration of the equipment they were using. The Director of Nursing (DON) was interviewed on 6/11/26 at 1:40 PM and reported the following information. The nurses supplied their own blood pressure equipment and their own thermometer. The facility had a thermometer if needed in backup that was stored in the Assistant Director of Nursing's office. The system of nurses supplying their own blood pressure equipment and thermometer had always been the facility's system since she was the DON and she did not know the reason. The DON was interviewed about how she knew the nurses' blood pressure machines and thermometers were accurate. The DON reported that since these two items were owned personally by the nurses, she could not say how often they were checked for accuracy and calibration. The Administrator was interviewed on 6/11/26 at 3:26 PM and reported the following information. He had begun as the Administrator during the current year, and it had just been that way that the nurses supplied their own blood pressure machines and thermometers. The Administrator indicated the Nurse Aides did not do vital signs at the facility. The Administrator was interviewed regarding how the equipment was deemed to be correct and accurate and replied that was a good question.

Based on record review and staff interviews, the facility failed to ensure the medical record was complete regarding a change in condition for 1 of 3 residents reviewed for medical record accuracy (Resident #2).The findings included: On 4/25/26 at 8:00 PM Nurse # 3 documented a nursing narrative note on 4/26/26 at 9:26 AM noting that Resident # 2's emergency contact was informed Resident # 2 was being transferred to the hospital Emergency Department (ED). This nursing note and any nursing narrative note before this entry did not include any assessment of the resident on 4/26/26 or reason the resident was being transferred. Review of hospital records for 4/26/26 through 5/8/26 revealed Resident # 2 was assessed in the ED (Emergency Department) and admitted to the intensive care unit for diabetic ketoacidosis with an elevated Beta-hydroxybutyrate (a condition when there is insufficient insulin and an individual starts to break down fat and therefore produce ketones), hyperosmolar hyperglycemic state, febrile illness, leukocytosis (elevated white blood count), dehydration, depressed level of consciousness, and acute renal failure. Nurse # 3 was interviewed on 6/10/26 at 10:51 AM and reported she was not assigned to Resident # 2 on 4/26/26 but was assisting Nurse # 1, who was assigned, when Resident # 2 was found to be unresponsive and transferred to the hospital. Nurse # 1 was interviewed on 6/10/26 at 9:49 AM and reported the following information. Resident # 2 had been found unresponsive on the morning of 4/26/26 and a blood sugar check had registered too high to register on the facility's glucometer. She had assessed the resident and called emergency medical services. She tried to put her assessment and the events of the morning into the resident's electronic medical record, and she did not know why the computer system had not saved the information in the resident's electronic medical record. The Director of Nursing (DON) was interviewed on 6/10/26 at 9:00 AM and reported the following information. The care and assessment of Resident # 2 should have been documented on 4/26/26. She could not find a record of the documentation which Nurse # 1 had tried to enter. The DON indicated she was not sure what happened but reported at times the computer system would glitch, and it might have affected the nursing documentation being saved. The DON further reported that the staff were to complete a specific form called E-Interact for any resident that had a change in condition and she could not find that this was completed in the resident's record. The DON validated Resident # 2's record was incomplete without the information regarding the events and care by the staff on the morning of 4/26/26 prior to EMS transport and the resident's hospitalization.

Based on record review, and interviews with staff, Physicians, and Nurse Practitioner, the facility staff failed to consult with the physician when a resident's fingerstick blood sugar result was 509. (A normal fasting blood sugar is typically 70 to 99 and a normal non-fasting blood sugar is typically less than 140. A blood sugar reading over 400 is considered severe hyperglycemia and can be a medical emergency). This was for 1 of 3 residents reviewed for notification to the physician (Resident # 2). The findings included:Review of Resident # 2's hospital Discharge summary, dated [DATE], revealed the following information. Resident # 2 was hospitalized from [DATE] until 4/23/26. Resident # 2 had a history of prior stroke and trigeminal neuralgia (chronic neuropathic pain condition that causes sudden, severe, electric shock-like or stabbing pain in the face). She was hospitalized on [DATE] secondary to worsening weakness and dysphagia (trouble swallowing). Resident # 2 was examined and found to have difficulty managing her own secretions and unable to swallow applesauce. In addition to dysphagia, Resident # 2 also had dysarthria (trouble speaking) secondary to her trigeminal neuralgia, and it was difficult to obtain information from her. While hospitalized , Resident # 2 underwent gastrostomy tube placement (tube inserted through the wall of the abdomen directly into the stomach) for her dysphagia with plans for follow up at another hospital for specialized surgery to address her trigeminal neuralgia. She was to receive her nutrition by means of the gastrostomy tube. Resident # 2 additionally had a diagnosis of diabetes. The hospital discharge summary further included the following information. Upon discharge, Resident # 2 was ordered to receive metformin 1000 mg (milligrams) twice per day (a diabetic medication). She was also ordered to receive Insulin Lispro 5 units three times per day. (Insulin lispro is a fast-acting insulin which typically starts working within 15-30 minutes after administration, peaks in about 1 hour, and lasts for 3-5 hours.) The discharge summary noted Resident # 2 should pause another insulin which she had been receiving until her future medical provider directed her to start taking the paused insulin. The paused insulin was insulin glargine 30 units every morning. (Insulin glargine is a long-acting insulin which is prescribed to help manage blood glucose levels in diabetic individuals by providing a steady release of insulin that lasts for 24 hours.) Resident # 2 was discharged on 4/23/26 for care at the facility.Record review revealed Resident # 2 resided at the facility for four days in April 2026 (4/23/26 to 4/26/26).Review of 4/23/26 facility admission orders revealed orders for Metformin 1000 mg (milligrams) via gastrostomy tube two times per day and Humalog 5 units subcutaneously three times per day. Additionally, the resident was ordered to receive all her nutrition by way of an enteral feeding.Review of Resident # 2's April 2026 MAR (Medication Administration Record) revealed with each Humalog 5 units of insulin administration the resident's fingerstick blood sugar was checked. Results on 4/24/26 and 4/25/26 were documented as follows:4/24/26 at 6:00 AM- 2914/24/26 at 12:00 PM- 2474/24/26 at 6:00 PM- 3034/25/26 at 6:00 AM- blank4/25/26 at 12:00 PM- 2204/25/26 at 6:00 PM- 509 (documented by Nurse # 1) Review of 4/25/26 and 4/26/26 nursing notes revealed no documentation the physician was contacted regarding the 6:00 PM fingerstick blood sugar on 4/25/26. Nurse # 1 had cared for Resident # 2 from 7:00 AM to 7:00 PM on 4/25/26. Nurse # 1 was interviewed on 6/10/26 at 9:49 AM and reported the following information. She did not call the physician about the fingerstick blood sugar result of 509 and she did not retake the blood sugar after giving the scheduled insulin. At the time that Resident # 2's blood sugar registered 509, Resident # 2 appeared alert, talking, and without symptoms. Resident # 2 did say her mouth was dry, but she (the nurse) attributed that to the resident being on an enteral feeding and not having anything by mouth. The reason she did not recheck the blood sugar and call the physician was because the resident was not showing any symptoms or problems and she knew Resident # 2 had received some insulin. Since 4/25/26, she (the nurse) had received education that she should have called the physician, and she should have rechecked the resident's blood sugar. On 4/26/26 at 12:00 AM Nurse # 2 initialed on Resident # 2's MAR she administered Resident # 2's scheduled bolus enteral feeding of 300 ml (milliliters) of Diabetasource (tube feeding formula). On 4/26/26 at 6:00 AM Nurse # 2 initialed again that she administered Resident # 2's scheduled bolus enteral feeding of 300 ml of Diabetasource. Nurse # 2 also documented on the MAR that Resident # 2's fingerstick blood sugar was 233 at 6:00 AM and she initialed the scheduled Humalog Insulin 5 units was administered at 6:00 AM. Nurse # 2, who cared for Resident # 2 from 7:00 PM on 4/25/26 until 7:00 AM on 4/26/26, was interviewed on 6/10/26 at 12:31 PM and reported the following information. She (Nurse #2) did not recall specifics of a report during shift change. She did not recall any problems the resident had which would have caused her to call the physician during her shift. Resident # 2 had been alert at the beginning of the shift. The resident's only complaint was that since admission she had not been able to sleep at night, which the resident reported was due to being new to the facility. She had requested not to be disturbed earlier than 6:00 AM so that she could get some rest. Nurse # 2 did not recall any specifics of how the resident was when she gave the enteral feeding at 12:00 AM. To honor her request to get more sleep, she (Nurse # 2) had not disturbed her earlier than 6:00 AM for the 6:00 AM enteral feeding, fingerstick blood sugar, and insulin. At that time, Resident # 2 could barely open her eyes, but she (the nurse) did not think that was unusual given that Resident # 2 had reported she had not slept for two nights. A lot of her residents, who had blood sugar checks between 5:00 AM and 6:00 AM would keep their eyes closed, stick out their hand when it was explained what she was going to do, and continue to keep their eyes closed due to being sleepy. That is how she recalled Resident # 2. Resident # 2 did jerk back her hand when her finger was pricked for the blood sugar. She did not react to the insulin administration but that was not unusual for her either. Her skin was not cold or sweaty. That was the only blood sugar check she recalled doing that shift and the result had not been unusual for the resident. Nurse Aide (NA) # 1 cared for Resident # 2 beginning at 11:00 PM on 4/25/26 until 7:00 AM on 4/26/26. NA # 1 was interviewed on 6/10/26 at 11:38 AM and reported the following information. Resident # 2 was still awake at 11:00 PM when she first started caring for her. At that time the resident was alert and reported she did not need anything. Around 4:30 AM to 5:00 AM, Resident # 2 rang her call bell and requested a sip of water and to be assisted up in bed. She (NA # 1) provided incontinence care and helped Resident # 2 reposition further up in the bed. The resident appeared okay. Her last check was at the end of the shift and Resident # 2 appeared to be sleeping at that time and was not disturbed. NA # 2 was assigned to care for Resident # 2 on 4/26/26 beginning at 7:00 AM and was interviewed on 6/10/26 at 11:29 AM. NA # 2 reported the following information. She had checked on Resident # 2 at the beginning of the shift, and she appeared to be asleep in bed and therefore she did not awaken her. Later that morning she went back to the room and Resident # 2 did not awaken. She touched Resident # 2's shoulder and the resident still did not respond. She immediately got Nurse # 1 who went right away, got Resident # 2's vital signs and did what she was supposed to do. A review of the vital signs portion of the medical record revealed on 4/26/26 at 8:55 AM Nurse # 1 documented Resident # 2's blood pressure was 144/69 (normal ranges are typically between 90/60 to 120/80), pulse 129 (normal 60 to 100), respirations 18 (normal 12 to 20), and temperature 98.8 (taken on forehead by non-contact thermometer). Nurse # 1, who had cared for Resident # 2 on 4/26/26 beginning at 7:00 AM, was interviewed on 6/10/26 at 9:49 AM and reported the following information. She had looked in on Resident # 2 at the beginning of the shift but did not awaken her. She (Nurse # 1) got report and started to give medications. While she was starting to give medications to other residents, the assigned Nurse Aide came to get her and let her know Resident # 2 was not responding. She got Resident # 2's vitals and tried doing a sternal rub, but the resident would not respond. She obtained the resident's temporal temperature. The resident's vitals seemed okay except for her pulse. Another Nurse (Nurse # 3) came in to help also. They checked her finger stick blood sugar, and it registered high. They called 911 for transport. It was only about 20 minutes from the time Resident # 2 was found to be nonresponsive and when EMS (Emergency Medical Services) arrived. She called the resident's RP who reported Resident # 2 had been sick the night before, but this had not been told to her (Nurse # 1). On 4/26/26 at 9:26 AM Nurse # 3 noted in the record that Resident # 2's emergency contact was informed Resident # 2 was being transferred to the hospital Emergency Department (ED). This nursing note did not include any information regarding why. Nurse # 3 was interviewed on 6/10/26 at 10:51 AM and reported the following information. She shared a nursing desk with Nurse # 1 and was at the desk when NA # 2 also grabbed her (Nurse # 3) to assist with Resident # 2 and Nurse # 1 also came. Resident # 2 did not respond, and they checked her blood sugar which registered high on the glucometer (A high reading typically indicates a blood sugar level has exceeded the device's measurable range and may indicate a dangerous level). Nurse #3 recalled she was the one to take the resident's blood pressure and heart rate. Resident #2's heart rate was elevated and her skin was pale but not mottled and they called EMS right away. Review of EMS (Emergency Medical Services) records revealed the following information. EMS received a call at 9:18 AM on 4/26/26 and were at patient at 9:21 AM. Upon arrival the paramedic noted Resident # 2 was unresponsive and tachypneic (elevated respirations). Her skin was hot to the touch and appeared mottled and pale. At 9:27 AM Resident # 2's respirations were 44. At 9:29 AM, the paramedic noted Resident # 2's heart rate was 129, blood pressure 63/35 and respirations 28. At 9:31 AM, the paramedic noted they obtained a manual blood pressure reading of 70/48 and respirations were 31. At 9:34 AM, the paramedic noted they obtained a temperature reading of 105.1 by a no touch infrared thermometer. Oxygen, intravenous fluids, and an intravenous antibiotic were administered by EMS, who transported the resident to the hospital with no sirens or lights by non-emergent transport. Review of hospital records for 4/26/26 to 5/8/26 revealed the following information. During transport from the facility to the hospital by EMS, Resident # 2 remained stable. Upon presentation to the hospital, she was largely unresponsive to stimulation. The resident's finger stick blood sugar was greater than 600 upon the first check. A serum blood draw glucose level was 1046 (noted in the timeline ED at 11:34 AM). The resident's blood pressure was low normal but did not require vasopressors (medications used to constrict blood vessels and thereby raise blood pressure). Her initial blood work showed an elevated white blood count of 17.1. (An elevated white blood count can indicate an infection at times with normal parameters between 3.5 to 10.5). Her blood urea nitrogen was 40 (normal 9-23) and creatinine results were 1.32 (normal 0.5 to .80). (Blood urea nitrogen and creatinine can indicate kidney function and level of hydration.) The resident's lactate level was 2.7 (normal .5 to 2.0.) (Levels can be elevated with lack of tissue perfusion). Resident # 2's admission history and physical noted the resident had diabetic ketoacidosis with an elevated Beta-hydroxybutyrate (a condition when there is insufficient insulin and an individual starts to break down fat and therefore produce ketones), hyperosmolar hyperglycemic state, febrile illness, leukocytosis (elevated white blood count), dehydration, depressed level of consciousness, and acute renal failure. She was admitted to ICU (Intensive care unit), given intravenous fluids and intravenous antibiotics, and Intravenous insulin infusion with titration. An infectious disease work during hospitalization revealed no source of the elevated white blood count although there had been a concern about possible aspiration. Upon discharge, Resident # 2 was documented as being alert and voicing wanting to go home. Her creatinine level had returned to her normal baseline. She was discharged with home health services. The facility's Nurse Practitioner (NP) was interviewed on 6/10/26 at 1:07 PM and reported the following. The staff should report any blood sugar that was over 500. She or another provider had not been notified. If she had been notified, she would have ordered additional insulin coverage the evening of 4/25/26 so that the resident would have received treatment for the elevated reading of 509. For a blood sugar reading of 509, she would probably have ordered an additional 16 units of Humalog (the fast-acting insulin). She would have also talked to the staff about other things that might be going on with the resident when they called with a result that high. She was familiar with the resident, who had previous stays at the facility. The resident was able to make her needs known and had particular ways she liked things done. Based on her (the NP's) personal dealings with the resident, Nurse # 2's report of Resident # 2 requesting not to be disturbed during the night of 4/25/26, Nurse # 2's report of Resident # 2 keeping her eyes closed at 6:00 AM on 4/26/26 and sticking her hand out to Nurse # 2 without interacting, did seem like something the resident might possibly do. It did not make sense to her (the NP) that Resident # 2's finger stick blood sugar came down to 233 after a result the previous evening of 509 with only 5 units of Humalog Insulin. It also did not make sense to her (the NP) that on 4/25/26 the resident's blood sugar went from 233 at 6:00 AM to 1046 later that same morning in the emergency room. She had seen the resident on 4/24/26 (Friday) and her plan at that time was to see her again on 4/27/26 (Monday) and evaluate her blood sugar trends to see how the resident's blood sugars could best be managed, but she had not had a chance to evaluate the resident's blood sugars before she was sent back to the hospital. Given that Resident # 2 was both a newly admitted resident on 4/23/26 and additionally she had new orders for an enteral feeding for her nutrition, she (the NP) would not have changed any insulin orders right away upon admission until she had been able to evaluate her further and look at trends. The facility Medical Director was interviewed on 6/10/26 at 2:00 PM and reported the following information. If a resident did not have other parameters, he would want to be notified if a resident's blood sugar was greater than 400. He was not familiar with Resident # 2 and without knowing her history he was hesitant to comment on the fluctuation of her fingerstick blood sugar results. Infection can make a resident's blood sugar go up. Some residents can also be labile (Labile diabetics experience unpredictable, severe, wide blood sugar swings between high to low). The hospital ED physician, who saw Resident # 2, on 4/26/26 was interviewed by phone on 6/11/26 at 12:30 PM and reported the following information. It was really difficult to reconcile a 6:00 AM blood sugar reading of 233 with a serum blood sugar later the same morning of over a 1000. For some reason, the glucometer machine may not have read correctly and possibly the 233 was not correct. This was especially a possibility considering the resident's blood sugar was over 500 the previous evening. A blood sugar change from over 500 to 233 would be a big swing with only 5 units of Humalog insulin having been administered. Infrared (non-touch) thermometers can give incorrect results at times. They sometimes read high. Given that the facility staff obtained a temperature reading of 98.8 just prior to calling EMS, EMS obtained a temperature reading of 105.1, both the facility staff and EMS assessed the resident to have a high pulse/heartrate combined with the finding in the ED that Resident # 2's white blood count was elevated, indicated that Resident # 2 was probably febrile at the facility before EMS arrived. According to the ED physician, more accurate temperature readings were obtained by oral and rectal routes. It was not uncommon not to find a source of infection in a patient although infection was a causative problem of an illness, and given Resident # 2 had an elevated white blood count, she may have had an infection which led to her illness, hospitalization, and affected her blood sugars. As an individual's blood sugar rises, the body tries to expel the blood sugar by more frequent urination which in turn affects their hydration status, BUN and creatinine levels. It was possible for some individual's blood sugar to be elevated at 509 without showing evident symptoms. Even if the facility staff had called their provider on the evening of 4/25/26 when Resident # 2's blood sugar registered 509 and she received further assessment and treatment for the elevated blood sugar, she may still have developed illness stemming from an infection the next morning which required hospitalization and care. After treatment, diabetic ketoacidosis did not typically affect an individual long term and given that there might be an underlying problem of possible infection, he did not feel it could be said by him that the resident was harmed by the facility's lack of follow up on the evening o 4/25/26. He would advise them to ensure their equipment was calibrated and working correctly. During interviews with the Director of Nursing (DON) on 6/10/26 at 9:00 AM, 6/10/26 at 6:30 PM, 6/11/26 at 4:35 PM and 4:40 PM, the DON reported the following information. When a resident was admitted to the facility and they are on insulin, the electronic MAR automatically populates to direct staff to check the resident's blood sugar when the insulin is due. There were no standing orders with parameters to call a physician for a certain level of blood sugar result. It was her expectation that Nurse # 1 should have called the provider on the evening of 4/25/26. She had taken corrective action by educating Nurse # 1 after the incident but had not implemented a plan that included all nurses.

Based on record review, and interviews with staff, Responsible Party, Physician, and Nurse Practitioner, for a newly admitted resident whose insulin orders had recently been changed before facility admission in conjunction with the resident being changed from an oral diet to an enteral feeding (the delivery of nutrition directly into the gastrointestinal tract when a person cannot eat enough by mouth), the facility failed to recheck the resident's finger stick blood sugar result of 509 within the timeframe the resident's prescribed insulin typically worked to cover elevated blood sugar levels. (A normal fasting blood sugar is typically 70 to 99 and a normal non-fasting blood sugar is typically less than 140. A blood sugar reading over 400 is considered severe hyperglycemia and can be a medical emergency). This was for 1 of 3 residents reviewed for professional standards of practice (Resident # 2). The findings included:Review of Resident # 2's hospital Discharge summary, dated [DATE], revealed the following information. Resident # 2 was hospitalized from [DATE] until 4/23/26. Resident # 2 had a history of prior stroke and trigeminal neuralgia (chronic neuropathic pain condition that causes sudden, severe, electric shock-like or stabbing pain in the face). She was hospitalized on [DATE] secondary to worsening weakness and dysphagia (trouble swallowing). Resident # 2 was examined and found to have difficulty managing her own secretions and unable to swallow applesauce. In addition to dysphagia, Resident # 2 also had dysarthria (trouble speaking) secondary to her trigeminal neuralgia, and it was difficult to obtain information from her. While hospitalized , Resident # 2 underwent gastrostomy tube placement (tube inserted through the wall of the abdomen directly into the stomach) for her dysphagia with plans for follow up at another hospital for specialized surgery to address her trigeminal neuralgia. She was to receive her nutrition by means of the gastrostomy tube. Resident # 2 additionally had a diagnosis of diabetes. The hospital discharge summary further included the following information. Upon discharge, Resident # 2 was ordered to receive metformin 1000 mg (medication used to treat diabetes) twice per day. She was also ordered to receive Insulin Lispro 5 units three times per day. (Insulin lispro is a fast-acting insulin which typically starts working within 15-30 minutes after administration, peaks in about 1 hour, and lasts for 3-5 hours.) The discharge summary noted Resident # 2 should pause another insulin which she had been receiving until her future medical provider directed her to start taking the paused insulin. The paused insulin was insulin glargine 30 units every morning. (Insulin glargine is a long-acting insulin which is prescribed to help manage blood glucose levels in diabetic individuals by providing a steady release of insulin that lasts for 24 hours.) Resident # 2 was discharged on 4/23/26 for care at the facility.Record review revealed Resident # 2 resided at the facility for four days in April 2026 (4/23/26 to 4/26/26).Review of 4/23/26 admission orders revealed orders for Metformin 1000 mg (milligrams) via gastrostomy tube two times per day and Humalog 5 units subcutaneously three times per day. Additionally, the resident was ordered to receive all her nutrition by way of an enteral feeding.Review of Resident # 2's April 2026 MAR (Medication Administration Record) revealed with each Humalog 5 units of insulin administration the resident's fingerstick blood sugar was checked. Results on 4/24/26 and 4/25/26 were documented as follows:4/24/26 at 6:00 AM 2914/24/26 at 12:00 PM 2474/24/26 at 6:00 PM 3034/25/26 at 6:00 AM blank4/25/26 at 12:00 PM 2204/25/26 at 6:00 PM 509 (documented by Nurse # 1) On 4/25/26 at 6:35 PM Nurse # 1 documented a nursing entry with the following information noted. Resident # 2 continued to ask for ice chips and sips of water although she was NPO (nothing by mouth). Resident # 2's responsible party (RP) was present, and she (Nurse # 1) talked to both Resident # 2 and her RP about Resident # 2 not having anything by mouth. They voiced understanding. There was no documentation regarding notification of the physician regarding the resident's finger stick blood sugar result and any reassessment or intervention to address the resident's blood sugar reading of 509. Nurse # 1 had cared for Resident # 2 from 7:00 AM to 7:00 PM on 4/25/26. Nurse # 1 was interviewed on 6/10/26 at 9:49 AM and reported the following information. She did not call the physician about the fingerstick blood sugar result of 509 and she did not retake the blood sugar after giving the scheduled insulin. At the time that Resident # 2's blood sugar registered 509, Resident # 2 appeared alert, talking, and without symptoms. Resident # 2 did say her mouth was dry, but she (the nurse) attributed that to the resident being on an enteral feeding and not having anything by mouth. The resident did not vomit during her shift. The reason she did not recheck the blood sugar and call the physician was because the resident was not showing any symptoms or problems and she knew Resident # 2 had received some insulin. Since 4/25/26, she (the nurse) had received education that she should have called the physician, and she should have retaken the resident's blood sugar. Resident # 2's RP was interviewed on 6/9/26 at 7:50 PM and reported the following information. She had visited Resident # 2 between 5:00 PM and 8:00 PM on 4/25/26. Resident # 2 vomited that evening, and her blood sugar was 500. She thought that the nurse was going to call the physician, but the nurse had not done so. Resident # 2 was not acting like herself. She (the RP) felt there was something wrong with her. After her visit, she called Resident # 2 around 9:30 PM and the resident was very sleepy and complained of being tired. She made unusual comments about letting people know she loved them, which the RP interpreted as Resident # 2 acting as if she felt she was going to die. She (the RP) tried to call and speak to a nurse but was unable to reach one that night. The next morning (4/26/26), she (the RP) was called around 9:30 AM and told that Resident # 2 was nonresponsive and going to the hospital. Following the nursing narrative entry on 4/25/26 at 6:35 PM, the next nursing narrative was entered on 4/25/26 at 8:00 PM by Nurse # 2. Nurse # 2 noted she reeducated the resident on safety concerns related to the resident wanting water and ice chips. The resident verbalized understanding but declined to be NPO (nothing by mouth). There was no notation of a recheck of the resident's blood sugar. On 4/26/26 at 12:00 AM Nurse # 2 initialed on Resident # 2's MAR she administered Resident # 2's scheduled bolus enteral feeding of 300 ml (milliliters) of Diabetasource (tube feeding formula). On 4/26/26 at 6:00 AM Nurse # 2 initialed again that she administered Resident # 2's scheduled bolus enteral feeding of 300 ml of Diabetasource. Nurse # 2 also documented on the MAR that Resident # 2's fingerstick blood sugar was 233 at 6:00 AM and she initialed the scheduled Humalog Insulin 5 units was administered at 6:00 AM. Nurse # 2, who cared for Resident # 2 from 7:00 PM on 4/25/26 until 7:00 AM on 4/26/26, was interviewed on 6/10/26 at 12:31 PM and reported the following information. She (the nurse) did not recall specifics of a report during shift change. She thought possibly it was told to her that the resident may have vomited, but she was not sure of that or any other specifics in report. She did not recall Resident # 2 having any problems on her shift. Resident # 2 had not vomited on her shift. Resident # 2 had been alert at the beginning of the shift. The resident's only complaint was that since admission she had not been able to sleep at night, which the resident reported was due to being new to the facility. She had requested not to be disturbed earlier than 6:00 AM so that she could get some rest. Nurse # 2 did not recall any specifics of how the resident was when she gave the enteral feeding at 12:00 AM. To honor her request to get more sleep, she (Nurse # 2) had not disturbed her earlier than 6:00 AM for the 6:00 AM enteral feeding, fingerstick blood sugar, and insulin. At that time, Resident # 2 could barely open her eyes, but she (the nurse) did not think that was unusual given that Resident # 2 had reported she had not slept for two nights. A lot of her residents, who had blood sugar checks between 5:00 AM and 6:00 AM would keep their eyes closed, stick out their hand when it was explained what she was going to do, and continue to keep their eyes closed due to being sleepy. That is how she recalled Resident # 2. Resident # 2 did jerk back her hand when her finger was pricked for the blood sugar. She did not react to the insulin administration but that was not unusual for her either. Her skin was not cold or sweaty. That was the only blood sugar check she recalled doing that shift and the result had not been unusual for the resident. Nurse Aide (NA) # 1cared for Resident # 2 beginning at 11:00 PM on 4/25/26 until 7:00 AM on 4/26/26. NA # 1 was interviewed on 6/10/26 at 11:38 AM and reported the following information. There had been no reports from the previous Nurse Aide on the 3:00 to 11:00 PM shift of Resident # 2 vomiting and she (NA # 1) had not noted any problems. Resident # 2 was still awake at 11:00 PM when she first started caring for her. At that time the resident was alert and reported she did not need anything. Around 4:30 AM to 5:00 AM, Resident # 2 rang her call bell and requested a sip of water and to be assisted up in bed. She (NA # 1) provided incontinence care and helped Resident # 2 reposition further up in the bed. The resident appeared okay. She saw Nurse # 2 going in Resident # 2's room during different times of the night and she (NA # 1) also had checked on the resident throughout the night. Her last check was at the end of the shift and Resident # 2 appeared to be sleeping at that time and was not disturbed. NA # 2 was assigned to care for Resident # 2 on 4/26/26 beginning at 7:00 AM and was interviewed on 6/10/26 at 11:29 AM. NA # 2 reported the following information. She had checked on Resident # 2 at the beginning of the shift, and she appeared to be asleep in bed and therefore she did not awaken her. Later that morning she went back to the room and Resident # 2 did not awaken. She touched Resident # 2's shoulder and the resident still did not respond. She immediately got Nurse # 1 who went right away, got Resident # 2's vital signs and did what she was supposed to do. A review of the vital signs portion of the medical record revealed on 4/26/26 at 8:55 AM Nurse # 1 documented Resident # 2's blood pressure was 144/69 (normal ranges are typically between 90/60 to 120/80), pulse 129 (normal 60 to 100), respirations 18 (normal 12 to 20), and temperature 98.8 (taken on forehead by non-contact thermometer). Nurse # 1, who had cared for Resident # 2 on 4/26/26 beginning at 7:00 AM, was interviewed on 6/10/26 at 9:49 AM and reported the following information. She had looked in on Resident # 2 at the beginning of the shift but did not awaken her. She (Nurse # 1) got report and started to give medications. While she was starting to give medications to other residents, the assigned Nurse Aide came to get her and let her know Resident # 2 was not responding. She got Resident # 2's vitals and tried doing a sternal rub, but the resident would not respond. She obtained the resident's temporal temperature. The resident's vitals seemed okay except for her pulse. Another Nurse (Nurse # 3) came in to help also. They checked her finger stick blood sugar, and it registered high. They called 911 for transport. It was only about 20 minutes from the time Resident # 2 was found to be nonresponsive and when EMS arrived. She called the resident's RP who reported Resident # 2 had been sick the night before, but this had not been told to her (Nurse # 1). Following the nursing entry on 4/25/26 at 8:00 PM, the next nursing narrative note was entered by Nurse #3 on 4/26/26 at 9:26 AM noting that Resident # 2's emergency contact was informed Resident # 2 was being transferred to the hospital ED (Emergency Department). This nursing note did not include any assessment of the resident or reason the resident was being transferred. Nurse # 3 was interviewed on 6/10/26 at 10:51 AM and reported the following information. She shared a nursing desk with Nurse # 1 and was at the desk when NA # 2 also grabbed her (Nurse # 3) to assist with Resident # 2. Nurse # 1 also came. Resident # 2 did not respond, and they checked her blood sugar which registered high on the glucometer. (A high reading typically indicates a blood sugar level has exceeded the device's measurable range and may indicate a dangerous level). She recalled she was the one to take the resident's blood pressure and heart rate. Her heart rate was elevated. Her skin was pale but not mottled and they called EMS right away. Review of EMS (Emergency Medical Services) records revealed the following information. EMS received a call at 9:18 AM on 4/26/26 and were at patient at 9:21 AM. Upon arrival the paramedic noted Resident # 2 was unresponsive and tachypneic (elevated respirations). Her skin was hot to the touch and appeared mottled and pale. At 9:27 AM Resident # 2's respirations were 44. At 9:29 AM, the paramedic noted Resident # 2's heart rate was 129, blood pressure 63/35 and respirations 28. At 9:31 AM, the paramedic noted they obtained a manual blood pressure reading of 70/48 and respirations were 31. At 9:34 AM, the paramedic noted they obtained a temperature reading of 105.1 by a no touch infrared thermometer. Oxygen, intravenous fluids, and an intravenous antibiotic were administered by EMS, who transported the resident to the hospital with no sirens or lights by non-emergent transport. Review of hospital records for 4/26/26 to 5/8/26 revealed the following information. During transport from the facility to the hospital by EMS, Resident # 2 remained stable. Upon presentation to the hospital, she was largely unresponsive to stimulation. The resident's finger stick blood sugar was greater than 600 upon the first check. A serum blood draw glucose level was 1046 (noted in the timeline ED at 11:34 AM). The resident's blood pressure was low normal but did not require vasopressors (medications used to constrict blood vessels and thereby raise blood pressure). Her initial blood work showed an elevated white blood count of 17.1. (An elevated white blood count can indicate an infection at times with normal parameters between 3.5 to 10.5). Her blood urea nitrogen was 40 (normal 9-23) and creatinine results were 1.32 (normal 0.5 to .80). (Blood urea nitrogen and creatinine can indicate kidney function and level of hydration.) The resident's lactate level was 2.7 (normal .5 to 2.0.) (Levels can be elevated with lack of tissue perfusion). Resident # 2's admission history and physical noted the resident had diabetic ketoacidosis with an elevated Beta-hydroxybutyrate (a condition when there is insufficient insulin and an individual starts to break down fat and therefore produce ketones), hyperosmolar hyperglycemic state, febrile illness, leukocytosis (elevated white blood count), dehydration, depressed level of consciousness, and acute renal failure. She was admitted to ICU (Intensive care unit), given intravenous fluids and intravenous antibiotics, and Intravenous insulin infusion with titration. An infectious disease work during hospitalization revealed no source of the elevated white blood count although there had been a concern about possible aspiration. Upon discharge, Resident # 2 was documented as being alert and voicing wanting to go home. Her creatinine level had returned to her normal baseline. She was discharged with home health services. The facility's Nurse Practitioner (NP) was interviewed on 6/10/26 at 1:07 PM and reported the following. She was familiar with the resident, who had previous stays at the facility. The resident was able to make her needs known and had particular ways she liked things done. Based on her (the NP's) personal dealings with the resident, Nurse # 2's report of Resident # 2 requesting not to be disturbed during the night of 4/25/26, Nurse # 2's report of Resident # 2 keeping her eyes closed at 6:00 AM on 4/26/26 and sticking her hand out to Nurse # 2 without interacting, did seem like something the resident might possibly do. It did not make sense to her (the NP) that Resident # 2's finger stick blood sugar came down to 233 after a result the previous evening of 509 with only 5 units of Humalog Insulin. If she had been notified, she would have ordered additional insulin coverage the evening of 4/25/26 so that the resident would have received treatment for the elevated reading of 509. For a blood sugar reading of 509, she would probably have ordered an additional 16 units of Humalog (the fast-acting insulin). It also did not make sense to her (the NP) that on 4/25/26 the resident's blood sugar went from 233 at 6:00 AM to 1046 later that same morning in the emergency room. She had seen the resident on 4/24/26 (Friday) and her plan at that time was to see her again on 4/27/26 (Monday) and evaluate her blood sugar trends to see how the resident's blood sugars could best be managed, but she had not had a chance to evaluate the resident's blood sugars before she was sent back to the hospital. Given that Resident # 2 was both a newly admitted resident on 4/23/26 and additionally she had new orders for an enteral feeding for her nutrition, she (the NP) would not have changed any insulin orders right away upon admission until she had been able to evaluate her further and look at trends. The facility Medical Director was interviewed on 6/10/26 at 2:00 PM and reported the following information. He was not familiar with Resident # 2 and without knowing her history he was hesitant to comment on the fluctuation of her fingerstick blood sugar results. Infection can make a resident's blood sugar go up. Some residents can also be labile (Labile diabetics experience unpredictable, severe, wide blood sugar swings between high to low). He historically had one specific patient whose blood sugar fluctuated within a very short time period from 100 to 600 because this other resident was so labile, and although the fluctuation was wide, this other patient would report he felt well and was not symptomatic, According to the physician, it would be his expectation that he be informed if a resident's blood sugar went above 400 so that it could be addressed if there were no other individual parameters for a resident. The hospital ED physician, who saw Resident # 2, on 4/26/26 was interviewed by phone on 6/11/26 at 12:30 PM and reported the following information. It was really difficult to reconcile a 6:00 AM blood sugar reading of 233 with a serum blood sugar later the same morning of over a 1000. For some reason, the glucometer machine may not have read correctly and possibly the 233 was not correct. This was especially a possibility considering the resident's blood sugar was over 500 the previous evening. A blood sugar change from over 500 to 233 would be a big swing with only 5 units of Humalog insulin having been administered. Infrared (non-touch) thermometers can give incorrect results at times. They sometimes read high. Given that the facility staff obtained a temperature reading of 98.8 just prior to calling EMS, EMS obtained a temperature reading of 105.1, both the facility staff and EMS assessed the resident to have a high pulse/heartrate combined with the finding in the ED that Resident # 2's white blood count was elevated, indicated that Resident # 2 was probably febrile at the facility before EMS arrived. According to the ED physician, more accurate temperature readings were obtained by oral and rectal routes. It was not uncommon not to find a source of infection in a patient although infection was a causative problem of an illness, and given Resident # 2 had an elevated white blood count, she may have had an infection which led to her illness, hospitalization, and affected her blood sugars. As an individual's blood sugar rises, the body tries to expel the blood sugar by more frequent urination which in turn affects their hydration status, BUN and creatinine levels. It was possible for some individual's blood sugar to be elevated at 509 without showing evident symptoms. Even if the facility staff had called their provider on the evening of 4/25/26 when Resident # 2's blood sugar registered 509 and she received further assessment and treatment for the elevated blood sugar, she may still have developed illness stemming from an infection the next morning which required hospitalization and care. After treatment, diabetic ketoacidosis did not typically affect an individual long term and given that there might be an underlying problem of possible infection, he did not feel it could be said by him the resident was harmed by the facility's lack of follow up on the evening o 4/25/26. He would advise them to ensure their equipment was calibrated and working correctly. During interviews with the Director of Nursing (DON) on 6/10/26 at 9:00 AM, 6/10/26 at 6:30 PM, 6/11/26 at 4:35 PM and 4:40 PM, the DON reported the following information. When a resident is admitted to the facility and they are on insulin, the electronic MAR automatically populates to direct staff to check the resident's blood sugar when the insulin is due. There were no standing orders with parameters to call a physician for a certain level of blood sugar result. It was her expectation that Nurse # 1 should have called the provider on the evening of 4/25/26 and rechecked the blood sugar to make sure it did come down. She had taken corrective action by educating Nurse # 1 after the incident but had not implemented a plan that included all nurses.

Based on record review, and interviews with staff, Pharmacists, and Medical Director the facility failed to 1) ensure they obtained medications from the pharmacy or the facility's back up supply for administration for a newly admitted resident and 2) upon admission clarify an order which directed a 12 hour extended release medication was to be administered via way of a gastrostomy tube so that the pharmacy would dispense an alternate form of the medication that was appropriate to be administered via gastrostomy tube (tube inserted through the wall of the abdomen directly into the stomach). This was for 1 of 1 resident whose medications were reviewed (Resident # 2).The findings included:Record review revealed Resident # 2 resided at the facility for four days in April 2026 (4/23/26 to 4/26/26). Resident # 2 had diagnoses which included history of stroke, trigeminal neuralgia, diabetes, and dysphagia with a gastrostomy tube placed for nutrition.On 4/23/26 at 4:19 PM Nurse # 4 documented in a nursing note that Resident # 2 had been admitted to the facility.1a. Review of 4/23/26 facility admission orders revealed an order for metformin 1000 mg (milligrams) one tablet via G-tube (gastrostomy tube) two times a day with meals. (Metformin is used to treat diabetes).On 4/23/26 at 11:52 AM Pharmacist # 1 was interviewed and reviewed the pharmacy's records for Resident # 2's dispensed metformin. Pharmacist # 1 reported they received the metformin order on 4/23/26 and it was sent to the facility the next day (on 4/24/26) around 8:30 PM during the regular delivery. Review of Resident # 2's April 2026 MAR (Medication Administration Record) revealed there were four scheduled times that appeared by the metformin order on the MAR. These were 6:00 AM, 8:30 AM, 6:00 PM, and 8:30 PM. The following was documented on the MAR and in the accompanying electronic MAR (EMAR) notes indicating no documentation Resident # 2 received the metformin on the day of admission and she missed one of two doses on the subsequent days of residency following admission.On 4/23/26 at 6:00 PM Nurse # 4 documented a 9 indicating other and see nursing note.(On 4/23/26 at 5:53 PM Nurse # 4 documented ordered from pharmacy in an EMAR note.)On 4/23/26 at 8:30 PM there was an xOn 4/24/26 at 6:00 AM, Nurse # 5 initialed and placed a check indicating administration.On 4/24/26 at 8:30 AM, there was an x.On 4/24/26 at 6:00 PM, Nurse # 1 documented a 5 indicating the metformin was held.(On 4/24/26 at 6:11 PM, Nurse # 1 documented the metformin was on order in an EMAR note.)On 4/24/26 at 8:30 PM there was an xOn 4/25/26 at 6:00 AM there was an xOn 4/25/26 at 8:30 AM Nurse # 1 documented a 5 indicating the metformin was held.(On 4/25/26 at 10:23 AM Nurse # 1 documented the metformin was on order In an eMAR note.)On 4/25/26 at 6:00 PM there was a x.On 4/25/26 at 8:30 PM Nurse # 2 initiated and checked administration. Nurse # 4, who had cared for Resident # 2 on the day of admission and written the medication was on order, was interviewed on 6/11/26 at 2:32 PM and reported the following information. She only filled in at the facility and did not recall anything about Resident # 2 or her medications. Nurse # 1, who had documented the metformin was on hold on 4/24/26 and 4/25/26, was interviewed on 6/10/26 at 9:49 AM and reported the following information. She was new in April 2026, and she did not realize that the metformin was in the facility's back up supply of medications. Therefore, she did not administer it when she put it was on hold on 4/24/26. Nurse # 1 was also interviewed about the held dose on 4/25/26 at 8:30 AM given that the medication had been delivered by the pharmacy on 4/24/26. Nurse # 1 reported that although the medications might be delivered, they were not always found on the cart for administration. Nurse # 1 also reported she was aware there was a backup pharmacy for medications and sometimes they would get needed medications from a backup pharmacy and in some instances the nurses had to leave work and go get the medication from the backup pharmacy. During the interview with Pharmacist # 1 on 4/23/26 at 11:52 AM, Pharmacist # 1 also reported the following information. Medications were filled and dispensed by the regular pharmacy if orders were sent in by 5:30 PM. If the facility needed medications before then, they could look in their backup supply of medications. Metformin was in the backup supply of medications. The facility staff could also call the backup pharmacy if the medication was not in the backup supply of medications. There were two backup pharmacies for which arrangements had been made to fill after hours medications for the facility. There was a backup agency which fielded calls for the backup pharmacy for the facility after normal pharmacy hours. The backup pharmacy could arrange for a courier. Pharmacist # 1 was interviewed about what the nurses were to do if they could not leave work and go get the medication as Nurse # 1 reported they sometimes had to do, and Pharmacist # 1 replied that a courier should be arranged and if not then they (the main pharmacy) would fill the medication. The Director of Nursing (DON) was interviewed on 6/10/26 at 9:00 AM and on 6/10/26 at 3:20 PM and reported the following information. Metformin was a medication that was in their backup medications in the dosage of 500 mg and the nurses could have pulled two 500 mg tablets to equal the needed 1000 mg from the emergency backup supply of medications and administered the dosage on the evening when Resident # 2 was admitted and again on 4/24/26. The facility's records showed that Resident # 2's supply of metformin was delivered to them on the evening/night delivery of 4/24/26 and therefore the resident's own supply should have been available on 4/25/26 when the dose was held on that date. If the metformin had been depleted from the facility's backup supply, there was a backup pharmacy, and at times the facility did have to send a nurse to get medications rather than the pharmacy arranging a courier. The facility Medical Director was interviewed on 6/10/26 at 2:00 PM regarding the held metformin and reported he would not consider the held metformin doses to be significant or have negatively impacted the resident. 1b. Review of Resident # 2's 4/23/26 facility admission orders revealed the resident was ordered to receive gabapentin 100 mg three times per day via gastrostomy tube for the diagnosis of trigeminal neuralgia. (Trigeminal neuralgia is a neuropathic pain condition that causes sudden, severe, electric shock-like or stabbing pain in the face.) Review of a 4/23/26 hospital MAR (Medication Administration Record) revealed Resident # 2 last received the gabapentin at 2:10 PM before discharge to the facility on 4/23/26. Review of Resident # 2's April 2026 facility MAR revealed the gabapentin was scheduled to be given at 6:00 AM, 12:00 PM, and 6:00 PM. The MAR also showed the following documentation: On 4/23/26 at 6:00 PM Nurse # 4 documented a 9 indicating other see nursing note.(There was no accompanying EMAR note for the 4/23/26 6:00 PM dose.)On 4/24/26 at 6:00 AM Nurse # 5 initialed and placed a check mark indicating administration.On 4/24/26 at 12:00 PM Nurse # 1 initialed and placed a check mark indicating administration.On 4/24/26 at 6:00 PM Nurse # 1 documented a 5 indicating the medication was held.(There was no accompanying EMAR note)On 4/25/26 at 6:00 AM Nurse # 2 initialed and placed a check mark indicating administration.On 4/25/26 at 12:00 PM Nurse # 2 documented a 5 indicating the medication was held.On 4/25/26 at 6:00 PM Nurse # 2 documented a 5 indicating the medication was held.(On 4/25/26 at 6:04 Nurse # 1 noted in an EMAR note that the gabapentin was on order. Nurse # 4, who had cared for Resident # 2 on the day of admission, was interviewed on 6/11/26 at 2:32 PM and reported the following information. She only filled in at the facility and did not recall anything about Resident # 2 or her medications. Nurse # 1 was interviewed on 6/10/26 at 9:49 AM and reported the following information. She was new in April 2026, and she did not realize that the gabapentin was in the facility's back up supply of medications and how to obtain it. She also reported that at times after delivery from the pharmacy, sometimes medications could not be found on the cart. On 6/10/26 at 9:00 AM and 3:20 PM the DON provided the facility's list of dispensed medications for Resident # 2 which they had received from the pharmacy and was interviewed regarding the medications. The interview and delivery sheets revealed the following information. No gabapentin was documented as delivered to the facility on 4/23/26 although the pharmacy delivered four other medications on 4/23/26 for Resident # 2. The first delivery of gabapentin for Resident # 2 was on 4/24/26. According to the DON, the 4/24/26 delivery would have been delivered somewhere between the hours of 7:00 PM and 9:00 PM. During an interview with Pharmacist # 1 on 4/23/26 at 11:52 AM, Pharmacist # 1 reported gabapentin was in the facility's backup supply of medications and could have been obtained from there. If the backup supply of medications was depleted, then the facility could have called the backup pharmacy to obtain the medication. On 6/11/26 at 4:19 PM the DON provided the documentation of removal for any medications for Resident # 2 from the facility's backup supply of medications. There had been no documentation of removal of gabapentin for Resident # 2. The facility Medical Director was interviewed on 6/10/26 at 2:00 PM regarding the held gabapentin and reported that he would not consider the held doses to be significant or to have negatively impacted the resident. 1c. Review of Resident # 2's 4/23/26 facility admission orders revealed the resident was ordered to receive Tegretol-XR Extended Release 12-hour 200 mg via gastrostomy tube two times per day. (Tegretol-XR is specifically designed to release the medication slowly over 12 hours and crushing or chewing the tablet destroys this special mechanism, causing all of the medicine to enter an individual's body at once. The Tegretol was ordered for Resident # 2's trigeminal neuralgia). Review of Resident # 2's electronic record revealed the admission order on 4/23/26 for Tegretol XR was entered into the electronic record by Nurse # 4 on 4/23/26. Review of the record revealed no clarification on the day of admission [DATE]) regarding what to do given that the medication was ordered to be given by gastrostomy tube and therefore necessitated being crushed if administered by this route.) Review of the facility's medication delivery records revealed on 4/23/26 the facility received 12 doses of carbamazepine extended release 200 mg for Resident # 2. (Carbamazepine extended release is the generic form of Tegretol XR). Review of Resident # 2's April 2026 Medication Administration Record (MAR) revealed the Tegretol XR 200 mg by gastrostomy tube was scheduled for 6:00 AM and 6:00 PM. There were no directions by the order not to crush the medication. On 4/23/26 at 6:00 PM Nurse # 4 documented a 9 on the MAR with not corresponding EMAR note. On 4/24/26 at 6:00 AM Nurse # 5 initialed and placed a check indicating administration of the Tegretol-XR by way of the gastrotomy tube. Nurse # 4, who cared for Resident # 2 on the day of admission, was interviewed on 6/11/26 at 2:32 PM regarding whether she had sought clarification upon admission when the order indicated the Tegretol should be administered by gastrostomy tube, but an extended-release form would have indicated this was not to be done. Nurse # 4 reported she only filled in at the facility and did not recall anything about Resident # 2 or her medications. Nurse # 5 was interviewed on 6/11/26 at 10:00 AM and reported the following information. The pharmacy generally sent directions not to crush medications and if there were directions not to crush it, then she would not have done so when she administered it. She did not recall other specifics about the administration. Pharmacist # 2 and the DON were interviewed on 6/11/26 at 4:26 PM. The DON reported the following information. When Resident # 2 arrived, she was strict NPO (nothing by mouth) and all her medications had to be given by gastrostomy tube and orders were entered accordingly. The facility sends both the facility's admission orders and the discharge summary orders to the pharmacy and the pharmacy checks for discrepancies as they are filling to avoid errors. Pharmacist # 2 reported the following. On Resident # 2's discharge summary they received orders that the Tegretol was to be given by mouth and they also received the facility admission orders that it was to be given by gastrostomy tube. They sent a request to the facility to obtain clarification. Clarification was obtained on 4/24/26 and the pharmacy then dispensed on 4/24/26 a liquid form of Tegretol that could be administered by gastrostomy tube. Interview with Pharmacist # 1 on 6/10/26 at 11:52 PM revealed when Tegretol ER medication is dispensed then directions are routinely sent with the medication not to crush the medication.

Based on observations and staff interviews the facility failed to label or date food items stored in 1 of 1 walk-in cooler. This had the potential to affect food served to residents.Findings included:On 3/16/26 at 10:31 AM during the initial kitchen tour an observation of the facility's walk-in cooler was conducted with the Dietary Manager. An unlabeled and undated rectangular metal container covered with clear plastic wrap was observed to contain what the Dietary Manager described as being about 10 ounces of pudding. An additional unlabeled and undated rectangular metal sheet pan covered with aluminum foil was observed to contain what the Dietary Manager described as being about 20 turkey sandwiches. The Dietary Manager reported that when she left the facility at 4:00 PM on Friday 3/13/26, neither the pudding nor the sandwiches were present in the walk-in cooler. She stated they must have been prepared and placed there sometime over the weekend, but because they were not labeled or dated, she could not say for sure. She indicated she and her Assistant Dietary Manager monitored the walk-in cooler for unlabeled or undated food items during the week, but there was no one designated to do this on weekends. She reported that all food items placed in the walk in cooler should be labeled or dated. The Dietary Manager stated whoever placed a food item in the walk in cooler would have been responsible for labeling or dating it.On 3/19/26 at 10:57 AM an interview with the Administrator indicated there should be no unlabeled or undated food items in the walk-in cooler.

Based on observations, staff interviews, and record review the facility failed to clean and maintain privacy curtains, oxygen concentrators, and walls in resident rooms for 3 of 44 resident rooms (Resident #18, Resident #79, and Resident #160) on 2 of 11 halls (200 and 300 Halls) observed for environment. The findings included: a. Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that she was severely cognitively impaired. An observation of Resident #18's room, located on the 300 hall, on 3/16/26 at 11:26 AM revealed there were two privacy curtains located around the resident's bed and the curtain closest to the window displayed multiple dark brown/red stains. An additional observation of Resident #18's room was conducted on 3/19/26 at 8:45 AM and revealed that the privacy curtain closest to the window displayed multiple dark brown/red stains. An observation of Resident #18's room was conducted during an interview with Housekeeper #1 on 3/19/26 at 8:49 AM. She revealed that she was assigned to Resident # 18's room on 3/17/26 and 3/18/26. She indicated that she was the staff responsible for replacing privacy curtains if they were dirty/soiled. Housekeeper #1 confirmed that the privacy curtain closest to the window in Resident #18's room needed to be changed due to the dark brown/red stains. Housekeeper #1 could not provide a reason for why the privacy curtain was not changed earlier in the week. The Housekeeping Manager was interviewed on 3/19/26 at 9:50 AM. He revealed that housekeepers were responsible for changing out the privacy curtains upon discharge or when soiled or stained. The Housekeeping Manager stated that Housekeeper #1 could have reported the curtain issue in Resident #18's room, and he believed the dark brown/red marks were burns from the dryer. He indicated that regardless of what the marks were from, the privacy curtain should have been changed as soon as the markings were noticed. b. Resident #79's significant change MDS assessment dated [DATE] revealed that she was severely cognitively impaired. An observation of Resident #79's room, located on the 200 hall, on 3/17/26 at 9:15 AM revealed the oxygen concentrator had visible white particles all over the top surface. An additional observation was conducted on 3/19/26 at 8:35 AM revealed the oxygen concentrator in Resident #79's room had visible white particles all over the top surface. Housekeeper #2 was interviewed on 3/19/26 at 9:38 AM. She revealed that it was the housekeeper's responsibility for wiping down the oxygen concentrators in resident rooms. An observation in Resident #79's room was conducted during an interview with Housekeeper #2 on 3/19/26 at 9:45 AM. Housekeeper #2 confirmed that it was her responsibility to clean the oxygen concentrator in Resident #79's room. She stated that she did not notice that the concentrator needed to be cleaned prior to 3/19/26. Housekeeper #2 could not provide a reason why it was not cleaned earlier in the week. The Housekeeping Manager was interviewed on 3/19/26 at 9:53 AM. He revealed that the oxygen concentrators were supposed to be cleaned on a weekly basis, usually on Wednesdays, along with any other medical equipment in resident rooms. He indicated the oxygen concentrators should also be cleaned if dirty, dusty, or soiled. The Housekeeping Manager stated the oxygen concentrator in Resident #79's room should have been cleaned on Wednesday 3/18/26 by Housekeeper #2. c. Resident #160's quarterly MDS assessment dated [DATE] revealed that he was severely cognitively impaired. An observation of Resident #160's room, located on the 200 hall, was conducted during an interview with Nurse Aide #2 on 3/16/26 at 2:19 PM. Resident #160 was lying in bed with his left knee bent and resting on the wall to the left of the window. Dark red marks that resembled a dripping pattern were observed on the wall where Resident #160's left knee was touching. Nurse Aide #2 stated that the drippings were in fact blood and displayed Resident #160's knee with 3 scabbed areas. Nurse Aide #2 further stated that the wall had not been cleaned since she started at the facility 2 weeks ago. She then went and retrieved a clean pillow and placed it in between Resident #160's knee and the wall. Housekeeper #2 was interviewed on 3/19/26 at 9:38 AM. She revealed that she did not notice the dark red marks on the wall in Resident #160's room prior to 3/18/26. Housekeeper #2 stated she noticed the dark red marks on the wall in Resident #160's room on 3/18/26 and cleaned the wall at that time. She added that if anything needed to be cleaned out of the ordinary, the Nurse Aides were supposed notify housekeeping. During a follow-up interview with Nurse Aide #2 on 3/19/26 at 3:41 PM, she revealed that she could not provide a reason why she did not notify housekeeping about the blood stains on Resident #160's wall. She stated, I just did not think about it. The Housekeeping Manager was interviewed on 3/19/26 at 9:52 AM. He revealed that when rooms were cleaned daily, housekeeping was expected to focus on wiping down all vertical and horizontal surfaces including walls. The Housekeeping Manager stated that Housekeeper #2 should have noticed the blood stains on the wall in Resident #160's room and cleaned the wall during routine room cleaning. The Administrator was interviewed on 3/19/26 at 1:18 PM. He revealed that perhaps the cleaning process was not outlined by the Housekeeping Manager with housekeeping staff, or they were rushing through their work. The Administrator indicated that the privacy curtain in Resident #18's room was replaced, the oxygen concentrator in Resident #79's room should have been cleaned, and the wall in Resident #160's room cleaned. He stated that these tasks should have been completed in a timely manner. The Administrator did not explain what specific period of time equated to a timely manner.

Based on observations, record review, and interviews with staff and Medical Director, the facility failed to follow the Resident Care Guide and use a mechanical lift prior to the transfer of a resident (Resident #1). On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) did not see any mechanical lifts immediately available and entered Resident #1's room at approximately 2:45 PM. Despite knowing that Resident #1 required a mechanical lift for all transfers, NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. At approximately 2:50 PM NA #1 asked NA #2 and Medication Aide for assistance with transferring the resident from the wheelchair to the bed. When Resident #1 was assisted into bed without a mechanical lift, she complained of right shoulder pain. The pain was treated with as needed pain medication; however, it was ineffective. An x-ray ordered for the right arm and shoulder did not result in a fracture. At approximately 7:20 PM, Resident #1 was noted to have a softball size area on her upper chest and when palpated and the resident stated it hurt. New orders were received to send the resident to the hospital emergency department (ED) for evaluation and treatment. The ED Physician documented there was acute swelling of the right chest wall and the exam revealed a large tense hematoma approximately the size of a grapefruit. The results of the chest x-ray revealed a right chest wall hematoma (localized collection of blood that has leaked from damaged blood vessels into the tissues of the chest wall) with active bleeding. On 12/12/25 at 11:28 AM Resident #1 was transferred to the second hospital with a higher level of care and that same day underwent a VIR (Vascular and Interventional Radiology) embolization (minimally invasive procedure performed by vascular and interventional radiologists to block or close off a specific blood vessel using embolic agents, often guided by real-time imaging such as fluoroscopy, CT, or ultrasound). Resident #1 developed repeat bleeding concerns 12/14/25 and stabilized without intervention. On 12/18/25 trauma surgery performed a hematoma evacuation (a surgical procedure to remove a localized collection of blood outside blood vessels, often necessary when a hematoma causes pressure or complications). The hospital discharge summary indicated resident was discharged back to the facility on [DATE] with an appointment to follow up with the surgeon on 12/30/25 for follow up of the right breast hematoma with drain placement. The deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, end stage renal disease (ESRD) with dependence on dialysis (HD), and diabetes. Resident #1 was sent to the hospital on [DATE] and was transferred to a higher-level care hospital on [DATE]. She returned to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was cognitively intact, had moderate difficulty hearing, and severely impaired vision. She was totally dependent on staff for transfers. Resident #1 received as needed pain medication, and pain presence was occasional. Review of the Resident Care Guide implemented on 11/13/23 and contained in the care plan revealed that Resident #1 required a mechanical lift of one person assist with all transfers. The sling size was medium. The care plan was revised on 1/16/25 and included the problem of activities of daily living (ADL)/personal care. Interventions included: Mechanical lift. Review of physician orders for Resident #1 revealed Oxycodone (opioid pain medication) 5 milligram (mg) tablet to be given every 4 hours as needed for pain was ordered from 7/22/25 through 12/19/25. Resident #1 also received Eliquis (blood thinner medication which raises the risk of bruising and bleeding) 2.5mg tablet to be given twice daily for history of portal vein thrombus (blood clot that obstructs the vein carrying blood to the liver). NA #1 was interviewed on 2/11/26 at 11:58 AM. She revealed that the Resident Care Guide contained resident transfer details. NA #1 stated that Resident #1 was alert most of the time and required a mechanical lift for all transfers. On 12/11/25 around 12:00 PM, Resident #1 returned from dialysis while NA #1 was in the middle of lunch meal service. Resident #1 requested to be transferred to bed because she was tired and hurting, which was usual for her after dialysis. NA #1 told Resident #1 that she could help her after meal service was complete. When NA #1 went to retrieve the mechanical lift, the two lifts in her section did not have any charge. NA #1 stated she told Resident #1 that she would have to wait a little longer since both mechanical lifts were not available at the time. Resident #1 was adamant about being transferred to bed immediately. Around 2:45 PM, NA #1 decided to accommodate Resident #1's request without a mechanical lift. As soon as NA #1 lifted Resident #1 out of the wheelchair, Resident #1 complained about her legs and began to panic. Resident #1 put all her weight on NA #1, and NA #1 assisted Resident #1 to the floor. NA #1 stated she did not want to leave Resident #1 on the floor and felt she needed to get her off the floor, so she lifted Resident #1 from the floor back to the wheelchair. However, Resident #1 appeared slumped in the wheelchair, and NA #1 pulled her more upright in the wheelchair. NA #1 then called for help and the Medication Aide and NA #2 entered the room. All three staff members lifted Resident #1 into the bed. NA #1 stated she then went and told the Unit Manager about the assisted fall. When the Unit Manager came to the room, she asked Resident #1 if she was hurting. Resident #1 responded that she felt pain in her right arm. The Unit Manager assessed her right arm and found no injuries. The Medication Aide provided Resident #1 with as needed pain medication. NA #1 stated that she received education on 12/12/25 to always follow the Resident Care Guide, including the use of a mechanical lift for Resident #1 with all transfers. During a follow up telephone interview with NA #1 on 2/11/26 at 4:09 PM, she revealed that Resident #1 was normally transferred from a stretcher to the bed by transportation personnel after all dialysis appointments. NA #1 stated that on 12/11/25, it was the first time she ever transferred Resident #1 to bed after dialysis. However, this day was different because a different transportation vendor was used to bring Resident #1 to/from dialysis on 12/11/25. Since Resident #1 refused to wait for an available mechanical lift on 12/11/25, NA #1 stated she just wanted to get Resident #1 in bed before shift change at 3:00 PM. She further stated that she already knew a mechanical lift was required to transfer Resident #1. NA #2 was interviewed via telephone on 2/11/26 at 12:29 PM. She revealed that she was sitting at the nurses' station on 12/11/25 around 2:45 PM when NA #1 called for help. When NA #2 came into the room, she saw Resident #1 sitting and slightly slanted in the wheelchair. The Medication Aide then came into the room. NA #2, NA #1, and the Medication Aide transferred Resident #1 to the bed. The Medication Aide and NA #1 held each of Resident #1's armpits, and NA #2 held her legs. Resident #1 was not screaming in pain or reporting pain. When the Medication Aide asked Resident #1 if she was ok, she said I'm ok, but can you give me some Tylenol? NA #2 then left the room. NA #2 stated that she was educated on 12/12/25 about fall protocol and the importance of following the Resident Care Guide details. The Medication Aide was interviewed on 2/11/26 at 11:24 AM. She revealed that Resident #1 returned to the facility around 12:00 PM on 12/11/25. Resident #1 said she was ready to go back to bed and asked NA #1, who was passing meal trays, to help her. NA #1 told Resident #1 she would do so after meal service. Resident #1 yelled again, and the Medication Aide told Resident #1 that NA #1 was busy with another resident. Then around 2:30 PM, NA #1 was in Resident #1's room yelling for help. When the Medication Aide came to the room, Resident #1 appeared slumped in her wheelchair, and it looked as though Resident #1 moved one inch she would fall. There were not any mechanical lifts available at the time. After she saw Resident #1 slumped in the wheelchair, she and two other staff members (NA #1 and NA #2) helped Resident #1 into bed. A nursing note dated 12/11/25 at 4:53 PM and completed by the Unit Manager revealed that she was made aware that Resident #1 had an assisted fall around 2:45 PM. Upon entering the room, Resident #1 was assisted back to bed by NA #1, NA #2, and the Medication Aide. Resident was noted in the center of the bed holding her right shoulder with the left hand. Resident stated, I was yelling because I wanted to get back in bed because I was hurting. The girl sat me on the floor. The Unit Manager assessed Resident #1, vital signs were obtained, and a head-to-toe evaluation was completed. No new skin issues were noted. Oxycodone 5mg was administered. The on-call provider was contacted, and an order for x-ray of the right arm and right shoulder was entered. During an interview with the Unit Manager on 2/11/26 at 3:25 PM, she revealed that if a mechanical lift battery was dead, she would expect nursing staff to find another lift battery for replacement. If none were charged, staff should let the resident know, or whoever requested the transfer, and check back on the charge in 30-60 minutes. When they finished using a mechanical lift, nursing staff were expected to plug it back in. Verbal education was provided to all 3 staff members (NA #1, NA #2, and the Medication Aide) immediately after the incident about waiting or a lift to be available prior to transferring a resident whose Resident Care Guide stated a lift was required. A change of condition assessment dated [DATE] at 1:00 PM completed by the Unit Manager revealed that after the on-call provider was contacted due to new acute pain, they recommended an x-ray to Resident #1's right shoulder and right arm and as needed pain medication. An electronic medication administration record note dated 12/11/25 at 2:47 PM and completed by the Medication Aide revealed that Resident #1 received 5mg of Oxycodone for pain and was effective. A telehealth on-call provider note dated 12/11/25 (no time specified) revealed that the Unit Manager reported Resident #1 had an assisted fall and now complaining of 10/10 pain in her right shoulder. Oxycodone 5mg was administered for pain, along with an order given for an x-ray of the right shoulder and right arm. Rounding provider to follow up. A physician order for a 2-view portable x-ray of the right shoulder and right arm one time only for pain was entered on 12/11/25. The x-ray report of Resident #1's right shoulder and right arm dated 12/11/25 showed no fractures or breaks. A nursing progress note dated 12/11/25 at 10:39 PM by Nurse #1 revealed that Nurse #1 went into Resident #1's room during rounds around 7:20 PM. Resident #1 complained of pain to her right shoulder and back after the assisted fall earlier in the day. A large soft ball sized area to the upper right part of her chest was observed. When the area was palpated, Resident #1 stated, yea that's where it hurts. The on-call provider was contacted at 7:30 PM and gave a verbal order to transfer Resident #1 to the emergency department (ED) for further evaluation. A telehealth on-call provider note dated 12/11/25 (no time specified) revealed that Nurse #1 reported that Resident #1 complained of 10/10 (a pain scale of 0 (zero) is no pain and a pain scale of 10 is the worst pain possible) pain adjacent to her right shoulder and now has a large hematoma forming above the dialysis site on the right arm. Orders were given for Resident #1 to be transferred to the ED. A Change in Condition Evaluation dated 12/11/25 at 9:00 PM by Nurse #1 revealed that Resident #1 had swelling noted to the right side of her chest below the shoulder. Resident #1 expressed a 10/10 pain scale due to acute musculoskeletal pain. Oxycodone 5mg was administered but ineffective. The on-call provider was notified at 7:30 PM to send Resident #1 to the ED for further evaluation. An ED provider note from the hospital dated 12/11/25 revealed Resident #1 presented with acute swelling of the right chest wall and the exam revealed a large, tense hematoma approximately the size of a grapefruit. There were no complications to Resident #1's dialysis access site on her right arm. Her hemoglobin was low at 9.0 grams/deciliter, but she remained stable in the ED. An x-ray of Resident #1's right breast showed a hematoma that measured 8 cm (centimeters) by 8 cm by 9 cm with active bleeding. The ED Physician further documented he had contacted another hospital with a higher level of care for possible transfer for interventional radiology services for potential embolization of blood vessels. On 12/12/25 at 11:28 AM Resident #1 was transferred to the second hospital. A hospital Discharge summary dated [DATE] revealed that Resident #1 was admitted on [DATE] and the principal problem was an arterial (the blood vessels that carry oxygen rich blood away from the heart) hemorrhage. On 12/12/25 Resident #1 underwent a VIR (Vascular and Interventional Radiology) embolization (minimally invasive procedure performed by vascular and interventional radiologists to block or close off a specific blood vessel using embolic agents, often guided by real-time imaging such as fluoroscopy, CT, or ultrasound). Resident #1 developed repeat bleeding concerns 12/14/25 and stabilized without intervention. On 12/18/25 trauma surgery performed a hematoma evacuation (a surgical procedure to remove a localized collection of blood outside blood vessels, often necessary when a hematoma causes pressure or complications). The hospital discharge summary indicated resident was discharged back to the facility on [DATE] with an appointment to follow up with the surgeon on 12/30/25 for follow up of the right breast hematoma with drain placement. An interview was attempted with Resident #1 on 2/11/26 at 11:18 AM; however, she was not alert and oriented and refused to answer any questions related to the incident on 12/11/25. Interim Administrator #2 was interviewed via telephone on 2/12/26 at 8:09 AM. She revealed that the focus of the incident after an investigation revealed that nursing staff must use a mechanical lift for all required residents. Education for all nursing staff included following the Resident Care Guide for all details, including transfers with a mechanical lift. The Medical Director was interviewed via telephone on 2/11/26 at 2:32 PM. He revealed that hematomas could occur adjacent to the area affected or touched and the hematoma could have taken days to develop. If pressure was applied to Resident #1's armpit, it could have caused hematoma. Also, regular contact with pressure could cause a hematoma. More than likely, the injury did not occur because of the fall but rather how she was transferred. The Medical Director stated that the hematoma was not preventable due to the extent of Resident #1's medical conditions and fragility. The Director of Nursing (DON) was interviewed on 2/11/26 at 2:20 PM. The DON stated that NA #1 should not have done a stand pivot transfer with Resident #1 and was expected to follow the Resident Care Guide for all transfer details. After the assisted fall, Resident #1 should have been left on the ground until a nurse arrived to assess. NA #1, NA #2, and the Medication Aide transferred Resident #1 from the wheelchair to the bed because it looked like Resident #1 was going to fall out of the chair. At that time, the DON stated Resident #1 should have been adjusted in the wheelchair, so that she was safe. The DON further stated that nothing was said to her about the mechanical lift batteries being dead on 12/11/25. However, NA #1 did say that she could not locate a free mechanical lift when Resident #1 wanted to be transferred to bed. During a joint interview with the DON and interim Administrator #1 on 2/11/26 at 4:35 PM, they revealed that NA #1 should have followed the Resident Care Guide and not attempted to transfer Resident #1 without a mechanical lift. During a follow up telephone interview with the DON on 2/13/26 at 10:25AM, she revealed that NA #1 should have looked at other nurse stations for an available mechanical lift. The DON stated NA #1 only checked the area was she was assigned. If a mechanical lift was not available immediately, NA #1 should have notified Resident #1 and waited until a mechanical lift became available. NA #1 could have asked other nursing staff to assist her with finding a mechanical lift or notify the Unit Manager. The facility provided the following corrective action plan with a completion date of 12/17/25: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was alert, oriented and able to make her needs known. On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. The assigned Nursing Assistant #1 (NA) entered Resident #1's room at approximately 2:45 PM. Resident requested to be put to bed and despite knowing that resident required a lift for transfer, NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1 was unable to complete the transfer; NA #1 lowered the resident safely to the floor. The resident had no complaints about pain. NA #1 then assisted the resident back into the wheelchair by placing her arms under the resident's arms and her knees against the resident's knees and lifted the resident slightly back into the wheelchair sitting on the edge of the seat of the wheelchair. NA #1 did not report the assisted fall to the floor to the nurse prior to moving the resident back to the wheelchair. At approximately 2:50pm NA #1 asked NA #2 and the Medication Aide for assistance with transferring the resident from the wheelchair to the bed. NA #1 did not inform NA #2, or the Medication Aide of the resident's assisted fall to the floor. Two staff were placed at the resident's upper body, and the third staff member was at the resident's feet. The three staff lifted the resident up out of the chair and onto the bed instead of utilizing the lift due to the positioning of the resident on the edge of the wheelchair seat and the potential risk of falling. After the resident was transferred, the resident was observed holding her arm and complaining of pain. NA #1 then advised the Medication Aide that prior to transferring from chair to bed, the resident had been assisted to the floor. The Medication Aide immediately reported the fall to the Unit Manager. The Unit Manager completed an assessment of the resident with no visible injury. At approximately 3:05 pm Nurse #1 notified the on-call provider of Resident #1's assisted fall and complaints of right arm pain. The on-call provider ordered an x-ray for right arm and shoulder. The resident representative (RR) was unable to be reached, and a detailed message was left to return call to facility. At approximately 7:00 PM, the x-ray was completed with no fractures identified. During the evening shift, at approximately 7:20 PM, Nurse #1 assessed Resident #1 and noted a softball size area on her upper chest. When palpated, Resident #1 stated that it hurt. Nurse #1 notified the on-call provider with new orders to send Resident #1 to the hospital for evaluation and treatment. At approximately 7:33pm, the resident representative was updated on Resident #1's condition and the order to transfer to the hospital. Diagnosis at the hospital was a right chest wall hematoma.Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 12/12/25, the treatment nurses completed skin checks of all residents not able to report for acute changes to include injuries not reported or addressed. There were no additional concerns identified. On 12/15/25, the Social Worker (SW) initiated resident questionnaires with current alert and oriented residents to identify any concerns related to transfer that had not been previously reported or addressed. The questionnaires were completed on 12/16/25. There were no concerns identified. On 12/12/25, the Minimum Data Set Nurse under the supervision of the Director of Nursing completed an audit of all resident care plans/ care guides. This audit was to ensure the care plan/ care guide included the appropriate transfer status and/ or use of positioning devices for resident safety. There were no concerns identified during the audit. On 12/12/25, interim Administrator #2 completed an audit of all incident reports for the past 30 days. This audit was to identify any incidents related to safe handling/not following care guide. There were no additional concerns identified.On 12/16/25, the Maintenance Director completed an audit of all mechanical lifts. This audit was to ensure the facility had adequate lifts for resident care and that all lifts were functioning properly to include a fully charged battery. There were no identified concerns.On 12/12/25 Interim Administrator #2, Staff Development Coordinator (SDC), Nurse Supervisor, Unit Manager, and the Director of Nursing initiated questionnaires with all nurses and nursing assistants regarding transfers. The questionnaires include (1) Do you know of any incidents during a transfer that has not been reported or addressed (2) where do you access the resident care guide (3) when you should check the resident care guide for transfers. Interim Administrator #2, Staff Development Coordinator, Nurse Supervisor, Unit Manager, and/ or DON addressed all concerns identified during the audit to include training of staff. The questionnaires were completed by 12/16/25. After 12/16/25, any nurse or nursing assistant who had not worked or completed the questionnaire completed it prior to the next scheduled work shift. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 12/12/25, the Quality Assurance nurse educated NA #1 on safe handling with emphasis on reading and following care guide for transfers, immediately notifying the nurse of all incidents during transfer to include but not limited to falls, never moving a resident until assessed by the nurse and what to do if appropriate equipment for transfer is not available. On 12/12/25, the DON, SDC, Nurse Supervisor, and Unit Manager initiated an in-service with all nurses and NAs to include NA #1 and agency regarding Safe Handling with emphasis on (1) reading the care guide on the iPad prior to transferring a resident for the correct transfer method (2) always following care guide when providing resident care to include method of transfer (3) what to do if they do not feel the current transfer method is safe or appropriate equipment is not available (4) to ensure that the equipment/aides are stored conveniently and safely to include charging batteries when not in use and (5) consequences for failure to follow safe handling policy. The in-service included a return demonstration on how to identify the resident transfer status on the iPad and to validate staff knowledge and understanding of appropriate techniques for transferring a resident. I-pads were in all nursing stations for certified nursing assistants to complete required shift documentation. Care plan/care guides were updated automatically whenever Registered Nurse updates resident care plan in facility software, Point Click Care (PCC). The in-service and return demonstration were completed by 12/16/25. After 12/16/25, any nurse or nursing assistant who had not completed the training with a return demonstration completed it upon the next scheduled work shift. All newly hired nurses and/or NAs to include agency staff were educated with return demonstrations during orientation by the SDC, DON, or Unit Managers. On 12/12/25, the DON, SDC, and the Unit Managers initiated quizzes with all nurses and nursing assistants regarding transfers to include (1) How do you determine the transfer status of a resident? (2) It is alright to transfer a resident using a different transfer method than listed on the care guide (3) When should you check the resident care guide? (4) What should you do if you feel the transfer status on the care guide is not accurate/ safe? And (5) What should you do if a resident complains of pain during/ following transfer? The quiz was to validate staff knowledge and understanding of education on safe handling and following care guides. Quizzes were completed by 12/16/25. After 12/16/25, any nurse or nursing assistant who had not worked or completed the quiz completed it upon the next scheduled work shift. On 12/12/25, interim Administrator #2 notified the DON of the responsibility to monitor completion of all in-serves, return demonstrations, questionnaires, and quizzes to ensure compliance for resident safety. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.On 12/12/25, the decision was made by interim Administrator #2 to monitor the plan for safe handling of residents and presented the plan of correction to the Quality Assurance Performance Improvement (QAPI) committee to include the Assistant Administrator, Director of Nursing, Unit Managers, Quality Assurance nurse, Staff Development Coordinator, Medical Records, Social Worker, and Minimum Data Set Nurse on 12/12/25. The DON and/or SDC completed 5 observations of transfers weekly for 4 weeks then monthly for 2 months to include all shifts and transfer methods with nurses and nursing assistants. This audit was to ensure sure staff followed safe handling procedures to include checking care guide prior to care to identify transfer status indicated, that the staff used appropriate technique/equipment during transfer and staff notified the nurse for any concerns identified to include falls or near miss falls. Interim Administrator #2 and/or DON reviewed all observations weekly x 4 weeks them monthly x 2 months to ensure all concerns are addressed. There were no concerns. The DON forwarded the Resident Care Transfer Audit Tools to the Quality Assurance and Performance Improvement (QAPI) Committee monthly x 3 months for review and determination of trends and/or issues that may need further interventions put into place to determine the need for further and/or frequency of monitoring. Alleged date of compliance:12/17/25The facility's corrective action plan was validated on 2/11/26. The validation process included staff interviews, record reviews, review of education provided to nursing staff, and review of initial auditing and monitoring audits. The training for staff included fall protocol (notification to a licensed nurse and no movement of resident until assessed), following the Resident Care Guide (including which residents required a mechanical lift), and how to use/where to find the mechanical lifts. During interviews staff confirmed they had received the education and were able to verbalize an accurate summary of the education. Review of incident report audits and nursing staff questionnaires revealed that they were completed as specified in the plan of correction and resulted with no issues. Observations of resident transfers revealed no concerns. The facility's corrective action plan compliance date of 12/17/25 was validated.

Based on observations, record review, and interviews with staff and the Medical Director, the facility failed to notify a nurse after an assisted fall and not move the resident after a fall before a licensed nurse's assessment. On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. Nursing Assistant #1 (NA) entered Resident #1's room at approximately 2:45 PM. NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1's legs gave out, and NA #1 lowered the resident to the floor. NA #1 then assisted the resident back into the wheelchair. NA #1 did not report the assisted fall to a nurse and did not get a nurse to assess the resident before transferring to the wheelchair. At approximately 2:50 PM NA #1 asked NA #2 and Medication Aide for assistance with transferring the resident from the wheelchair to the bed; however, NA #1 did not inform NA #2, or the Medication Aide of the resident's assisted fall to the floor. When Resident #1 was assisted into bed, she complained of right shoulder pain. The pain was treated with as needed pain medication; however, it was ineffective. An x-ray ordered for the right arm and shoulder was negative for a fracture. At approximately 7:20 PM, Resident #1 was noted to have a softball size area on her upper chest and when palpated, the resident stated it hurt. New orders were received to send the resident to the hospital emergency department (ED) for evaluation and treatment. The ED Physician documented there was acute swelling of the right chest wall and the exam revealed a large tense hematoma approximately the size of a grapefruit. The results of the chest x-ray revealed a right chest wall hematoma (localized collection of blood that has leaked from damaged blood vessels into the tissues of the chest wall) with active bleeding. On 12/12/25 at 11:28 AM Resident #1 was transferred to the second hospital with a higher level of care and that same day underwent a VIR (Vascular and Interventional Radiology) embolization (minimally invasive procedure performed by vascular and interventional radiologists to block or close off a specific blood vessel using embolic agents, often guided by real-time imaging such as fluoroscopy, CT, or ultrasound). Resident #1 developed repeat bleeding concerns 12/14/25 and stabilized without intervention. On 12/18/25 trauma surgery performed a hematoma evacuation (a surgical procedure to remove a localized collection of blood outside blood vessels, often necessary when a hematoma causes pressure or complications). The hospital discharge summary indicated resident was discharged back to the facility on [DATE] with an appointment to follow up with the surgeon on 12/30/25 for follow up of the right breast hematoma with drain placement. The deficient practice occurred for 1 of 3 residents reviewed for quality of care (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, end stage renal disease (ESRD) with dependence on dialysis (HD), and diabetes. Resident #1 was sent to the hospital on [DATE] and was transferred to a higher-level care hospital on [DATE]. She returned to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 was cognitively intact, had moderate difficulty hearing, and severely impaired vision. She was totally dependent on staff for transfers. Resident #1 received as needed pain medication, and pain presence was occasional. Review of the Resident Care Guide implemented on 11/13/23 and contained in the care plan revealed that Resident #1 required a mechanical lift of one person assist with all transfers. The sling size was medium. The care plan was revised on 1/16/25 and included the problem of activities of daily living (ADL)/personal care. Interventions included: Mechanical lift. Review of physician orders for Resident #1 revealed Oxycodone (opioid pain medication) 5 milligram (mg) tablet to be given every 4 hours as needed for pain was ordered from 7/22/25 through 12/19/25. Resident #1 also received Eliquis (blood thinner medication which raises the risk of bruising and bleeding) 2.5mg tablet to be given twice daily for history of portal vein thrombus (blood clot that obstructs the vein carrying blood to the liver). NA #1 was interviewed on 2/11/26 at 11:58 AM. She revealed that the Resident Care Guide contained resident transfer details and typically if she witnessed a fall, she would leave the resident on the floor, call code green, and wait for a nurse to assist. NA #1 stated that Resident #1 was alert most of the time and required a mechanical lift for all transfers. NA #1 explained on 12/11/25 around 12:00 PM, Resident #1 returned from dialysis while NA #1 was in the middle of lunch meal service. Resident #1 requested to be transferred to bed because she was tired and hurting, which was usual for her after dialysis. NA #1 told Resident #1 that she could help her after meal service was complete. When NA #1 went to retrieve the mechanical lift, the two lifts in her section did not have any charge. NA #1 stated she told Resident #1 that she would have to wait a little longer since both mechanical lifts were not available at the time. Resident #1 was adamant about being transferred to bed immediately. Around 2:45 PM, NA #1 decided to accommodate Resident #1's request without a mechanical lift. As soon as NA #1 lifted Resident #1 out of the wheelchair, Resident #1 complained about her legs and began to panic. Resident #1 put all her weight on NA #1, and NA #1 assisted Resident #1 to the floor. NA #1 stated she did not want to leave Resident #1 on the floor and felt she needed to get her off the floor, so she lifted Resident #1 from the floor back to the wheelchair. However, Resident #1 appeared slumped in the wheelchair, and NA #1 pulled her more upright in the wheelchair. NA #1 then called for help and the Medication Aide and NA #2 entered the room. All three staff members lifted Resident #1 into the bed. NA #1 stated she then went and told the Unit Manager about the assisted fall. When the Unit Manager came to the room, she asked Resident #1 if she was hurting. Resident #1 responded that she felt pain in her right arm. The Unit Manager assessed her right arm and found no injuries. The Medication Aide provided Resident #1 with as needed pain medication. NA #1 stated that she received education on12/12/25 related to fall protocol and to always follow the Resident Care Guide. During a follow up telephone interview with NA #1 on 2/11/26 at 4:09 PM, she revealed that Resident #1 was normally transferred from a stretcher to the bed by transportation personnel after all dialysis appointments. NA #1 stated that on 12/11/25, it was the first time she ever transferred Resident #1 to bed after dialysis. However, this day was different because a different transportation vendor was used to bring Resident #1 to/from dialysis on 12/11/25. Since Resident #1 refused to wait for an available mechanical lift on 12/11/25, NA #1 stated she just wanted to get Resident #1 in bed before shift change at 3:00 PM. She further stated that she already knew a mechanical lift was required to transfer Resident #1. When she assisted Resident #1 to the floor, she did not think at the time and did not want to leave her on the floor even though that was the protocol. NA #1 indicated that she told the Medication Aide that Resident #1 had an assisted fall prior to lifting Resident #1 into bed with the Medication Aide and NA #2. NA #1 stated she transferred Resident #1 to the bed because her goal was to get Resident #1 in the bed as soon as she was assisted to the floor. NA #1 explained she wanted to make Resident #1 comfortable and not in pain anymore. NA #2 was interviewed via telephone on 2/11/26 at 12:29 PM. She revealed that she was sitting at the nurses' station on 12/11/25 around 2:45 PM when NA #1 called for help. When NA #2 came into the room, she saw Resident #1 sitting and slightly slanted in the wheelchair. The Medication Aide then came into the room. NA #2 indicated she (NA #2), NA #1, and the Medication Aide transferred Resident #1 to the bed. The Medication Aide and NA #1 held each of Resident #1's armpits, and NA #2 held her legs. Resident #1 was not screaming in pain or reporting pain. When the Medication Aide asked Resident #1 if she was ok, she said I'm ok, but can you give me some Tylenol? NA #2 then left the room. NA #2 stated that she was educated on 12/12/25 about fall protocol and the importance of following the Resident Care Guide details. During a follow up telephone interview with NA #2 on 2/11/26 at 4:38 PM, she revealed that she was unaware Resident #1 had an assisted fall prior to her assisting with transfer to bed. NA #2 stated if she knew about the assisted fall beforehand, she would never have transferred Resident #1 to bed and waited for a nurse's assistance. The Medication Aide was interviewed on 2/11/26 at 11:24 AM. She revealed that Resident #1 returned to the facility around 12:00 PM on 12/11/25 and Resident #1 said she was ready to go back to bed and asked NA #1, who was passing meal trays to help her. NA #1 told Resident #1 she would do so after meal service. Resident #1 yelled again, and the Medication Aide told Resident #1 that NA #1 was busy with another resident. Then around 2:45 PM, NA #1 was in Resident #1's room yelling for help. When the Medication Aide came to the room, Resident #1 appeared slumped in her wheelchair, and it looked as though Resident #1 moved one inch she would fall. The Medication Aide stated she did not call for a nurse because Resident #1 was in the wheelchair, and the Medication Aide did not witness a fall. There were not any mechanical lifts available at the time. After she saw Resident #1 slumped in the wheelchair, she and two other staff members (NA #1 and NA #2) helped Resident #1 into bed. NA #1 then retrieved the Unit Manager who came to assess Resident #1 and Resident #1 expressed 10/10 pain (a pain scale of 0 (zero) is no pain and a pain scale of 10 is the worst pain possible) in her right shoulder. The Medication Aide then administered 5mg of oxycodone. The Medication Aide indicated every time Resident #1 returned from dialysis, Resident #1 requested a pain pill due to 10/10 on the pain scale. The pain medication was effective on 12/11/25 at 2:47 PM, and there were no further issues with Resident #1 prior to shift change at 7:00 PM when she gave report to the oncoming nurse. During a follow up interview with the Medication Aide on 2/11/26 at 3:30 PM, she revealed that the reason why she, NA #1, and NA #2 transferred Resident #1 from the wheelchair to the bed after the assisted fall was because she was not aware Resident #1 had an assisted fall until after the transfer from the wheelchair to the bed. The Medication Aide stated her first thought was to get Resident #1 in bed and did not think about adjusting Resident #1 in the wheelchair first. A nursing note dated 12/11/25 at 4:53 PM and completed by the Unit Manager revealed that she was made aware that Resident #1 had an assisted fall around 2:45 PM. Upon entering the room, Resident #1 was assisted back to bed by NA #1, NA #2, and the Medication Aide. Resident was noted in the center of the bed holding her right shoulder with the left hand. Resident stated, I was yelling because I wanted to get back in bed because I was hurting. The girl sat me on the floor. The Unit Manager assessed Resident #1, vital signs were obtained, and a head-to-toe evaluation was completed. No new skin issues were noted. Oxycodone 5mg was administered. The on-call provider was contacted, and an order for x-ray of the right arm and right shoulder was entered. A change of condition assessment dated [DATE] at 1:00 PM completed by the Unit Manager revealed that after the on-call provider was contacted due to new acute pain, they recommended an x-ray to Resident #1's right shoulder and right arm and as needed pain medication. An electronic medication administration record note dated 12/11/25 at 2:47 PM and completed by the Medication Aide revealed that Resident #1 received 5mg of Oxycodone for pain and was effective. A telehealth on-call provider note dated 12/11/25 (no time specified) revealed that the Unit Manager reported Resident #1 had an assisted fall and now complaining of 10/10 pain in her right shoulder. Oxycodone 5mg was administered for pain, along with an order given for an x-ray of the right shoulder and right arm. Rounding provider to follow up. A physician order for a 2-view portable x-ray of the right shoulder and right arm one time only for pain was entered on 12/11/25. The x-ray report of Resident #1's right shoulder and right arm dated 12/11/25 showed no fractures or breaks. An electronic Medication Administration Record note dated 12/11/25 at 2:47 PM and completed by the Medication Aide revealed that Resident #1 received 5mg of Oxycodone for pain and was effective. The Unit Manager was interviewed on 2/11/26 at 12:36 PM. She revealed that if a resident had a fall, she would assess the resident to ensure there were no injuries before moving the resident. On 12/11/25 around 2:45 PM, she was made aware of Resident #1's assisted fall from NA #1. Once she arrived at the room, Resident #1 was already back in bed, and the Unit Manager assessed her. When asked what happened, Resident #1 told her that she was lowered to the floor earlier. Resident #1 reported 10/10 pain to her right shoulder and received pain medication. A head-to-toe skin assessment revealed no concerns or injuries. The Unit Manager indicated Resident #1 had a history of pain, but the shoulder pain was new. The Unit Manager stated she did not hear of any further concerns with Resident #1 when she left the facility at 5:00 PM that evening. Education was provided to all staff on 12/12/25 related to following the Resident Care Guide and fall protocol. She could not recall if any nursing staff reported any issues with the mechanical lifts on 12/11/25. During a follow-up interview with the Unit Manager on 2/11/26 at 3:25 PM, she revealed that a licensed nurse must assess a resident after a fall prior to staff moving them. The Unit Manager stated that NA #1 should not have moved Resident #1 after the assisted fall, and all three nursing staff should not have transferred Resident #1 to bed before the Unit Manager arrived at the room. Verbal education was provided to all three staff members (NA #1, NA #2, and the Medication Aide) immediately after the incident about waiting for a nurse to assess the resident after a fall. A nursing progress note dated 12/11/25 at 10:39 PM by Nurse #1 revealed that Nurse #1 went into Resident #1's room during rounds around 7:20 PM. Resident #1 complained of pain to her right shoulder and back after the assisted fall earlier in the day. A large soft ball sized area to the upper right part of her chest was observed. When the area was palpated, Resident #1 stated, yea that's where it hurts. The on-call provider was contacted at 7:30 PM and gave a verbal order to transfer Resident #1 to the emergency department (ED) for further evaluation. A telehealth on-call provider note dated 12/11/25 (no time specified) revealed that Nurse #1 reported that Resident #1 complained of 10/10 pain adjacent to her right shoulder and now has a large hematoma forming above the dialysis site on the right arm. Orders were given for Resident #1 to be transferred to the ED. A Change in Condition Evaluation dated 12/11/25 at 9:00 PM by Nurse #1 revealed that Resident #1 had swelling noted to the right side of her chest below the shoulder. Resident #1 expressed a 10/10 pain scale due to acute musculoskeletal pain. Oxycodone 5mg was administered but ineffective. The on-call provider was notified at 7:30 PM to send Resident #1 to the ED for further evaluation. An ED provider note from the hospital dated 12/11/25 revealed Resident #1 presented with acute swelling of the right chest wall and the exam revealed a large, tense hematoma approximately the size of a grapefruit. There were no complications to Resident #1's dialysis access site on her right arm. Her hemoglobin was low at 9.0 grams/deciliter, but she remained stable in the ED. An x-ray of Resident #1's right breast showed a hematoma that measured 8 cm (centimeters) by 8 cm by 9 cm with active bleeding. The ED Physician further documented he had contacted another hospital with a higher level of care for possible transfer for interventional radiology services for potential embolization of blood vessels. On 12/12/25 at 11:28 AM Resident #1 was transferred to the second hospital. A hospital Discharge summary dated [DATE] revealed that Resident #1 was admitted on [DATE] and the principal problem was an arterial (the blood vessels that carry oxygen rich blood away from the heart) hemorrhage. On 12/12/25 Resident #1 underwent a VIR (Vascular and Interventional Radiology) embolization (minimally invasive procedure performed by vascular and interventional radiologists to block or close off a specific blood vessel using embolic agents, often guided by real-time imaging such as fluoroscopy, CT, or ultrasound). Resident #1 developed repeat bleeding concerns 12/14/25 and stabilized without intervention. On 12/18/25 trauma surgery performed a hematoma evacuation (a surgical procedure to remove a localized collection of blood outside blood vessels, often necessary when a hematoma causes pressure or complications). The hospital discharge summary indicated resident was discharged back to the facility on [DATE] with an appointment to follow up with the surgeon on 12/30/25 for follow up of the right breast hematoma with drain placement. An interview was attempted with Resident #1 on 2/11/26 at 11:18 AM; however, she was not alert and oriented and refused to answer any questions related to the incident on 12/11/25. Interim Administrator #2 was interviewed via telephone on 2/12/26 at 8:09 AM. She revealed that the focus of the incident with Resident #1 after an investigation revealed that nursing staff must notify a licensed nurse if a resident fell, so that the resident could be assessed prior to transfer/movement. Education to all nursing staff included following the Resident Care Guide for all details, including transfers with a mechanical lift, as well as following fall protocol. The Director of Nursing (DON) was interviewed on 2/11/26 at 2:20 PM. The DON stated NA #1 was new to the facility and tried to transfer Resident #1 back to bed with a stand pivot transfer on 12/11/25, and Resident #1 could not support herself on her feet. NA #1 stated she assisted Resident #1 to the floor. NA #1 indicated she lifted Resident #1 back up into the wheelchair and then NA #1 went to get assistance from NA #2 and the Medication Aide. All three staff members transferred Resident #1 back to bed. After Resident #1 was transferred back to bed, the Medication Aide was told by NA #1 that Resident #1 had an assisted fall, and the Unit Manager was retrieved by NA #1. The DON stated that NA #1 should not have done a stand pivot transfer with Resident #1 and was expected to follow the Resident Care Guide for all transfer details. After the assisted fall, Resident #1 should have been left on the ground until a nurse arrived to assess. NA #1, NA #2, and the Medication Aide transferred Resident #1 from the wheelchair to the bed because it looked like Resident #1 was going to fall out of the chair. The DON stated Resident #1 should have been adjusted in the wheelchair so that she was safe instead of being transferred back to bed. The DON further stated that nothing was said to her about the mechanical lift batteries dead on 12/11/25. However, NA #1 did say that she could not locate a free mechanical lift when Resident #1 wanted to be transferred to bed. The interview further revealed education provided to all nursing staff on 12/12/25 and included what to do after a fall, how to use the Resident Care Guide, and fall prevention. Included in the fall protocol was if an NA found a resident on the floor or assisted a resident to the floor, they were instructed not to move them before a licensed nurse assessed the resident. During a joint interview with the DON and interim Administrator #1 on 2/11/26 at 4:35 PM, they revealed that NA #1 should have notified a nurse immediately when the assisted fall took place. NA #1 should not have moved or transferred Resident #1 prior to a nurses' assessment. The facility provided the following corrective action plan with a completion date of 12/17/25: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident # 1 was admitted to the facility on [DATE] with a diagnosis of dementia, portal vein thrombosis, aneurysm of the upper extremity artery, end stage renal disease on hemodialysis, and diabetes. Medications included anticoagulants. Resident #1 was alert, oriented and able to make needs known. On 12/11/25, at approximately 1:45 PM, Resident #1 returned to the facility from dialysis, ate lunch, and then requested to be put back into bed. The assigned Nursing Assistant #1 (NA) entered Resident #1's room at approximately 2:45 PM. Resident #1 requested to be put to bed and despite knowing that Resident #1 required a lift for transfer, NA #1 attempted to complete a stand pivot transfer from the wheelchair to the bed. Resident #1 was unable to complete the transfer; NA #1 lowered the resident safely to the floor. The resident had no complaints about pain. NA #1 then assisted Resident #1 back into the wheelchair by placing her arms under the resident's arms and her knees against the resident's knees and lifted the resident slightly back into the wheelchair sitting on the edge of the seat of the wheelchair. NA #1 did not report the assisted fall to the nurse and did not get a nurse to assess the resident before moving Resident #1 to the wheelchair. At approximately 2:50pm NA #1 asked NA #2 and the Medication Aide for assistance with transferring Resident #1 from the wheelchair to the bed. NA #1 did not inform NA #2, or the Medication Aide of Resident #1's assisted fall to the floor. After transferring Resident #1 to the bed, NA #1 then advised the Medication Aide that prior to transferring from the chair to bed, Resident #1 had been assisted to the floor. The Medication Aide did not get a nurse to assess the resident before moving the resident to bed. The Medication Aide immediately reported the fall to the Unit Manager. The Unit Manager completed an assessment of the resident with no visible injury. At approximately 3:05 pm, the Unit Manager notified the on-call provider of Resident #1's assisted fall and complaints of right arm pain. The on-call provider ordered an x-ray for the right arm and shoulder. The resident representative (RR) was unable to be reached, and a detailed message was left to return call to facility. At approximately 7:00 PM, the x-ray was completed with no fractures identified. During the evening shift, at approximately 7:20 PM, Nurse #1 assessed Resident #1 and noted a softball size area on her upper chest. When palpated, Resident #1 stated it hurt. Nurse #1 notified a different on-call provider with new orders to send Resident #1 to the hospital for evaluation and treatment. At approximately 7:33pm, the resident representative was updated on Resident #1's condition and the order to transfer to the hospital. Diagnosis at the hospital was a right chest wall hematoma. On 12/12/25, Resident #1 was taken to Interventional Radiology for embolization to control bleeding. On 12/18/25, Resident #1 was taken back to the operating room for a surgical procedure to remove the hematoma and remained hemodynamically stable. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 12/12/25, interim Administrator #2 completed an audit of all incident reports for the past 30 days. This audit was to ensure staff immediately notified the nurse of all falls (assisted or unassisted) and not moved a resident until assessed by the nurse. There were no additional concerns identified. On 12/12/25, interim Administrator #2, Staff Development Coordinator, Nurse Supervisor, Unit Manager, and the Director of Nursing (DON) initiated questionnaires with all nurses and nursing assistants regarding transfers. The questionnaires include (1) Do you know of any incidents during a transfer that has not been reported or addressed? (2) Where do you access the resident care guide? (3) when should you check the resident care guide for transfers? Interim Administrator #2, Staff Development Coordinator, Nurse Supervisor, Unit Manager, and/or DON addressed all concerns identified during the audit to include training of staff. The questionnaires were completed by 12/16/25. After 12/16/25, any nurse or nursing assistant who had not worked or completed the questionnaire completed it prior to the next scheduled work shift. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 12/12/25, interim Administrator #2, Staff Development Coordinator, Nurse Supervisor, Unit Manager, and the Director of Nursing (DON) initiated questionnaires with all nurses and nursing assistants regarding transfers. The questionnaires include (1) Do you know of any incidents during a transfer that has not been reported or addressed? (2) Where do you access the resident care guide? (3) when should you check the resident care guide for transfers? Interim Administrator #2, Staff Development Coordinator, Nurse Supervisor, Unit Manager, and/or DON addressed all concerns identified during the audit to include training of staff. The questionnaires were completed by 12/16/25. After 12/16/25, any nurse or nursing assistant who had not worked or completed the questionnaire completed it prior to the next scheduled work shift. On 12/12/25, the DON, SDC, Nurse Supervisor, and Unit Manager initiated an in-service with all nurses and NAs to include NA #1 and agency regarding Fall Protocol with emphasis on (1) Definition of a fall (2) immediately notifying the nurse of a fall (assisted or unassisted) or a near miss fall and (3) never moving a resident following a fall until assessed by the nurse. The in-service was completed by 12/16/25. After 12/16/25, any nurse or nursing assistant who did not complete the training completed it upon the next scheduled work shift. All newly hired nurses and/or NAs to include agency staff will be educated during orientation by the SDC, DON, or Unit Managers. On 12/12/25, interim Administrator #2 notified the DON of the responsibility to monitor completion of all in-services and questionnaires to ensure compliance for resident safety. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. On 12/12/25, the decision was made by interim Administrator #2 to monitor the plan for immediate notification of the nurse of resident falls and to ensure residents are not moved until assessed by a nurse and presented the plan of correction to the Quality Assurance Performance Improvement (QAPI) committee to include the Assistant Administrator, Director of Nursing, Unit Managers, Quality Assurance nurse, Staff Development Coordinator, Medical Records, Social Worker, and Minimum Data Set Nurse on 12/12/25. The DON will complete review 5% of residents falls weekly x 4 weeks then monthly x 2 months to ensure the staff immediately notified the nurse of all incidents to include falls and that the residents were not moved following a fall until assessed by the nurse. The DON will address all concerns identified during the audit to include but not limited to re-training of staff. The DON forwarded the Incident Review to the Quality Assurance and Performance Improvement (QAPI) Committee monthly x 3 months for review and determination of trends and/or issues that may need further interventions put into place to determine the need for further and/or frequency of monitoring. Alleged date of compliance: 12/17/25 The facility's corrective action plan was validated on 2/11/26. The validation process included staff interviews, record reviews, review of education provided to nursing staff, and review of initial auditing and monitoring audits. The training for staff included fall protocol (notification to a licensed nurse and no movement of resident until assessed), following the Resident Care Guide (including which residents required a mechanical lift), and how to use/where to find the mechanical lifts. During interviews staff confirmed they had received the education and were able to verbalize an accurate summary of the education. Review of incident report audits and nursing staff questionnaires revealed that they were completed as specified in the plan of correction and resulted with no issues. Observations of resident transfers revealed no concerns. The facility's corrective action plan compliance date of 12/17/25 was validated.

Based on record review, staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a significant change in a resident's condition that included transport and admission to the hospital for 1 of 4 residents reviewed for notification of change (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's medical record revealed his family member was his RP. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. The discharge MDS dated [DATE] showed Resident #1 was moderately cognitively impaired. Resident #1's active diagnoses included delirium. A nursing note dated 12/18/24, written by Nurse #1 revealed Resident #1 requested to be transported to the emergency room . At 11:40 PM the resident was transported to the hospital via stretcher. A nursing note dated 12/19/24, written by Nurse #2 documented she called the hospital to get a status update on Resident #1. The nurse documented she was told the resident was being admitted for intestinal obstruction. Nurse #2 reported the status update to Nurse #1. A phone interview with Resident #1's RP was conducted on 1/8/25 at 10:15 AM. She stated no one from the facility notified her Resident #1 was transported to the hospital on 12/18/24 or that he was admitted to the hospital. She learned of the situation on 12/20/24 when the hospital social worker called her. Attempts made to interview Nurse #1 who discharged Resident #1 to the hospital on 12/18/24 were unsuccessful. An interview with Nurse #2 on 1/8/25 at 1:57 PM revealed she did not notify the family when Resident #1 was transferred to the hospital on 12/18/24 as it would have been the responsibility of Nurse #1. The Administrator, the Director of Nursing and the [NAME] President of Clinical Services were interviewed on 1/8/24 at 4:00 PM. The Director of Nursing stated they had reviewed the progress notes and facilitated an in-service with Nurse #1 on the notification requirements for RPs. The Administrator stated her expectation would have been for the hall nurse to notify Resident #1's RP of transport and admission to the hospital.

Based on record review, and staff, physician, and pharmacist interviews, the facility failed to ensure two residents received Ozempic subcutaneous injections as ordered for 2 of 7 residents reviewed for medication errors. (Resident #116 and Resident #163) Findings included: 1. Resident #116 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #116's orders revealed on 1/16/24 she was ordered Ozempic inject 0.25 mg (milligrams) subcutaneously one time a day every Tuesday for diabetes mellitus. A review of Resident #116's Medication Administration Record (MAR) revealed on 4/30/24 Nurse #10 documented Ozempic was not available to be administered. On 5/7/24 Nurse #9 documented Ozempic was not available to be administered. On 5/14/24 Nurse #10 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 9:53 AM Nurse #9 who documented Ozempic as unavailable and not administered to Resident #116 on 5/7/24 stated she did not remember the incident as it was a long time ago. She further stated she if she did not have a medication available that was scheduled, she would call the physician to get a hold order or follow whatever orders he provided after being made aware as well as letting her supervisor know. She stated she would also call the pharmacy to check on the medication or reorder it. She concluded to her knowledge; Resident #116 did not have any negative side effect of not receiving a medication including Ozempic on her shift but she reiterated she did not remember the incident or that Resident #116 was on Ozempic but Resident #116 had always had stable blood sugars. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated the pharmacy dispensed a 3 milliliter Ozempic pen for Resident #116 on 4/24/24. This pen was reported as lost by the facility and was never returned by the facility. The facility was charged for the replacement which was dispensed on 5/15/24 and received by the facility. This pen would have lasted 12 weeks per dosing, however, per the manufacturer it would only be good for 56 days after opening. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. It was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #163's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. He concluded he expected medications to be given as ordered. During an interview on 12/5/24 at 8:13 AM the Director of Nursing stated medications should be given as prescribed. Nurse #10 who documented not having available or administering Ozempic to Resident #116 on 4/30/24 and 5/14/24 was unavailable for interview. 2. Resident #163 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #163's orders revealed on 4/10/24 she was ordered Ozempic inject 2 mg (milligrams) subcutaneously one time a day every 7 days for diabetes mellitus. A review of Resident #163's Medication Administration Record (MAR) revealed on 4/24/24 and 5/15/24 Nurse #12 documented Ozempic was not available to be administered. On 5/1/24 Nurse #11 documented Ozempic was not available to be administered. On 5/8/24 Nurse #13 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 8:39 AM Nurse #12 who documented Ozempic as not available and not administered to Resident #163 on 4/24/24, and 5/15/24 stated she did not remember the incident or the resident. Stated if she was working and discovered a medication such as Ozempic was not available to be given and it was due, she would call the pharmacy to see if the medication was sent out or if it could be reordered. She stated she would let the physician or nurse practitioner know as well that it was not available to give. She concluded she did not know of any negative outcomes for Resident #163 due to not having Ozempic available. During a telephone interview on 12/5/24 at 8:17 AM Nurse #11 who documented Ozempic as not available and not administered to Resident #163 on 5/1/24 stated she did not remember that Resident #163 was on Ozempic. She further stated she did not recall specifically not having Ozempic for Resident #163 but whenever medication was not available when it was due, she would call the pharmacy to get it reordered and would check to see when it could be given, or she would get her manager to call the pharmacy. She stated she did not remember the incident but would notify the pharmacy and physician or nurse practitioner. She stated Resident #163's bloods sugars never went out of baseline for the resident as far as she could recall, and she did have insulin coverage if her blood sugars were elevated, and the resident did not have any negative outcomes due to Ozempic not being available. She stated she only worked with Resident #163 a short time and did not have concerns about not having the medication not being available regularly. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated an 8mg Ozempic pen was dispensed on 4/10/24 for Resident #163 and arrived at the facility. This pen should have lasted 28 days per dosing. The pen was not returned. On 5/16/24 this pen was refilled, and the facility reported the 4/10/24 pen as lost and paid for the pen dispensed on 4/10/24. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. It was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #163's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. He concluded he expected medications to be given as ordered. During an interview on 12/5/24 at 8:13 AM the Director of Nursing stated medications should be given as prescribed. Nurse #13 who documented Ozempic as not available and not administered to Resident #163 on 5/8/24 was not available for interview.

Based on record review, and resident, staff, pharmacist and physician interviews, the facility failed to protect a resident's right to be free from the misappropriation of medication for 2 of 2 residents (Resident #116, Resident #163) reviewed for misappropriation of resident property. Findings included: 1. Resident #116 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #116's orders revealed on 1/16/24 she was ordered Ozempic inject 0.25 mg (milligrams) subcutaneously one time a day every Tuesday for diabetes mellitus. A review of Resident #116's Medication Administration Record (MAR) revealed on 4/23/24 Nurse #8 documented Ozempic was not available to be administered. During an interview on 12/4/24 at 2:49 PM Nurse #8 who documented Ozempic as unavailable and not administered to Resident #116 on 4/23/24 stated she did work with Resident #116 on night shifts in 4/2024. She further stated at that time Resident #116's Ozempic was being administered once a week at night on Tuesdays. She stated it was a long time ago, but she believed she gave the resident her Ozempic a few times prior to 4/23/24 with no issues. She stated she did not recall that night (4/23/24) very well. She stated this was her only experience with Ozempic not being available for her to administer the medication. She stated Resident #116's blood sugars were baseline and the resident did not display any negative side effects from the lack of the medication. She concluded had Resident #116 developed hyperglycemia they had faster acting insulin available in their e-kit and would have been able to provide coverage per physician orders had it been necessary which it was not. A review of a pharmacy packing slip dated 4/24/24 revealed the facility received a pen containing 12 doses of Ozempic for Resident #116. A review of Resident #116's MAR revealed on 4/30/24 Nurse #10 documented Ozempic was not available to be administered. On 5/7/24 Nurse #9 documented Ozempic was not available to be administered. On 5/14/24 Nurse #10 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 9:53 AM Nurse #9 who documented Ozempic as unavailable and not administered to Resident #116 on 5/7/24 she stated she did not remember the incident as it was a long time ago. She reported that to her knowledge; Resident #116 did not have any negative side effect of not receiving Ozempic on her shift but she reiterated she did not remember the incident or that Resident #116 was on Ozempic but stated Resident #116 had always been stable when she worked with her. Nurse #10 who documented not having available or administering Ozempic to Resident #116 on 4/30/24 and 5/14/24 was unavailable for interview. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated the pharmacy dispensed a 3 milliliter Ozempic pen for Resident #116 on 4/24/24. This pen was reported as lost by the facility and was never returned by the facility. The facility was charged for the replacement which was dispensed on 5/15/24 and received by the facility. A review of the facility's investigational summary dated 5/18/24 completed by the Director of Nursing revealed on 5/16/24 the facility noted a pattern of Ozempic being unavailable for Resident #116 and conducted a 100% audit of all residents receiving GLP1 (a class of drugs used to treat type 2 diabetes and obesity) medications. During this audit all GLP1 medications were counted, and control substance count sheets were placed in the narcotic books. On 5/18/24 the facility initiated an in-service with the Minimum Data Set (MDS) nurses as it related to pulling reports to capture the past 24 hours of medications not available and medications not given. On 5/18/24 the facility initiated an in-services with all nurses and medication aides related to counting GLP1 injectable pens during shift/break changes including adding control substance count sheets on arrival of new supplies. During an interview on 12/3/24 at 8:20 AM Resident #116 stated sometime this year her Ozempic went missing, and she did not receive a few doses of it. She stated she gets the medication every Saturday currently. At the time, she was getting it every Tuesday. When the facility identified that her Ozempic was missing they changed the day it was being given to Saturday. They also reordered the medication. She had no issues since. On 12/04/24 at 9:10 AM the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were interviewed and stated during Inter-Disciplinary Team (IDT) morning meeting on 4/24/24 they noted Ozempic was documented as not available and not given to Resident #116 on 4/23/24 based on the report provided by the Minimum Data Set (MDS) nurses which was pulled each morning for the IDT morning meeting. This did not raise any concern at that time because upon review, the medication was to be delivered that evening on 4/24/24. Nurse Practitioner #1 was a part of this discussion and was following the resident for Diabetes Mellitus and blood sugars. They ensured they had coverage (medication to control blood sugar levels) for her blood sugars. The DON stated during morning IDT meeting on 5/1/24 it was noted that Resident #116's Ozempic was again not available and not given on 4/30/24. She then told the nurse to reorder it through the computer from the pharmacy. She stated at that time she believed it was due to pharmacy delivery error and did not think there would be any reason for someone to take the medication. The medication was not given and not available on 5/7/24 but this was not captured in the IDT morning meeting on 5/8/24 due to an error in the way the MDS nurses were pulling the report. They were unaware of this at that time and assumed the medication had come in and was being given correctly. The next dose was to be given on 5/14/24 and it was not available and not given. This time it did show up on the MDS report and was flagged. The IDT team noted it was not available and not given to Resident #116 on 4/23/24, 4/30/24, 5/7/24, and 5/14/24. This caused them to do a more in-depth review of the medication and try to discover what was going on. The ADON stated she went to the unit refrigerator and looked for the medication for Resident #116 and was unable to find it. All unit managers went and checked all of the facility carts and unit refrigerators to ensure the medication had not been misplaced in the facility. They were unable to find the medication. She then called the pharmacy and pulled the packing slip which came with the medication when it was delivered. The packing slip was found with a delivery date of 4/24/24 and one pen with 12 doses was delivered to the facility. When the nurse had reordered the medication via the computer on 5/1/24 the pharmacy had not sent the medication because it was too soon to refill. She then called the pharmacy, and the pharmacy told her it was not time for the medication to be reordered and if they wanted another delivery of a pen with 12 doses the facility would have to pay out of pocket for the medication. She stated she then went to the Administrator to get permission to reorder the medication from the pharmacy out of the facility's pocket. The medication was ordered and filled on 5/16/24 and arrived that night. On 12/4/24 at 1:27 PM the interview with the Administrator, DON, and ADON continued and the ADON stated at that point they felt the pen had been thrown away in error or misplaced. However, the next day they pulled a report on all residents that were prescribed antidiabetic medications and highlighted the residents prescribed GLP1 medications. Then they pulled the MAR for all those residents for the time range they were prescribed a GLP1. They then pulled all the packing slips from the pharmacy showing the amount and when the GLP1s were delivered to the facility for all residents identified as receiving GLP1 medications. They then compared the packing slip delivery quantities to the MARs to account for every dose that was received by the facility for the length of each GLP1 prescribed. They then checked all the medications currently in the facility to ensure what was in the facility was accurate compared to the delivery slips and what should be in the facility according to the packing slips. During this investigation it was also found that another resident (Resident #163) also had missing doses. These discrepancies were not captured by the MDS report for the IDT morning meetings the next day due to a mistake in how MDS pulled the records. At this point they felt this was not a pharmacy error or the pens were simply misplaced and initiated sign-in and out count sheets for all GLP1 medications currently in the facility and ensured locks were on the medication storage refrigerators. The nursing and medication aide staff were in-serviced on the use of the count sheets for GLP1 medications. The MDS nurses were educated on how to pull all missing medications to be reviewed in the morning IDT meetings. They implemented the process of signing in and out the countdown sheets for GLP1 medications and implemented a monitoring tool to check the medications daily. She stated from the point where they implemented the new count down sheet process and the monitoring tool, they had not had any discrepancies with GLP1 medications. She stated on 5/17/24 the police, Department of Health and Human Services, and Adult Protective Services were notified of the misappropriation of resident property. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. He explained that Ozempic was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #115's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. During a follow up interview on 12/5/24 at 9:01 AM the Administrator stated following the investigation they concluded the facility was unable to substantiate the misappropriation of resident property because they were unable to determine the location of the Ozempic pens after they were last known to have been received by the facility from the pharmacy. The pens were replaced at no cost for both residents and the facility paid for the replacement pens. 2. Resident #163 was admitted to the facility on [DATE]. Her active diagnoses included diabetes mellitus. Review of Resident #163's orders revealed on 4/10/24 she was ordered Ozempic inject 2 mg (milligrams) subcutaneously one time a day every 7 days for diabetes mellitus. A review of a pharmacy packing slip dated 4/10/24 revealed the facility received a pen containing 4 doses of Ozempic for Resident #163. A review of Resident #163's Medication Administration Record (MAR) revealed on 4/24/24 and 5/15/24 Nurse #12 documented Ozempic was not available to be administered. On 5/1/24 Nurse #11 documented Ozempic was not available to be administered. On 5/8/24 Nurse #13 documented Ozempic was not available to be administered. During a telephone interview on 12/5/24 at 8:39 AM Nurse #12 who documented Ozempic as not available and not administered to Resident #163 on 4/24/24 and 5/15/24 stated she did not remember the incident or the resident. She indicated she did not know of any negative outcomes for Resident #163 due to not having Ozempic available. During a telephone interview on 12/5/24 at 8:17 AM Nurse #11 who documented Ozempic as not available and not administered to Resident #163 on 5/1/24 stated she did not remember that Resident #163 was on Ozempic. She further stated she did not recall specifically not having Ozempic for Resident #163. She stated Resident #163's bloods sugars never went out of baseline for the resident as far as she could recall, and she did have insulin coverage (medication to control blood sugar levels) if her blood sugars were elevated, and the resident did not have any negative outcomes due to Ozempic not being available. Nurse #13 who documented Ozempic as not available and not administered to Resident #163 on 5/8/24 was not available for interview. During a telephone interview on 12/05/24 at 1:01 PM Pharmacist #2 stated an 8mg Ozempic pen was dispensed on 4/10/24 for Resident #163 and arrived at the facility. This pen should have lasted 28 days per dosing. The pen was not returned. On 5/16/24 this pen was refilled, and the facility reported the 4/10/24 pen as lost and paid for the pen dispensed on 4/10/24. A review of the facility's investigational summary dated 5/18/24 completed by the Director of Nursing revealed on 5/16/24 the facility noted a pattern of Ozempic being unavailable for another resident (Resident #116) and conducted a 100% audit of all residents receiving GLP1 (a class of drugs used to treat type 2 diabetes and obesity) medications. During this audit all GLP1 medications were counted, and control substance count sheets were placed in the narcotic books. The audit identified Resident #163 had not had available or received her Ozempic on 4/24/24, 5/1/24, 5/8/24, and 5/15/24. On 5/18/24 the facility initiated an in-service with the Minimum Data Set (MDS) nurses as it related to pulling reports to capture the past 24 hours of medications not available and medications not given. On 5/18/24 the facility initiated an in-services with all nurses and medication aides related to counting GLP1 injectable pens during shift/break changes including adding control substance count sheets on arrival of new supplies. During an interview on 12/4/24 at 1:27 PM the Assistant Director of Nursing stated another resident had triggered concerns that GLP1 medications were not available and administered. On 5/16/24 they pulled a report on all residents that were prescribed antidiabetic medications and highlighted the residents prescribed GLP1 medications. Then they pulled the MAR for all those residents for the time range they were prescribed a GLP1. They then pulled all the packing slips from the pharmacy showing the amount and when the GLP1s were delivered to the facility for all residents identified as receiving GLP1 medications. They then compared the packing slip delivery quantities to the MARs to account for every dose that was received by the facility for the length of each GLP1 prescribed. They then checked all the medications currently in the facility to ensure what was in the facility was accurate compared to the delivery slips and what should be in the facility according to the packing slips. During this investigation it was also found Resident #163 had not had available or received her dose of Ozempic on 4/24/24, 5/1/24, 5/8/24, and 5/15/24. These discrepancies were not captured by the MDS report for the IDT morning meetings the next day due to a mistake in how MDS pulled the records. At this point they felt this was not a pharmacy error or the pens were simply misplaced and initiated sign-in and out count sheets for all GLP1 medications currently in the facility and ensured locks were on the medication storage refrigerators. The nursing and medication aide staff were in-serviced on the use of the count sheets for GLP1 medications. The MDS nurses were educated on how to pull all missing medications to be reviewed in the morning IDT meetings. They implemented the process of signing in and out the countdown sheets for GLP1 medications and implemented a monitoring tool to check the medications daily. She stated from the point where they implemented the new count down sheet process and the monitoring tool, they had not had any discrepancies with GLP1 medications. She stated on 5/17/24 the police, Department of Health and Human Services, and Adult Protective Services were notified of the misappropriation of resident property. During a telephone interview on 12/5/24 at 1:58 PM Physician #1 stated he was made aware of the incident when the Ozempic pens were missing. He further stated he was notified by the nurses on the hall when the medication was not available to be given. He explained that Ozempic was not a medication that controlled blood sugars on a day-to-day basis, but it helped stabilize hemoglobin A1C (a blood test that measures your average blood sugar level over the past three months) over the course of multiple months. He stated he had no concerns about any negative outcomes due to the lack of the Ozempic in the facility and was monitoring Resident #163's bloods sugars and the resident had coverage available. They had no negative out comes because of the lack of Ozempic. During a follow up interview on 12/5/24 at 9:01 AM the Administrator stated following the investigation they concluded the facility was unable to substantiate the misappropriation of resident property because they were unable to determine the location of the Ozempic pens after they were last known to have been received by the facility from the pharmacy. The pens were replaced at no cost for both residents and the facility paid for the replacement pens. The facility provided the following corrective action plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 4/23/2024, scheduled Ozempic pen was not available to administer to Resident #116 per physician order. On 4/24/24, the facility received 3ml (2mg/ml) Ozempic pen via pharmacy courier. On 4/30/24, the scheduled dose of Ozempic for resident #116 was noted as not available to administer per nursing documentation. On 5/1/24, the Assistant Director of Nursing (ADON) was notified of Resident #116 scheduled Ozempic medication was not available to administer. The ADON submitted a refill request via the computer. On 5/7/24 and 5/15/24, the scheduled dose of Ozempic medication for Resident #116 was documented as not available to administer per nursing documentation. The ADON notified the pharmacy for a refill of the medication at the cost of the facility. The medication arrived on 5/16/24. On 5/17/24, the physician was notified of scheduled Ozempic medication not available to administer on 4/23/24, 4/30/24, 5/7/24 and 5/14/24 with new order to resume medication on 5/18/24. On 5/18/24, Resident #116 was administered Ozempic per physician order. On 4/10/24, the scheduled Ozempic pen for Resident #163 was documented as not available to administer per nursing documentation. The assigned nurse notified the pharmacy for refill request. On 4/10/24, 3ml Ozempic (8mg/ml) pen were delivered to the facility via pharmacy courier. On 4/17/24, Resident #163 received Ozempic per physician order. On 4/24/24, Resident #163 was moved from station 4 to station 2. The nurse documents that the scheduled Ozempic dose as not available to administer. The assigned nurse requested a refill via the electronic record. On 5/16/24, the administrative nurse identified during the audit of residents receiving Ozempic that the resident had not received scheduled doses due to the drug not available to administer. The ADON notified the pharmacy for a refill of the medication at the cost of the facility. The medication arrived on 5/16/24. On 5/17/24, the physician was notified of scheduled Ozempic medication not available to administer on 4/10/24, 4/17/24, 4/24/24, 5/1/24 and 5/8/24 with new order to resume medication on 5/18/24. On 5/18/24, Resident #163 was administered Ozempic per physician order. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 5/16/2024 Facility conducted an audit of all residents receiving (glucagon-like peptide 1 (GLP1) medications (Ozempic/Semaglutide and Trulicity/Dulaglutide). This audit was to ensure medications were administered per physician order and/or the physician notified for further recommendations. The Administrative nurses addressed all concerns identified during the audit to include ordering medication not available to administer, notification of the physician for further recommendations and/or education of the nurse. During this audit all GLP1 Medications (Ozempic/Semaglutide and Trulicity/Dulaglutide) were counted, and the facility proactively initiated Control Substance Count sheets and placed in the appropriate Narcotic Books. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 5/18/2024 the Facility completed an in-service with the Minimum Data Set (MDS) nurses as it relates to pulling reports to capture the past 24 hours of medications documented as Not Available or Medications Not Given for review by the Interdisciplinary team (IDT). On 5/18/2024 the Staff Development Coordination initiated an in-service with all nurses and medication aides regarding (1) Counting GLP1 Injectables Pens during shift/break changes, including adding Control Substance Count Sheets on arrival of new Supplies (2) documentation on electronic medication record (eMAR) Administration note to include in detail reason the medication was not given or not available and (3) Misappropriation to include misappropriation or medications. In-services were completed by 5/18/2024. After 5/18/2024 any Nurse/Medication Aide to include agency nurses, agency medication aides, who have not worked nor received the in-service will review/sign prior to next scheduled shift. All newly hired staff members to include agency nurses, agency medication aids will be in-serviced during orientation by the SDC regarding Counting GLP1 Medications, documentation on eMAR when meds not available to administer and Misappropriation of Residents Property Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; On 5/17/24, the Administrator and Director of Nursing made the decision to monitor resident's receiving GLP1 medications and to ensure they were administered per physicians' order. The Unit Managers will audit all residents receiving GLP 1 medications to include Resident #116 and Resident #163 utilizing the GLP 1 Audit Tool 5 times a week x 4 weeks to ensure medication was administered per physician orders and/or the provider notified for further recommendations. Any identified areas of concern will be addressed with the Director of Nursing. The Director of Nursing will forward the results of the GLP 1 Audit tool to the Quality Assurance Performance Improvement (QAPI) Committee monthly x 1 month. The QAPI Committee will meet monthly x 1 month and review the GLP1 Audit tool to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. Completion date 5/19/24 Onsite validation of the facility's corrective action plan was completed on 12/6/24. The initial audit results were reviewed. The in-service education record dated 5/18/24 were reviewed. Interviews with nurses and medication aides indicated they attended and/or received in-service training on misappropriation of resident property including medications and handling of GLP1 medications to include count sheets and reconciliation. The monitoring results were reviewed. The QA meeting minutes were reviewed. The facility's completion date of 5/19/24 was validated.

Based on observation, record review, and staff and Nurse Practitioner (NP) #1 interview the facility failed to follow professional standards of practice and infection prevention measures when a nurse failed to perform hand hygiene between the removal of soiled gloves and the application of sterile gloves, when Nurse #4 touched the outside of the tracheostomy packaging with sterile gloves and did not change them and when she dropped a sterile q-tip onto the residents nightgown and proceeded to use it to clean the tracheostomy site. She further failed to keep sterile technique when she touched the new, sterile, inner cannula with contaminated sterile gloves that had touched the outside of the tracheostomy tray. This was for 1 of 1 resident (Resident #85) reviewed for respiratory care. Findings included: Resident #85 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia (low blood oxygen level), history of neoplasm (tumor) of nasal cavity and mid ear and chronic tracheostomy. Resident #85's Annual Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and required complete assistance with all activities of daily living. He was documented to receive tracheostomy care in the facility. Resident #85's care plan revealed him to be at risk for ineffective breathing pattern related to having a tracheostomy. A continuous observation of tracheostomy care was observed on 12/4/24 at 10:00 AM with Nurse #4. At 10:10 AM she donned (put on) clean gloves and removed the residents soiled split gauze that rests between the skin and the tracheostomy collar, and removed the residents used inner cannula and threw both away. She then doffed (removed) the soiled gloves and immediately donned (put on) sterile gloves without performing hand hygiene first in between. After donning the sterile gloves, she touched the outside of the tracheostomy care tray that held the sterile supplies needed for the care. At 10:23 AM, while wearing the same gloves, she picked up a sterile q-tip, dipped it into sterile water, dropped it onto the residents clothing covered chest, picked it up again and used it to clean around the tracheostomy stoma (entry into the windpipe from the outside). Wearing the same gloves she then opened the inner cannula package by touching the outside, removed the sterile inner cannula and inserted it into the residents outer cannula. In an interview with Nurse #4 on 12/4/24 at 10:47 AM she stated only sterile items should be touched with sterile gloves and the q-tip that she dropped should have been thrown away and a new one used. Nurse #4 indicated she should have performed hand hygiene between doffing soiled gloves and donning sterile gloves by washing her hands with soap and water. She further indicated she should have removed the sterile gloves after touching the outside of packaging, performed hand hygiene and donned new sterile gloves. An interview with the Staff Development Coordinator (SDC) on 12/5/24 at 8:45 AM revealed she trained all nurses who worked with Resident #85 on tracheostomy care. She stated she trained Nurse #4 on 12/4/24. In a follow-up interview on 12/6/24 at 8:32 AM the SDC stated she performed a hands-on demonstration with Nurse #4 on 12/4/24 at the beginning of the shift, before the investigation observation. In a follow-up telephone interview with Nurse #4 on 12/6/24 at 9:27 AM she stated she was not provided training on tracheostomy care by the SDC until the afternoon of 12/4/24, after the investigation observation of tracheostomy care. In an interview with the Director of Nursing (DON) and Administrator on 12/4/24 at 11:41 AM they stated if non-sterile items are touched with sterile gloves, the contaminated sterile gloves should be removed, hand hygiene performed and new sterile gloves donned. They indicated sterile items that become contaminated, such as the q-tip, should be discarded immediately, and hand washing with soap and water should be performed after doffing soiled gloves and before donning sterile ones. They further stated sterile technique in tracheostomy care is important to prevent bacteria from being introduced into the airway and causing respiratory illness. During an interview on 12/5/24 at 8:20 AM the infection preventionist (IP) stated Nurse #4 should have washed her hands with soap and water after removing the dirty gloves and before donning the sterile gloves. She further stated the outside of the tracheostomy care tray should not have been touched with sterile gloves as it is not sterile. Nurse #4 should have performed hand hygiene and donned new sterile gloves after touching the outside of the tracheostomy tray. The IP indicated the q-tip should have been thrown away and a new one should have been used after it fell on the residents clothing covered chest and hand hygiene should have been performed and new sterile gloves donned before getting a new sterile q-tip. She further indicated that bacteria could be introduced into the residents airway and this could lead to infection if sterile procedure is not followed. In an interview with NP #1 on 12/5/24 at 8:30 AM she stated that Resident #85 had a permanent tracheostomy and no current respiratory infection. NP #1 further stated it is important to follow infection control prevention procedures when performing tracheostomy care to avoid introducing bacteria into the residents airway and potentially causing an infection such as Pneumonia. NP #1 would have expected Nurse #1 to perform hand hygiene by washing her hands between doffing dirty gloves and donning sterile ones. She indicated that nonsterile items should not be touched with sterile gloves, and the sterile q-tip that was contaminated by falling onto the residents clothing should have been discarded and a new one should have been used after performing hand hygiene and donning new sterile gloves.

Based on record review and staff interview the facility failed to develop a comprehensive care plan in the area of fall risk for 1 of 3 residents reviewed for accidents (Resident #81). The findings included: Resident #81 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of lower end of left radius, unspecified dementia and history of falling. A review of Resident #81's Minimum Data Set (MDS) dated [DATE] revealed he was coded as having had a fall in the previous 30 days. A review of Resident #81's comprehensive care plan did not reveal a care plan in the area of falls risk. In an interview with the Minimum Data Set (MDS) nurse on 12/5/24 at 8:04 AM she looked for Resident #81's falls risk care plan in his record and stated he did not have one. She stated the MDS nurse is responsible for completing the comprehensive care plan and the missing falls risk care plan was an oversight. An interview with the Director of Nursing (DON) on 12/5/24 at 10:45 AM revealed the MDS nurse was ultimately responsible for developing comprehensive care plans. She was unaware Resident #81 did not have a care plan to address his risk for falls. An interview with the Administrator was conducted on 12/5/24 at 10:45 AM where she stated she was not aware Resident #81 did not have a falls risk care plan.

Based on observation and staff interview the facility failed to ensure a Nurse was competent to provide tracheostomy care for 1 of 1 resident reviewed for tracheostomy (surgically created airway in the front of the neck) care (Resident #85). Findings include: A continuous observation of tracheostomy care was observed on 12/4/24 at 10:00 AM with Nurse #4 (agency). At 10:10 AM she donned (put on) clean gloves and removed the residents soiled split gauze that rests between the skin and the tracheostomy collar, and removed the residents used inner cannula and threw both away. She then doffed (removed) the soiled gloves and immediately donned (put on) sterile gloves without performing hand hygiene first in between. After donning the sterile gloves, she touched the outside of the tracheostomy care tray that held the sterile supplies needed for the care. At 10:23 AM, while wearing the same gloves, she picked up a sterile q-tip, dipped it into sterile water, dropped it onto the residents clothing covered chest, picked it up again and used it to clean around the tracheostomy stoma (entry into the windpipe from the outside). Wearing the same gloves she then opened the inner cannula package by touching the outside, removed the sterile inner cannula and inserted it into the residents outer cannula. In an interview with Nurse #4 on 12/4/24 at 10:47 AM she stated only sterile items should be touched with sterile gloves and the q-tip that she dropped should have been thrown away and a new one used. Nurse #4 indicated she should have performed hand hygiene between doffing soiled gloves and donning sterile gloves by washing her hands with soap and water. She further indicated she should have removed the sterile gloves after touching the outside of packaging, performed hand hygiene and donned new sterile gloves. Nurse #4 revealed she worked for agency and had not had hands on training for tracheostomy care at the facility. An interview with the Staff Development Coordinator (SDC) on 12/5/24 at 8:45 AM revealed completed hands on tracheostomy training with all nurses who work with Resident #85 before they work with him. She stated she trained Nurse #4 on 12/4/24. In a follow-up interview on 12/6/24 at 8:32 AM the SDC stated she performed a hands-on demonstration with Nurse #4 on 12/4/24 at the beginning of the shift, before the investigation observation. In a follow-up telephone interview with Nurse #4 on 12/6/24 at 9:27 AM she stated she was not provided training on tracheostomy care by the SDC until the afternoon of 12/4/24, after the investigation observation of tracheostomy care. In an interview with the Director of Nursing (DON) and Administrator on 12/4/24 at 11:41 AM they stated new Nurses, including agency Nurses were trained on tracheostomy care before working with Resident #85. They indicated the SDC provided the education upon hire.

Based on observations and staff interviews, the facility failed to replace a damaged bed mattress for 1 of 32 residents reviewed for environment (Resident #9). The findings included: Resident #9 was admitted on [DATE] with diagnoses that included right sided hemiplegia (paralysis), neuropathy (nerve pain), artificial knee joint, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Work order # 9213 created on 11/15/24 revealed a request had been entered by Med Aide (MA) #1 for Resident #9's current room for mattress extremely uncomfortable, has a deep dip in it. The notes stated Resident #9 is requesting a new mattress, it causes his back to hurt. He is out of bed right now if you can change it. The work order was assigned to the Maintenance Assistant, who referred the work order to central supply and set the status to completed. In an interview with MA #1 on 12/04/24 2:44 PM she stated on 11/15/24 Resident #9 told her he felt like he was down in a hole when he laid on his mattress. She stated she placed a work order, and the mattress had been replaced within about 15 minutes or so on 11/15/24. She stated the Central Supply Manager told her he replaced it with a new mattress, and the replacement mattress on 11/15/24 did not look worn to her. MA #1 stated Resident #9 told her that the replacement mattress was uncomfortable and he felt like he was sitting in a hole again. She stated she told Resident #9 the Central Supply Manager told her it was new so it was not the mattress, and she told Resident #9 it might be because he was so tall that it felt like that. MA #1 stated that she did not assess the mattress herself to see if it had an indentation in it. During an interview with the Maintenance Assistant on 12/04/24 at 1:45 PM he stated he received a work order placed on 11/15/24 for Resident #9's bed mattress and took the work order to the Central Supply Manager so a new mattress could be ordered. After he assigned it to the Central Supply Manager on 11/15/24 he marked the work order as completed. During an interview with the Central Supply Manager on 12/04/24 at 2:26 PM he stated that he replaced old mattresses on beds and if the mattresses were still in good condition, he placed them on another bed. He further indicated that he had not replaced a mattress on Resident #9's bed on 11/15/24. The Central Supply Manager stated if a resident complained about a mattress, he just replaced it regardless of condition. An observation was conducted on 12/02/24 at 12:06 PM of Resident #9's bed mattress. The mattress was observed to be without bed linens and the mattress slanted down from the left side of the mattress toward the right side of the mattress. A 15-inch by 15-inch in diameter indentation was visible midway of the mattress towards the right side. The cover of the mattress was observed to have a faded, rough, cracked, worn appearance as compared to the remainder of the mattress cover. During an interview with Resident #9 on 12/02/24 at 12:06 PM he stated he moved from another room to his current room about a month ago and his first mattress was in bad shape and had a sag in it that was like the sag in the current mattress. He stated he told Medication Aide (MA) #1 the mattress was uncomfortable, and he received a replacement mattress about 3 weeks ago. He stated the mattress was replaced with the current mattress and the man (did not know his name or title) who put it on his bed told him it was a new mattress but, within a few days he could tell it was not new because it sagged worse than the first mattress. Resident #9 stated when he laid on the second mattress, he felt like his buttocks dipped in a hole and it caused him to have discomfort in his back. He stated he had back surgery about 3 years ago and it aggravated his back. When asked if he had pain from laying on the mattress, he stated it felt like there was something pressing between his shoulder blades and it made him feel achy at times. Resident #9 stated a week ago he told another Nursing Assistant (NA) (could not recall her name) that the second mattress was uncomfortable, and she told him she talked to someone about it, but it never got changed. During an observation and interview with Nurse # 1 on 12/02/24 at 12:21 PM she stated she was unaware of the condition of Resident #9's bed mattress but it should not sag like it did and should be replaced. She stated she would put in a work order immediately to have it replaced. Housekeeper #1 assigned to Resident #9's hall was interviewed on 12/05/24 at 11:26 AM and stated she was responsible for inspecting the mattresses on her assigned hall when she deep cleaned the rooms, and if they were damaged or had sags in them, they would need to be replaced. Housekeeper #1 further indicated she had deep cleaned Resident #9's room before he moved in around 11/01/24. She stated she could not recall if the mattress had an indentation or damage and that she just wiped down the mattress. In an interview with the Housekeeping Supervisor, on 12/04/24 at 2:05 PM he stated the housekeepers kept him informed when a mattress needed to be replaced related to poor condition. He stated he was not informed about a mattress in poor repair for Resident #9 on 11/15/24 and had not changed the mattress on that date. He stated the Central Supply Manager changed mattresses on beds when needed. In an interview with the Maintenance Director on 12/04/24 at 9:28 AM he stated he had received a work order for Resident #9's room on 11/15/24. He stated the request was related to Resident #9's bed mattress. He stated the work orders were assigned to the Maintenance Assistant who would have made a referral to Central Supply so a new mattress could be ordered. In an interview with a family member of Resident #9 on 12/05/24 at 11:54 AM she stated she visited the resident sometime around 11/17/24. She stated that during her visit Resident #9's bed had been stripped of linen and the mattress was visible. The family member stated the mattress was cracked and broken up, and had a saggy look to it in the middle and stated she did not know another way to describe the appearance of the mattress. Resident #9's family member said no one should have to sleep on a mattress in that poor of a condition. She stated she told a NA (name unknown to her), and the NA told her she was new, and Resident #9 should not have had a mattress in that poor of a condition. In an interview with Nurse Practitioner # 1 on 12/05/24 at 10:59 AM she stated laying on a mattress with an indentation would not cause long lasting effects for Resident #9 because he got out of the bed to a wheelchair during the day, but he had right sided hemiplegia and neuropathy and had pain in general and it could have added to his pain. During a combined interview with the Administrator and the Central Supply Manager on 12/04/24 11:50 AM the Administrator stated if residents had a concern about a bed mattress the resident told the unit staff, and a work order would be placed and the Maintenance Director or the Administrator notified the Central Supply Manager so a new mattress could be ordered. The Central Supply Manager did not recall a replacement mattress being placed on Resident #9's bed on 11/15/24. He stated if a work order had been placed on 11/15/24 it would have been assigned to him to get a new mattress and he would have replaced the mattress. In interviews with the Administrator on 12/04/24 at 3:18 PM and 12/5/24 at 9:47 AM she shared she was unaware that Resident #9 had slept on a mattress in poor condition from 11/15/24 until 12/2/24, when it was observed by the surveyor. The Administrator stated a replacement mattress should be provided if a resident requested one. She further stated that if Resident #9 requested to have a mattress replaced because of discomfort, then it should have been replaced immediately.

Based on record review, and resident, staff, physician, physician assistant, and pharmacist interviews the facility failed to ensure ear drop medication was administered via the correct route into the ears and not into the eyes. This was for 1 of 7 residents (Resident #2) reviewed for medication errors. Findings included: Resident #2 was admitted to the facility on [DATE] with a diagnosis of left arm fracture. A review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact. Her vision was impaired. She could see large print but not regular print in newspapers/books. She had functional limitation in range of motion in her upper and lower extremities on one side. She was independent with eating and personal hygiene. A review of Resident #2's comprehensive care plan revealed a focus area initiated on 7/23/24 of inability to read regular sized print without glasses. The goal was for Resident #2 to have no injuries and to feel safe and secure in her environment through the next review. An intervention was to use large print items for Resident #2. A review of a physician's order for Resident #2 revealed an order dated 8/8/24 for lubricant eye drops (carboxymethylcellulose sodium ophthalmic (eye) solution) instill one drop in both eyes two times a day for dry eyes. A review of a physician's order for Resident #2 revealed an order dated 9/17/24 for ciprofloxacin (an antibiotic medication) 0.3 percent-dexamethasone (a steroid medication) 0.1 percent instill 2 drops in left ear every 12 hours for 5 days for ear infection. A review of Resident #2's September 2024 Medication Administration Record (MAR) revealed documentation indicating the ciprofloxacin -dexamethasone ear drops were administered to Resident #2 by Nurse #5 on 9/18/24 at 8:00 AM and by Nurse #7 on 9/18/24 at 8:00 PM. On 12/3/24 at 4:51 PM a telephone interview with Nurse #5 indicated although she could not recall the date, she had been orienting with Nurse #6 on the 7:00 AM to 7:00 PM shift. Nurse #5 stated Resident #2 had both eye drops and ear drops due and she brought both of these with her into Resident #2's room. She reported Nurse #6 told her that Resident #2 could give her eye drops to herself. She went on to say she had gone into Resident #2's room by herself, explained to Resident #2 that the bottle she was handing her was her ear drops, and she stood at Resident #2's bedside. Nurse #5 stated when Resident #2 started to put the drops into her eyes, she tried to stop Resident #2, but the medication had already gone into Resident #2's eyes. She reported she had immediately notified Nurse #6 what happened, and Nurse #6 reported it to the Director of Nursing (DON). Nurse #5 stated Physician #1 had been notified, and Resident #2's eyes had been flushed. She reported she received some education after the incident regarding ensuring the correct route for medications. On 12/4/24 at 9:59 AM a telephone interview with Nurse #6 indicated Nurse #5 had been on her second or third day of orientation (Nurse #6 could not recall the date) and he had asked Nurse #5 if she wanted to observe him administer medications, but she had said she was comfortable and could do this herself. Nurse #6 stated Resident #2 had both eye drops, and ear drops to be administered that day. He reported he saw Nurse #5 knock on Resident #2's door, enter the room and introduce herself, and explain to Resident #2 that she had both eye drops and ear drops for her. Nurse #6 explained from where he was standing in Resident #2's room doorway, he could see Nurse #5 administer drops into Resident #2's eyes and set the bottle down on Resident #2's table, then administer ear drops to Resident #2 and set the bottle down. Nurse #6 stated as Nurse #5 picked the bottles up from Resident #2's table, he heard Resident #2 state, You gave my ear drops in my eyes. He reported he entered Resident #2's room and reassured her he didn't think Nurse #5 had done this, but Resident #2 became upset and replied that she knew her medications and she wouldn't lie. He stated at that point he just went to notify the DON. Nurse #6 stated from where he had been standing in the doorway, he couldn't really tell which drops were which. On 12/4/24 at 8:56 AM an interview with the Staff Development Coordinator (SDC) indicated on 9/18/24 Resident #2 reported that Nurse #5 administered her ear drops into her eyes. She stated Nurse #5 had still been in her 90-day orientation period at that time, so she asked Nurse #5 to demonstrate to her which drops she administered in Resident #2's ear, and which drops she administered into Resident #2's eyes. The SDC reported she asked Nurse #5 to read the medication labels, and they discussed what optic (eye) versus otic (ear) meant with regards to routes of administration. She stated Nurse #5 indicated to her that she had administered the ear drops (ciprofloxacin-dexamethasone) into Resident #2's ear, and the eye drops (carboxymethylcellulose sodium) into Resident #2's eyes. The SDC recalled Nurse #5 reported she had administered the medications to Resident #2, and denied having administered Resident #2's ear drops into her eyes. The SDC reported education had only been completed with Nurse #5 regarding this issue. On 12/4/24 at 8:00 AM a telephone interview with Nurse #7 indicated she was assigned to care for Resident #2 on 9/18/24 on the 7:00 PM until 7:00 AM shift. She stated when she spoke with Resident #2 on that day, Resident #2 told her the nurse on the day shift that day put her ear drops into her eyes and she was very concerned about it. She went on to say she had gone to notify the DON, but the DON was already aware of this. Nurse #7 stated Resident #2 had not been complaining of any symptoms, and she had not observed any eye concerns. On 12/2/24 at 11:57 AM in an interview Resident #2 stated on 9/18/24, the nurse assigned to care for her put the drops that were supposed to be for her ear into her eyes. She indicated she could not recall the name of this nurse, as it was this first time this nurse worked with her. She reported the nurse had not said anything to her, but she knew the nurse was about to put her eye drops in because of the motion the nurse made with the bottle. Resident #2 went on to say she had not paid much attention, because she trusted the nurse to do the right thing. She reported the drops that this nurse put into her eyes had been thicker than her eye drops usually were, and although she had not felt any pain at the time, her vision had been blurry since then. Resident #2 stated when the nurse set the bottle down on her table, she could see that it was the ear drops and not the eye drops bottle. She reported this nurse had been working with Nurse #6 that day, and she went out into the hallway to let Nurse #6 know what had happened. Resident #2 stated no one seemed to pay any attention when she reported this, and she felt everyone acted like it was nothing. Resident #2 indicated she had seen an eye doctor after the incident, and the doctor told her the blurry vision was not from the ear drops going into her eyes but was from age related changes. She stated she didn't believe this, because she had not had any blurry vision prior to the incident. Resident #2 went on to say she asked to see a second eye doctor and the second eye doctor had also told her having her ear drops administered into her eyes wouldn't cause any vision changes. On 12/5/24 at 1:55 PM a telephone interview with Physician #1 indicated he had been notified that Resident #2's ear drops had potentially been administered into her eyes. He stated Resident #2's eyes were flushed with saline, and he had seen Resident #2 at the facility that same day. Physician #1 stated Resident #2 had not had any eye redness, or irritation. Physician #1 reported if a medication was ordered to be administered into a resident's ear, he would expect it to be administered into the resident's ear and not their eye. A review of a physician's order for Resident #2 dated 9/18/24 revealed consultation for blurry vision at eye clinic. A review of the eye clinic examination note for Resident #2 dated 12/23/24 written by Physician #2 revealed she was being seen due to having ear drops administered into her eyes. She did not have any symptoms. On 12/4/24 at 11:30 AM a telephone interview with Physician #2 indicated he examined Resident #2's eyes on 9/23/24. He stated Resident #2 was concerned after having ear drops administered into her eyes. He reported that the ciprofloxacin 0.3 percent-dexamethasone 0.1 percent designed to be administered into Resident #2's ear would not have caused any vision changes if it had been administered into Resident #2's eyes. He went on to say while it could cause mild transient irritation and burning, it would not cause any vision damage. Physician #2 stated it had been the right thing to flush Resident #2's eyes with saline as this would help prevent any irritation. A review of a physician's order for Resident #2 dated 9/24/24 revealed to schedule a second opinion consultation at an eye clinic due to blurry vision. A review of the eye clinic visit note for Resident #2 dated 10/2/24 written by Physician's Assistant (PA) #1 revealed Resident #2 was being seen for complaints of blurry vision. Resident #2 reported that a couple of weeks ago, a nurse administered her ear drops into her eyes. The impression from the examination was mild anterior basement membrane dystrophy (a genetic disorder of the cornea that causes recurrent erosions and blurred vision). PA #1 did not think ear drops caused Resident #2's current symptoms. On 12/4/24 at 9:50 AM a telephone interview with PA #1 indicated she had seen Resident #2 in the eye clinic on 10/2/24 and examined her eyes. She stated Resident #2 was certain that having her ear drops administered into her eyes was causing her to have blurry vision. PA #1 went on to say she had reassured Resident #2 that while this could cause mild temporary irritation, it would not cause her to have any vision changes or permanent damage to her eyes. On 12/5/24 at 12:35 PM a telephone interview with the facility's consultant Pharmacist indicated she had been made aware that Resident #2 was reporting her ear drops were mistakenly administered into her eyes. She stated while ciprofloxacin 0.3 percent-dexamethasone 0.1 percent designed to be administered into Resident #2's ears could potentially cause a mild irritation if administered into her eyes, it would not cause any vision damage. The Pharmacist reported Resident #2 had been seen by an eye doctor, and no lasting ill effects had been confirmed. On 12/4/24 at 8:42 AM an interview with the DON indicated on 9/18/24 she was notified that Resident #2 reported Nurse #5 put her ear drops into her eyes. She stated she immediately went to Resident #2's room, and Resident #2 was holding the ear drop medication package in her hand and was speaking with someone from the facility's consulting pharmacy. She reported after Resident #2 finished with her telephone call, she asked Resident #2 what happened, and how she knew it was the ear drops that went into her eyes. The DON stated Resident #2 told her she knew what her medications looked like, and which one was which. The DON reported Resident #2 had not been having any eye redness or irritation at the time, but she spoke with Resident #2's Physician (Physician #1) and was told to flush Resident #2's eyes with saline, which was done. She went on to say Resident #2's Physician #1 had seen her that same day. She reported Resident #2 had requested to see an eye doctor, so a consultation appointment was made. She went on to say Resident #2 had not been happy with the results of this eye consultation, so Resident #2 asked for a second opinion eye consultation which was also done. On 12/5/24 at 1:20 PM an interview with the Administrator indicated Nurse #5 had denied putting Resident #2's ear drops into Resident #2's eyes during the facility's investigation of the incident. She stated Nurse #5 had been in her orientation period at the time of the incident and had denied this occurred. She reported the SDC had completed education with Nurse #5 regarding the proper routes of medication administration. The Administrator stated incorrect routes of ear drop administration had not been a trend at the facility.

Based on record review and staff interviews, the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF ABN) by omitting the estimated out of pocket cost for care for 3 of 3 residents reviewed for beneficiary notices (Residents #70, #134, #393). Findings included: a. Resident #70 was admitted to the facility on [DATE]. Review of Resident #70's record indicated the SNF ABN dated 11/8/23 had no estimated out of pocket cost for care documented on the form. Resident #70 remained in the facility with benefit days remaining. b. Resident #134 was admitted to the facility on [DATE]. Review of Resident #134's record indicated the SNF ABN dated 11/22/23 had no estimated out of pocket cost for care documented on the form. Resident #134 remained in the facility with benefit days remaining. c. Resident #393 was admitted to the facility on [DATE]. Review of Resident #393's record indicated the SNF ABN dated 11/21/23 had no estimated out of pocket cost for care documented on the form. Resident #393 remained in the facility with benefit days remaining. During an interview with Social Worker #1 on 11/30/23 at 3:00 PM, she indicated she had been in her position for [AGE] years and had never been made aware the estimated out of pocket cost for care needed to be on the SNF ABN. She further stated the SNF ABN came prefilled from the corporate office. She indicated that the Social Work office was the only one to distribute the SNF ABN to Residents. An interview with Social Worker #2 on 11/30/23 at 3:00 PM revealed she also was unaware the estimated out of pocket cost for care needed to be included on the SNF ABN. She further stated that Social Work was the only office to distribute the SNF ABN to Residents and that they came prefilled from the facility Corporate Office. During an interview with the Administrator on 11/30/23 at 1:30 PM, she indicated she was unaware that the estimated out of pocket cost or care was to be included on the SNF ABN and that she would have the forms updated going forward.

Based on record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This was for one repeat deficiency in the area of Medicaid/Medicare Coverage Liability Notice (F582) originally cited on 7/29/21 during a recertification and complaint investigation survey and subsequently recited on 11/30/23 during the recertification and complaint investigation survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. Findings included: This tag is cross referenced to: F582: Based on record review and staff interviews, the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of non-coverage (SNF ABN) by omitting the estimated out of pocket cost for care for 3 of 3 residents reviewed for beneficiary notices (Residents #70, #134, #393). During the recertification and complaint investigation survey of 7/29/21, the facility failed to provide an acknowledged Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and a Notice of Medicare Non-Coverage prior to discharge from Medicare Part A skilled services. During an interview on 11/30/23 at 12:14 PM, the Administrator revealed she was unaware of the need to complete the cost rate on the SNF ABN form.

Based on observation, record review, and resident and staff interviews, the facility failed to ensure that smoking materials were secured by staff for three of three sampled residents observed for accidents (Resident #101, Resident #107, and Resident #119). Findings included: The facilities smoking policy dated 2019 stated all resident smoking materials were maintained in a secured area and were accessible only through the assistance of the facility staff. Assessment of Residents ability to smoke in a safe manner would occur prior to smoking in designated outdoor areas. Safe smokers would be reassessed at least monthly utilizing the Smoking Evaluation by a Licensed Nurse. The interdisciplinary team would review the care plans of smokers and update based on the Smoking Evaluation. 1. Resident #101 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia (one sided weakness), Seizure disorder and Diabetes Mellitus II. A review of the care plan dated 10/26/23 revealed that Resident #101 was an independent and safe smoker of cigarettes. The goal was for the Resident to continue to smoke safely in designated areas and would continue to use smoking materials safely through the next review. Interventions included staff assistance obtaining smoking materials from a secured storage area upon request, evaluate resident's continued ability to smoke safely on a consistent and regular basis, and for staff to observe for potential violations of the smoking policy. It further stated staff were to document and report observations to Administrator and/or Administrative staff and to provide education on safe smoking to the resident. Resident #101's smoking evaluation dated 11/3/23 indicated the Resident was a safe smoker and may smoke in designated areas without supervision. A review of the Resident's smoking evaluations revealed they were performed monthly since admission to the facility in June 2023. Resident #101 was observed walking alone out to the smoking area on 11/28/23 at 8:25 AM without stopping at the lock box area. He then removed smoking materials from his front shirt pocket and proceeded to light a cigarette. In an interview with Resident #101 on 11/28/23 at 8:30 AM he revealed he smoked several times a day. He further stated there were lock boxes for Residents to keep their smoking materials in, and each box had a key that was kept by the Resident it was assigned to. He was unaware if staff knew he kept his smoking materials on his person. An observation of the smoking area on 11/30/23 at 08:25 AM revealed metal shelving with lock boxes secured to the shelves. Each box was individually numbered. An interview with Nursing Assistant (NA) #1 on 11/30/23 at 9:30 AM stated she believed Residents were prohibited from keeping smoking materials on their person or in their rooms. She was unaware of where Resident #101 kept his smoking materials. An interview with Nurse #2 revealed Residents had a smoking evaluation done on admission and then monthly by Nursing to assess if the Resident could remain an independent smoker, or if they needed supervision for safety. She further stated she was unaware of where Resident #101 kept his smoking materials. In an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 AM, she indicated that staff should notify her if a Resident had smoking materials on their person or had not utilized the lock box system. She stated she was unaware that Resident #101 kept smoking materials on his person instead of using the lock box. The DON indicated that staff had a duplicate key for each box in case a key was lost. An interview with the Administrator on 11/30/23 at 1:00 PM indicated that staff smoked outside in the same area as the Residents. She further stated staff were able to supervise the smoking area from inside the building in case of emergency. She indicated there was no system in place to check if independent smokers were using the lock boxes and she was unaware of any Residents not using the lock boxes for smoking materials safe keeping. 2. Resident #107 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus II, Chronic Obstructive Pulmonary Disease and Heart Failure. A review of Resident #107's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. It also indicated the Resident was a tobacco user. A review of Resident #107's care plan dated 8/7/23 revealed the Resident was an independent and safe smoker of cigarettes. The goal was for the Resident to continue to smoke safely in designated areas and would continue to use smoking materials safely through the next review. Interventions included staff assistance obtaining smoking materials from a secured storage area upon request, evaluate resident's continued ability to smoke safely on a consistent and regular basis, and for staff to observe for potential violations of the smoking policy. It further stated staff were to document and report observations to Administrator and/or Administrative staff and to provide education on safe smoking to the resident. Resident #107's smoking evaluation dated 11/1/23 indicated the Resident was a safe smoker and may smoke in designated areas without supervision. A review of the Residents smoking evaluations revealed they were performed monthly since admission to the facility in August 2023. Resident #107 was observed wheeling himself out to the smoking area in his wheelchair on 11/28/23 at 8:45 AM. He then removed smoking materials from his front shirt pocket and proceeded to light a cigarette without first going to the lock box area. An observation of the smoking area on 11/30/23 at 8:25 AM revealed metal shelving with lock boxes secured to the shelves. Each box was individually numbered. In an interview with Resident #107 on 11/28/23 at 8:50 AM he revealed he smoked several times a day. He stated in the interview there were lock boxes for Residents to keep their smoking materials in, and each box had a key that was kept by the Resident it was assigned to. The Resident stated he did not use the lock box. He further stated staff knew he kept smoking materials on his person as he had refused to give them to staff or use the lock box. In an interview with Nursing Assistant (NA) #1 on 11/30/23 at 9:37 AM, she stated she believed Residents were prohibited from keeping smoking materials on their person or in their rooms, and she believed Resident #107 kept his smoking materials at the Nurses station. An interview with Nurse #1 revealed Residents had a smoking evaluation done on admission and then monthly by Nursing to assess if the Resident could remain an independent smoker, or if they needed supervision for safety. She further stated Resident #107 kept his smoking materials on his person as he had refused to give them to Nursing in the past. Nurse #1 further revealed a large plastic toolbox that was kept at the Nurses station that had three packs of cigarettes inside that had no names on them. She further stated they used to use this toolbox to keep Resident smoking materials before they implemented the lock box system. Nurse #1 did not know to whom the cigarettes belonged. It was observed that the toolbox was not kept locked. In an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 AM, it was revealed that staff should have notified her if a Resident had smoking materials on their person or were not utilizing the lock box system. She was unaware there were cigarette packs in the toolbox at the nurse's station. She further stated she was unaware that Resident #107 kept smoking materials on his person instead of using the lock box. The DON indicated that staff had a duplicate key for each box in case a key was lost. An interview with the Administrator on 11/30/23 at 1:00 PM indicated that staff smoked outside in the same area as the Residents. She further stated staff were able to supervise the smoking area from inside the building in case of emergency. She indicated there was no system in place to check if independent smokers were using the lock boxes and she was unaware of any Residents not using the lock boxes for smoking materials safe keeping. 3. Resident #119 was admitted to the facility on [DATE] with diagnoses that included acquired absence of right leg below the knee, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. A review of Resident #119's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with no behaviors. It also indicated the Resident was a tobacco user. A review of the care plan dated 10/26/23 revealed that Resident #119 was an independent and safe smoker of cigarettes. The goal was for the Resident to continue to smoke safely in designated areas and would continue to use smoking materials safely through the next review. Interventions included staff assistance obtaining smoking materials from a secured storage area upon request, evaluate resident's continued ability to smoke safely on a consistent and regular basis, and for staff to observe for potential violations of the smoking policy. It further stated staff were to document and report observations to Administrator and/or Administrative staff and to provide education on safe smoking to the resident. Resident #119's smoking evaluation dated 11/1/23 indicated the Resident was a safe smoker and may smoke in designated areas without supervision. A review of the Residents smoking evaluations revealed they were performed monthly since admission to the facility in February 2023. In an interview with Resident #119 on 11/28/23 at 12:10 PM he revealed he smoked on days he did not have dialysis. He stated in the interview there were lock boxes for Residents to keep their smoking materials in, and each box had a key that was kept by the Resident it was assigned to. The Resident stated he does not use the lock box as he only smokes a few times a week. He was unaware if staff knew he kept his smoking materials on his person. An observation of the Resident on 11/30/23 at 08:19 AM revealed Resident was outside in the designated smoking area when I arrived. He had not yet started to smoke. Resident #119 removed a pack of cigarettes from the back of his wheelchair. An observation of the smoking area on 11/30/23 at 08:25 AM revealed metal shelving with lock boxes secured to the shelves. Each box is numbered. An interview with Nursing Assistant (NA) #1 on 11/30/23 at 9:30 AM stated she believed Residents were prohibited from keeping smoking materials on their person or in their rooms. She was unaware of where Resident #119 kept his smoking materials. An interview with Nurse #2 revealed Residents had a smoking evaluation done by Nursing before being allowed to smoke at the facility. This evaluation was to assess if the Resident can be an independent smoker, or if they need supervision for safety. The evaluation was completed monthly. She further stated she was unaware of where Resident #119 kept his smoking materials. In an interview with the Director of Nursing (DON) on 11/30/23 at 10:00 AM, it was revealed that staff should have notified her if a Resident had smoking materials on their person or were not utilizing the lock box system. She further stated she was unaware that Resident #119 kept smoking materials on his person instead of using the lock box. The DON indicated that staff had a duplicate key for each box in case a key was lost. An interview with the Administrator on 11/30/23 at 1:00 PM indicated that staff smoked outside in the same area as the Residents. She further stated staff were able to supervise the smoking area from inside the building in case of emergency. She indicated there was no system in place to check if independent smokers were using the lock boxes and she was unaware of any Residents not using the lock boxes for smoking materials safe keeping.

Based on interviews with staff, pharmacist, physician, and review of facility, Emergency Medical Service (EMS) and hospital records, the facility failed to recognize that blood sugar monitoring was indicated for a resident whose medication for diabetes was increased at a time when July blood sugars and A1C were within normal limits. The facility failed to check the blood sugar on a resident who was diabetic with altered mental status 1 of 1 resident (Resident #1). On August 4, 2021, Resident #1 was found to have altered mental status. Once EMS arrived, fingerstick was performed and it was 27. Resident #1 was started on an intravenous infusion of glucose and taken to the emergency room . Immediate Jeopardy began on 8/1/21 when the facility failed to monitor blood sugar levels for a resident whose medication for diabetes was increased when the hemoglobin A1C (measurement of blood glucose levels over the past 3-month period) lab results were within normal limits. Immediate Jeopardy was removed as of 8/16/21 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: Interview with Hospital Pharmacist on 8/13/21 at 11:05 A. M. revealed Resident # 1 was admitted to the hospital on 7/20/21, the Admission Nurse did a medication review with Resident #1 on this day. The order for [MEDICATION(S)] 5-500mg (a combination medication of [MEDICATION(S)] 5mg and [MEDICATION(S)] 500mg) two tablets twice a day was reviewed. The Admission Nurse made a note in Resident #1's medical chart that read Resident #1 stated he took the medication differently and stated his physician decreased the medication to 1 tablet daily on 1/7/21. During Resident #1's hospital admission from 7/20/21-7/25/21 for a fracture of the left hip, Resident #1 was ordered [MEDICATION(S)] 5mg twice a day with meals and was administered insulin based off a sliding scale. The Hospital Pharmacist revealed a clarification of the frequency for [MEDICATION(S)] was needed from Resident #1's physician had Resident #1 continued [MEDICATION(S)] at the hospital to verify if the physician agreed with the dose change Resident #1 reported. Hospital Discharge summary dated 7/25/21 under the heading continue taking these medications showed the order [MEDICATION(S)]-[MEDICATION(S)] 5-500mg per tablet take one tablet by mouth two times a day with meals. Decreased to 1 tablet daily by physician on 1/7/21. Resident #1, an [AGE] year-old, was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An order was written on the July 2021 Medication Administration Record showed finger stick blood sugar twice a day. Resident #1's care plan dated 7/27/21 revealed a care plan for potential for complications for hyper/[CONDITION(S)] and state of nourishment less than body requirements. Interventions included finger stick blood sugar as ordered by the physician and/or per facility protocol, administer medications as ordered, observe for [CONDITION(S)]/[CONDITION(S)], report to unit supervisor when 75% of meal not eaten and refer to dietician for evaluation. On 7/27/21 a Pharmacist sent an Admission Drug Regimen Review for a clarification on [MEDICATION(S)] 5-500mg to be administered daily or twice a day. Pharmacist stated the discharge summary did not read clearly to the administration frequency. Interview with the Pharmacist #1 conducted via telephone on 8/12/21 at 12:15 P.M. revealed after reviewing notes from a coworker who was unreachable, the Pharmacy's responsibility included an Admission Review of each resident within a few days of admission into the facility. After completing an Admission Review of Resident #1's medication, a request was sent to the physician to clarify the dose frequency of [MEDICATION(S)] (a combination pill for [MEDICATION(S)] and [MEDICATION(S)]) for either one time or two times a day. During the interview the Pharmacist stated when a resident was prescribed a sulfonylurea (drug class for [MEDICATION(S)] a component of [MEDICATION(S)]) routine blood sugar monitoring was recommended. The Pharmacist revealed she liked to see blood sugar monitoring after a dose change to see if the desired response was achieved, but the frequency of the blood sugar monitoring was left up to the doctor. Lab resulted on 7/28/21 showed hemoglobin A1C 4.5%. (A normal A1C level is below 5.7%, a level of 5.7% to 6.4% indicated prediabetes, and a level of 6.5% or more indicates diabetes). Physician#1 wrote a medication clarification order for Resident #1 on 7/29/21 that read [MEDICATION(S)]-[MEDICATION(S)] 2.5-500mg by mouth two tablets twice a day. Interview with Physician #1 on 8/13/21 at 12:14 P.M. revealed based off the pharmacy request for clarification on the [MEDICATION(S)]-[MEDICATION(S)] frequency, Resident #1's hemoglobin A1C lab result was reviewed. Physician #1 stated his intention was to write a new order to decrease the [MEDICATION(S)] to the following order [MEDICATION(S)] 2.5-500mg one tablet daily twice a day. Physician #1 mistakenly wrote to administer two tablets instead of one tablet. During the interview Physician #1 revealed the [MEDICATION(S)] dose had stayed the same and the increase dose of [MEDICATION(S)] would not cause [CONDITION(S)] in Resident #1. Physician #1 stated in three months a hemoglobin A1C would be ordered to monitor Resident #1's diabetes. Physician #1 stated with a resident with an A1C of 4.5, he would not have ordered blood finger sticks to be completed. Medication Administration Record for July 2021 showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication was first administered on 7/26/21 at 7 A.M. and discontinued after the 7/29/21 5 P.M. dose. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication Administration Record for July 2021 showed finger stick blood sugars completed twice a day from 7/25/21 4:30 P.M. dose through 7/31/21. The 4:30 P.M. blood sugars readings on 7/30/21 and 7/31/21 were not documented on the MAR. Blood sugar readings ranged from 93-192 mg/dl. (Normal range of blood sugar is 70-120 mg/dl before meals and under 140 mg/dl at two hours after eating). Resident #1 Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was alert and oriented. Resident #1 did not refuse care. The MDS further revealed Resident #1 was independent with feeding with help with setup only. Medication Administration Record for August 2021 showed [MEDICATION(S)]-[MEDICATION(S)] 2.5-500mg two tablets twice a day with meals. Medication Administration Record for August 2021 showed no order Resident #1 was to receive finger stick blood sugars checks to monitor blood sugar daily. Intake log showed on 8/3/21, Resident #1 ate 100% of breakfast; 100% of lunch and 25% of super. On 8/4/21 Resident #1 ate 25% of breakfast. Interview was conducted by telephone with Nurse Aide (NA) #1 assigned Resident #1 on 8/3/21 on the 3 P.M. to 11 P.M. shift, revealed he did not recall Resident #1. NA#1 was unable to state how much Resident #1 ate for supper or if Resident #1 ate a bedtime snack. During the interview the NA stated diabetic residents were offered a snack each night. The NA further stated when a resident he was assigned care did not eat any of a meal, the information was reported by the NA to the resident's assigned nurse. Unable to reach Nurse #3 assigned Resident #1 on 8/3/21 on the 3 P.M. to 11 P.M. shift by telephone for interview. Interview on 8/11/21 at 11:15 A.M. with Nurse #1 assigned Resident #1 on the 7 A.M. to 3 P.M. shift on 8/4/21 revealed Resident #1 was an alert, quiet person, who was able to make his needs known to staff. Nurse #1 stated she was unsure how much Resident #1 ate for breakfast. When residents had not eaten a meal, the NA assigned the resident reported the information to the assigned nurse. Nurse #1 revealed no NA had reported to her Resident #1 had not eaten his meal. Nurse #1 revealed she does not specifically remember administering Resident #1 his medications on the morning of 8/4/21, however Resident #1 took his medications as prescribed with no refusals. Nurse#1 stated Resident #1 showed nothing out of character compared with his normal behavior to make Nurse #1 think Resident #1 was having any complications. Nurse #1 was at lunch when Resident #1 was sent to the emergency room . Interview with Physical Therapy (PT) on 8/11/21 at 2:15 P.M. revealed on 8/4/21 PT arrived at Resident #1's room after the lunch trays were passed out, to set up a time for therapy, When PT entered the room, Resident #1 appeared to have been woken up and his speech was a little garbled. PT assisted Resident #1 from lying in his bed to sitting on the side of the bed. After a few seconds, Resident #1 required more assistance from PT to remain upright and Resident #1's speech became slurred. Resident #1 was repositioned to lay back in bed. PT revealed he felt like Resident #1 had a stroke in front of him and left the room to get the first available nurse (Staff Development Coordinator) to assess Resident #1. PT stated Resident #1 was able to follow commands, was never unconscious, not sweating, and was moving both his arms. PT revealed vital signs were obtained and the physician was made aware of Resident #1's condition and reported to Resident #1's room to evaluate Resident #1. Interview with Staff Development Coordinator (SDC) on 8/11/21 at 2:45 P.M. revealed on 8/4/21 PT told her he needed assistance with Resident #1. SDC arrived in Resident #1's room and completed an assessment. SDC asked Resident #1 to smile and he was unable to. SDC assessed Resident #1's mouth and found his tongue deviated to the left side. SDC completed bilateral upper grip test with Resident #1 and discovered Resident #1 to have left sided weakness. SDC stated she was concerned Resident #1 had a stroke and needed to be sent to the hospital for the stroke reversal therapy. Physician #1 was at the end of the Resident's hallway when SDC stepped out of Resident #1's room and responded to SDC's request to evaluate Resident #1. SDC stated based off her assessment of Resident #1 she thought Resident #1 had a stroke and did not feel like low blood sugar had caused the observed symptoms. Interview conducted by telephone with Nurse Aide (NA) #2 on 8/11/2021 at 1:38 P.M. revealed NA #2 was unsure which nurse aide was assigned Resident #1 on 8/4/21 for the 7 A.M. to 3 P.M. shift, as both NA #2 and NA #3 worked together and completed resident care. NA #2 stated he arrived after breakfast and was unsure how much Resident #1 had eaten. NA#2 helped set Resident #1 up for lunch ten minutes prior to PT telling NA #2 Resident #1 had a stroke. NA#2 revealed Resident #1 was at his baseline when the food tray was set up. NA #2 described Resident #1's baseline as Resident #1 talked low, answered yes/no questions and was alert. NA #2 stated PT told him in the hallways Resident #1 was not okay, may have had a stroke, and needed help. NA #2 returned to Resident #1's room and completed vital signs at that time. The vital sign results were Blood Pressure 146/87, Pulse 86, Respirations 16, and Oxygen Saturation Level 99%. NA #2 stated Resident #1 was waving his arms in the air and was not sweaty or clammy. NA#2 further revealed facility staff did not check Resident #1's blood sugar after Resident #1 had a change of condition. Unable to reach NA #3 by telephone for interview. Physician Assistant Progress Note dated 8/4/21 written by Physician Assistant #1 read in part Physical Therapy was with patient and noticed a change in patient's mental status. Patient became confused, incoherent, and had left side facial drooping. Patient was in bed when provider came into room lying supine with arms extended. He was unable to provide an accurate history. Transport to ED via EMS. Interview with Nurse #2 on 8/13/21 at 4:22 P.M. revealed when Nurse #2 returned to the hallway Resident #1 resided on, she saw several staff members gathered around Resident #1's room. Nurse #2 stated she was informed Resident #1 had a stroke and Emergency Medical Service (EMS) were called. Nurse #2 stated when EMS arrived Resident #1's blood sugar was taken by EMS. When Nurse #2 heard Resident #1's blood sugar was 27 she went to retrieve [MEDICATION(S)] (used to treat very low blood sugar). When Nurse #2 arrived back at Resident #1's room, EMS had Resident #1 loaded onto the stretcher and were transporting him down the hall. Emergency Medical Service (EMS) report dated 8/4/21 revealed EMS received a call at 1:38 P.M. and dispatched to the facility at 1:39 P.M. The EMS crew arrived at the resident at 1:46 P.M. and left the facility at 2:00pm. The EMS crew arrived at the emergency room at 2:04 P.M. and transferred care of the resident at 2:15 P.M. The EMS notes stated they were dispatched for a stroke. When they arrived, the patient was moving all limbs slowly, erratically and moaning. Patient was in a semi-fowlers position (usually on their back with the head of the bed angled between 30 degrees and 45 degrees) with cool clammy pale skin. Patient was confused and only responded to painful stimuli. Medic was suspicious of a low blood glucose level and asked staff if the patient was diabetic, and it was confirmed. Blood glucose level was assessed to be 27. When patient was secured in the truck an IV (intravenous) access gained and [MEDICATION(S)] administered IV. Patient became alert and oriented, with warm, pink, dry, skin and stated he felt much better. A telephone interview with Emergency Medical Services (EMS) #1 on 8/16/21 at 9:39 A. M. revealed on initial entrance into Resident #1's room she suspected Resident #1 had low blood sugar and stated the symptoms did not resemble a stroke. EMS stated Resident #1 presented with sweaty, clammy, pale, combative but not directed towards anyone, and was moving both of his upper extremities. EMS further stated the presentation of a stroke is one side of the patient is flaccid and unmoving. Staff were asked if Resident #1 was a diabetic and when facility staff confirmed Resident #1 was diabetic, EMS asked had a blood sugar been obtained. EMS stated the facility staff became confused and kept repeating a blood pressure reading to them. EMS heard facility staff state the blood sugar must not have been taken. EMS stated the facility staff argued over why a blood sugar wasn't completed and facility staff were heard by EMS to state a blood sugar should have been completed. A telephone interview with EMS #2 on 8/16/21 at 9:59 A.M. stated EMS was dispatched on 8/4/21 to Resident #1 for a stroke. When EMS arrived on scene, Resident #1 was found to be moving both of his arms in the air and swaying back and forth. EMS #2 revealed Resident #1 was able to pull on both of her arms and showed no deficient to one side of his body. Stroke victims presented as unable to speak and unresponsible, EMS stated Resident #1 did not present as a stroke victim. Resident #1 had full motion of bilateral upper extremities and was moving back and forth. EMS #2 revealed she felt Resident #1 had displayed signs of a low blood sugar. During the interview EMS #2 stated the facility confirmed Resident #1 was diabetic after being asked. The facility was unable to provide a recent blood sugar result. EMS checked Resident #1's blood sugar and discovered the blood sugar was in the 20's. EMS transferred Resident #1 to the EMS truck for treatment. Hospital Discharge Summary dated 8/9/21 showed the primary problem diagnosed as [CONDITION(S)]. Hospital Course showed Resident #1 arrived at the emergency roiagnom on [DATE] feeling mildly dizzy, denied any chest pain, sweating, shakiness, or any other symptoms. At the emergency room his blood glucose was 29. Resident #1 was given multiple ampules of D50 (25 grams of glucose in a 50-milliliter syringe) without improvement and was started on D10 (10% [MEDICATION(S)]) drip. Resident #1 hospital records stated associated hypo-osmolar [CONDITION(S)], most likely due to volume depletion and multiple electrolyte abnormalities including [CONDITION(S)] and hypophosphatemia. Resident #1's medical records indicated a precipitous drop in hematocrit without ongoing GI blood loss. This was thought to be multifactorial including nutritional and [CONDITION(S)]. On discharge the hospital stopped Resident #1's order for [MEDICATION(S)]. On 8/14/21 at 8:02 P.M, the facility's Administrator was informed of the immediate jeopardy. The facility provided an acceptable credible allegation of Immediate Jeopardy removal on 8/16/21. The allegation of immediate jeopardy removal indicated: Credible Allegation of Immediate Jeopardy Removal for F684 Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance Resident # 1 is alert and oriented to self with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/25/2021, Resident #1 was admitted to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was transcribed to the medication administration record by the admitting nurse per the hospital discharge summary. On 7/27/2021, the pharmacist consultant conducted an admission drug regimen review and requested a clarification of [MEDICATION(S)] 5-500 mg. On 7/29/2021 the physician reviewed the [MEDICATION(S)] order per the pharmacy recommendation. On 7/29/21 the physician wrote a clarification order that shows an increase of the [MEDICATION(S)]. There was no justification as to why physician #2 increased the medication. There was no order from the provider to check finger stick blood sugars related to the increase in the diabetic medication. On 8/4/21, during the physical therapy treatment, resident #1 became unable to speak. The nurse was notified and assessed the resident. Resident's blood pressure, pulse, and oxygen saturation were obtained by the nurse and were within normal limits. No blood sugar was obtained at this time. The Physician Assistant was on site and made aware of resident's condition. The Physician Assistant examined the resident and noted that resident was confused, incoherent, and had left facial drooping. When the provider arrived in the room, the resident was in supine position with left facial drooping, arm extended and unable to provide an accurate history. A new order was received to send resident to the emergency department STAT. No additional orders were given by the Physician Assistant to include obtaining a blood sugar. 911 was called and resident was transferred to the emergency room per provider's order. EMS arrived and obtained blood sugar at 27 and administered [MEDICATION(S)]. Resident was admitted to hospital for [CONDITION(S)] associated with Type II diabetes, Type II diabetes with other specified complications without insulin, hypertension. Medications ordered during encounter: IV [MEDICATION(S)]. Resident discharged home from the hospital after 5 day stay. On 8/15/2021 the Pharmacist reviewed all residents on diabetic medications and completed a review of the dosing. The Pharmacist reviewed any increases in diabetic medications by the physician to ensure justification was appropriate. The pharmacist will contact the director of nursing with all findings and the director of nursing will contact the physician for any necessary clarifications. The clarification orders will be obtained and/or justification documentation will be completed by the physician for any errors identified. On 8/15/2021, MDS and treatment nurse will review all diabetic residents to ensure orders are in place for fingersticks as ordered by the physician. The MDS and treatment nurse will contact the physician for any diabetic residents identified without a fingerstick order. A justification note will be documented in the clinical record by the MDS and/or treatment nurse for any diabetic resident that the physician does not want a blood sugar obtained. Orders will be written for all other diabetic residents that require blood sugars. On 8/15/2021, MDS, director of nursing and/or registered nurse facility consultants will review medication administration records from 8/1/2021 to 8/14/2021 for all diabetic residents to assure diabetic medications were administered and blood sugar checks were obtained per physician orders. The physician will be contacted, and an incident report initiated by MDS, director of nursing, and/or registered nurse facility consultants for any identified areas of concern. On 8/15/2021, MDS, director of nursing, and/or registered nurse facility consultants will review meal intake for all diabetic residents per the alert system in PCC from 8/1/21-8/14/21. This review is to identify any diabetic resident in the alert system that ate 25% or less. All identified residents will be referred to Dietary for nutritional management to include snacks between meals. Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring On 8/15/2021, an in-service was initiated with all nursing assistants, nurses, dietary, housekeeping, medical records, accounts receivable, accounts payable, maintenance, social work, receptionists, admissions, administrator and therapy regarding: 1. Signs and symptoms of [CONDITION(S)] to include but not limited to Per CDC guidelines, signs and symptoms of low blood sugars are palpitations, shaking, diaphoresis, nervous or anxiety, irritability or confusion, dizziness. 2. Monitoring meal intakes for diabetic residents through the alert system, identifying anyone eating 25% or less and to obtain blood sugars per physician orders. The nurse should check alerts on dashboard following each meal. Any resident who eats 25% or less of a meal should be assessed by the nurse to include obtaining a finger stick blood sugar per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse should ensure a snack is offered with documentation in the electronic record when residents refuse a meal or eats 25% or less. Snacks must be offered at bedtime for all residents to include diabetics. 3. Clarifying orders and/or justification when a physician has increased a diabetic medication when the hemoglobin A1C and blood sugars are normal. 4. Clarifying order for medications and blood sugar monitoring with physician if they are not clear and/or precise prior to transcribing to the MAR. 5. Obtaining blood sugars when an acute change in condition is observed on a diabetic resident and clarification orders to obtain blood sugars if a diabetic resident does not have an order. 6. Snacks are to be offered to all residents including diabetic residents. In-services will be completed by 8/15/2021. After 8/15/2021, the Administrator will ensure the remaining in-services for staff who have not worked or have not received the in-services are mailed certified mail with instructions to review, sign the in-service, and return to the staff facilitator and/or director of nursing prior to next scheduled work shift. On 8/15/2021, questionnaires were initiated by assistant director of nursing and/or staff facilitator with all nurses to validate knowledge and understanding of the diabetic management in-services with questions to include: 1. What should you do if a provider increases diabetic medication but the hemoglobin A1C and/or blood sugars are normal? 2. What is the protocol when a diabetic resident does not have an order to check fingersticks? 3. When a diabetic resident has an acute episode, what vital signs should be obtained? 4. If a diabetic medication order is not clear, what should you do? 5. What are signs and symptoms of [CONDITION(S)] to include but not limited to? Any nurse who does not correctly answer the questions, will be immediately retrained by the assistant director of nursing and/or staff facilitator. The questionnaires will be completed by 8/15/2021. Any employee who has not worked and not received the questionnaire will complete upon next scheduled shift. Date of corrective action completion Immediate Jeopardy Removal date will be. 8/16/2021 The facility's credible allegation of Immediate Jeopardy removal was validated on 8/17/21 1:20 P.M. The validation was evidenced by interviews with both licensed nursing staff and unlicensed staff about the signs and symptoms of [CONDITION(S)], monitoring meal intake, clarifying physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the pharmacy review, meal intake audit, orders in place for glucose finger sticks, and ensuring documentation on the medication administration record is accurate and effective 8/16/21.

Based on observation, staff interviews and record review, the facility failed to assess for pain and administer as needed prescribed pain medication prior to a dressing change for 1 of 3 residents (resident #1) reviewed for pain. Findings included: Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a significant change MDS dated [DATE] which indicated resident #1 had severe cognitive impairment and required extensive assistance with bed mobility, total assistance with transfers, supervision for eating and total assistance with hygiene, bathing and toileting. He was coded for scheduled pain medication with no presence of pain. The last pain assessment was completed on 4/15/14 and indicated resident #1 was not experiencing pain. According to the facility incident report and nursing note, resident #1 developed an open area to his right ankle on 4/16/14. He was scheduled to see the physician at the wound clinic on 4/23/14 at which time the wound clinic physician documented the right ankle unstagable pressure ulcer was "fairly constant 4 out of 10" for pain. The wound clinic orders indicated resident #1 was prescribed [MEDICATION NAME] which was a narcotic [MEDICATION NAME] every 4-6 hours as needed for pain on 4/23/14. An arterial Doppler ultrasound completed 4/25/14 suggested the area was an arterial ulcer. A review of the April 2014 medication administration record (MAR) revealed resident #1 had been receiving Tylenol 650mg twice daily since 3/4/14 as ordered for a pressure area to his sacrum but the [MEDICATION NAME] for pain ordered 4/23/14 did not appear on the April MAR until 4/28/14 and no doses were documented as given. A review of the May 2014 MAR revealed resident #1 received the Tylenol 650mg twice daily as ordered 3/4/14 and no doses of the [MEDICATION NAME] for pain were documented as given. In an interview on 5/12/14 at 3:30 PM, nurse #1 recalled seeing the order for [MEDICATION NAME] on the discharge paper from the wound clinic and she put the order in the physician box since he had already made rounds that day and resident #1 had not expressed any complaints of pain to her. Nurse #1 stated she would have contacted the physician and got a one time order for a narcotic in house stock until the physician could come in and write the order if resident #1 expressed pain. In an interview on 5/12/14 at 3:55 PM, the facility physician stated he did not recall seeing any order for a pain medication for resident #1. He stated he was not aware of resident #1 experiencing pain so he may not have written the order if he saw it on 4/23/14 because he felt it was a "recommendation." In an interview on 5/12/14 at 5:40 PM, nurse #2 recalled on 4/28/14, the RP approached her at her medication cart and inquired when resident #1 last had pain medication because she stated resident #1 complained of "toothache like pain" in his right foot. Nurse #2 stated she reviewed the MAR and only saw the scheduled Tylenol and an order for [REDACTED]. She informed the RP that resident #1 had not expressed any pain to her but she would follow up with the DON. She stated the DON told her to consult the physician who was currently in the facility to write an order for [REDACTED]. There was no documented pain medication administered to resident #1 on 4/28/14. In an interview on 5/13/14 at 10:20 AM, nursing assistant #1 stated resident #1 would tell the staff to be careful washing his right foot because if was so painful. NA #1 stated the nurses were aware his right foot hurt if it was manipulated. In a wound care observation on 5/13/14 at 10:45 AM, the treatment nurse along with the assistance of NA #1 changed the dressing to resident #1's right ankle. When the treatment nurse cleansed the right ankle using normal saline and gauze, resident #1 stated "that hurts." The treatment nurse did not stop rendering care but stated to resident #1 "I ' m almost done." The treatment nurse then applied [MEDICATION NAME] gel (an antimicrobial agent) and a foam dressing to the right ankle and secured the dressing with gauze and tape. She stated the treatment was ordered 3 times weekly and this treatment order started 5/7/14. Resident #1 demonstrated outward signs of pain to include labored breathing, grasping the side rail and clenched teeth. The treatment nurse stated she was unsure if resident #1 had anything ordered for pain. In an interview on 5/13/14 at 10:50 AM, the treatment nurse stated resident #1 was known to complain of pain with the dressing changes to his right ankle. She stated she looked at the MAR before the interview and saw he had an order for [REDACTED].#1 was given anything for pain. The treatment nurse stated she was uncertain if resident #1 had ever received any pain medication prior to the dressing change to his right ankle. The treatment nurse stated if a resident was experiencing pain during a treatment, they should be medicated prior to the treatment to prevent pain. She was unable to explain why she did not ensure resident #1 was medicated prior to his wound care. In a review of resident #1 weekly wound assessment completed by the treatment nurse, she documented on 4/17/14 that resident #1 experienced pain to his right ankle with touch. On 4/23/14, the wound assessment completed by the treatment nurse indicated resident #1 experienced pain at times on touch to the right ankle. The wound assessment dated [DATE] read "pain on movement and touch" to the right ankle and on 5/7/14, the treatment nurse documented pain described as "tender" on the weekly wound assessment. In an interview on 5/13/14 at 11:10 AM, the director of nursing stated her expectation was that the treatment nurse ensured any resident who expressed pain during a treatment or a dressing change should be pre-medicated 30 minutes before any care.

Based on staff and resident interviews and record review, the facility failed to process a new order for pain medication for 5 days after it was prescribed for 1 of 3 (resident #1) residents reviewed for pain. Findings included: Resident #1 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was a significant change MDS dated [DATE] which indicated resident #1 had severe cognitive impairment and required extensive assistance with bed mobility, total assistance with transfers, supervision for eating and total assistance with hygiene, bathing and toileting. He was coded for scheduled pain medication with no presence of pain. According the facility incident report and nursing note dated 4/16/14, resident #1 developed an open area to his right ankle on 4/16/14. He was scheduled to see the physician at the wound clinic on 4/23/14 at which time the wound clinic physician documented the right ankle was "fairly constant 4 out of 10" for pain. The wound clinic orders indicated resident #1 was prescribed [MEDICATION NAME], a narcotic [MEDICATION NAME] every 4-6 hours as needed for pain on 4/23/14. A review of the April 2014 medication administration record (MAR) revealed resident #1 had been receiving Tylenol 650mg twice daily since 3/4/14 as ordered for a pressure area to his sacrum but the [MEDICATION NAME] for pain ordered 4/23/14 did not appear on the April MAR until 4/28/14 and no doses were documented as given. A review of the May 2014 MAR revealed resident #1 received the Tylenol 650mg twice daily as ordered 3/4/14 and no doses of the [MEDICATION NAME] for pain were documented as given. A chart review revealed a hand written physician order [REDACTED]. In an interview on 5/12/14 at 3:30 PM, nurse #1 recalled resident #1 returning from the wound clinic via ambulance and the responsible party (RP) giving her a yellow discharge paper along with an appointment card. She recalled making 2 copies of the yellow paper, one for transport and one for the wound nurse. She put the original in the physician's box for him to write the order for the [MEDICATION NAME]. Nurse #1 stated the physician made rounds daily between 2:00 PM-300 PM. Nurse #1 stated resident #1 returned around 5:00 PM from the wound clinic so to her knowledge, the physician did not see the order for the [MEDICATION NAME] until the next day. Nurse #1 stated that if resident #1 had voiced pain, she would have contacted the physician and got a one time order for a narcotic in house stock until the physician could come in and write the order using his prescriber number. Nurse #1 stated the facility pharmacy did not accept any narcotic orders from outside providers and that the facility physician had to write the order and put his presriber number on each narcotic order before the pharmacy would fill the order. Nurse #1 stated resident #1 had never expressed any pain to her so she did not feel she needed to call the physician for an order that day. In an interview on 5/12/14 at 3:45 PM, the administrator stated he felt the issues were resolved on 4/28/14. He stated he was not aware that there was a narcotic ordered for resident #1 until 4/28/14 when the RP approached him with concerns. He stated he notified the director of nursing (DON). In an interview on 5/12/14 at 3:55 PM, the facility physician stated he did not recall seeing any order for a pain medication for resident #1. He stated he was not aware of resident #1 experiencing pain so he may not have written the order if he saw it on 4/23/14 because he felt it was a "recommendation." In an interview on 5/12/14 at 5:40 PM, nurse #2 recalled on 4/28/14, the RP approached her at her medication cart and inquired when resident #1 last had pain medication because she stated resident #1 complained of "toothache like pain" in his right foot. Nurse #2 stated she reviewed the MAR and only saw the scheduled Tylenol and an order for [REDACTED]. She informed the RP that resident #1 had not expressed any pain to her but she would follow up with the DON. She stated the DON told her to consult the physician who was currently in the facility to write an order for [REDACTED]. In an interview on 5/12/14 at 6:00 PM, the DON stated the expectation was for the nurse to follow up immediately with the facility physician on any orders written by any outside providers and not just put in his box for him to address on his next facility visit.

Based on record review, staff interviews, and physician interview, the facility failed to prevent a significant medication error for 1 of 3 sampled residents receiving [MEDICATION NAME], an anti-neoplastic agent, for the treatment of [REDACTED]. The resident was given [MEDICATION NAME] daily instead of weekly as ordered. The resident was sent to the emergency room for evaluation on [DATE]. She was determined to have [MEDICATION NAME] toxicity and was admitted to the intensive care unit of the hospital. The resident expired on [DATE] at 1:00AM. The Immediate Jeopardy began on [DATE] at 10AM. The facility was informed of the Immediate Jeopardy on [DATE] at 5:55PM. Immediate Jeopardy was removed on [DATE] at 5:59PM, after the facility provided a credible allegation of compliance. The facility remained out of compliance at a scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete employee training and to monitor its corrective action. Findings include: The facility policy, titled Medication Administration, undated, read in part "any deviation from the following principles shall be considered a medication error: 1. To the right resident 2. Administration of the right medication 3. In the right dose 4. By the right route 5. By the right method 6. At the right time." Resident #170 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the resident's minimum data set ((MDS) dated [DATE] revealed she was cognitively intact. The MDS revealed the resident had no signs or symptoms of a swallowing disorder. Record review of laboratory results dated [DATE] revealed a complete blood count (CBC) with hemoglobin (Hg) 13 g/dl (grams/deciliter) (normal ,[DATE] g/dL), hematocrit 38.7% (normal ,[DATE]%), and platelets 125 K/uL (thousand/microliter) (normal ,[DATE] K/uL). Results of a basic metabolic panel dated [DATE] revealed blood urea nitrogen (BUN) 92 mg/dL (milligram/deciliter) (normal ,[DATE] mg/dL), creatinine 2.43 mg/dL (normal 0XXX,[DATE].10 mg/dL), and estimated glomerular filtration rate (GFR) of 19 ml/min (milliliter/minute) (normal > 60 ml/min). BUN, creatinine, and GFR are indicators of renal function. Record review of the rheumatologist's progress notes dated [DATE] revealed a [DIAGNOSES REDACTED]." Review of the resident's clinical record revealed physician orders [REDACTED]. [MEDICATION NAME] is an anti-neoplastic agent indicated for the treatment of [REDACTED]. The manufacturer's product information for [MEDICATION NAME] read in part: "Warnings - Deaths have been reported with the use of [MEDICATION NAME] in the treatment of [REDACTED]. Such patients require especially careful monitoring for toxicity. Potentially fatal opportunistic infections may occur with [MEDICATION NAME] therapy. Precautions - [MEDICATION NAME] has the potential for serious toxicity. Toxic effects may be related in frequency and severity to dose or frequency of administration but have been seen at all doses. The clinical pharmacology of [MEDICATION NAME] has not been well studied in older individuals. Due to diminished hepatic and renal function, relatively low doses should be considered, and these patients should be closely monitored for early signs of toxicity. Geriatric use - post-marketing experience suggests that the occurrence of bone marrow suppression, [MEDICAL CONDITION], and pneumonitis may increase with age. Renal - [MEDICATION NAME] may cause renal damage that may lead to acute [MEDICAL CONDITION]. Overdosage - symptoms commonly reported following oral overdose include those symptoms and signs reported at pharmacologic doses, particularly hematologic and gastrointestinal reactions. For example, [DIAGNOSES REDACTED] (low white blood cells), [MEDICAL CONDITIONS], pancytopenia (low white blood cells, red blood cells, and platelets), bone marrow suppression, mucositis, stomatitis, oral ulceration, nausea, vomiting, and [MEDICAL CONDITION]. There have been reports of death following overdose. In these cases, events such [MEDICAL CONDITION] or septic shock, [MEDICAL CONDITION], and [MEDICAL CONDITIONS] were also reported." Review of the resident's September medication administration record (MAR) revealed a handwritten entry dated [DATE] for [MEDICATION NAME] 2.5mg 4 tablets by mouth every 7 days. Review of the MAR revealed 4 tablets of [MEDICATION NAME] were given on Wednesday [DATE] and Wednesday [DATE] at 10AM. Review of the provider pharmacy's delivery sheet revealed 16 [MEDICATION NAME] 2.5mg tablets were delivered to the facility for resident #170 on [DATE]. The resident' October MAR read "[MEDICATION NAME] tab 2.5mg 4=10 mg by mouth every 7 days ***Note Dose and Frequency!!***" There was no blocking or other marking on the MAR that noted the weekly administration times. The medication was due to be given on Wednesday [DATE] and Wednesday [DATE]. Review of the MAR revealed [MEDICATION NAME] was given at 10AM `on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], as indicated by the med aides' and nurse's initials. The entry for [DATE] was initialed and marked through with an "X" with no explanation on the back of the MAR. Entries for [DATE] and [DATE] were blank with no explanations on the back of the MAR. The entry for [DATE] was initialed and circled, indicating the medication was not given. Review of the October MAR revealed the 8PM doses of [MEDICATION NAME] (antihypertensive) and [MEDICATION NAME] (anti-arrhythmic) were held on [DATE], [DATE], and [DATE] due to low blood pressure. Review of nursing notes dated [DATE] at 9:49AM revealed the resident refused her scheduled medications due to swallowing issues. Her [MEDICATION NAME] and [MEDICATION NAME] were held due to low blood pressure. The nurse assessed the resident and called the physician. The physician ordered [MEDICATION NAME] and [MEDICATION NAME] oral suspension (antifungal agents). Review of nursing notes dated [DATE] at 7:26AM revealed the resident complained of sore mouth and throat. She refused all morning meds except one-half of a [MEDICATION NAME] ,[DATE] (narcotic [MEDICATION NAME]). Review of nursing notes dated [DATE] at 4:41PM revealed the resident was found with dried frank red blood to her lips with complaints of pain. The dried blood was cleansed away which revealed several open areas to the bottom lip. Pressure was applied to stop the bleeding and a lip moisturizer was applied. Record review revealed physician orders [REDACTED]. The physician added [MEDICATION NAME] (narcotic [MEDICATION NAME]) for the resident's ulcerative stomatitis, held her [MEDICATION NAME] (corticosteroid) and [MEDICATION NAME] (arthritis medication), and started ? normal saline solution intravenously (IV) at 70 ml/hr (milliliter/hour). Record review revealed an Incident Report dated [DATE] at 9:30AM for resident #170. The report read "resident has order for [MEDICATION NAME] 10mg every 7 days, on MAR signed for every day for 7 days. Predisposing factors - staff related. MD notified." Record review revealed physician orders [REDACTED]. When the staff was unable to obtain an adequate blood sample for the labs, the physician sent the resident to the emergency room for evaluation. Nursing notes dated [DATE] at 10:20AM revealed the resident was sent to the emergency room with [MEDICAL CONDITION] and bleeding mouth sores. Record review of the hospital emergency room (ER) record revealed the resident presented with [MEDICAL CONDITION] and altered mental status. The physician noted some dried blood on her lips and was told she was being treated for [REDACTED]. The physician note read "she seems to understand my questions and will nod her head yes or no to appropriate questions. When she initially arrives, as mentioned, seems to be alert certainly to her name and to where she is, i.e. the hospital." When the physician asked if she hurt, the resident said "my mouth hurts." The physical examination in the ER revealed pulse of 70, respirations 16, blood pressure initially ,[DATE], temperature 95.4, and oxygen saturation of 90% on nasal cannula. A cardiac monitor, urinary catheter, occult blood test, and laboratory monitoring were ordered. Hematology results revealed a white blood count (WBC) of 2.1 K/mm3 (thousand/cubic millimeter) (normal 4.5 - 13.5 M/mm3), Hg 7.5 g/dL (normal ,[DATE] g/dL), hematocrit 22.8% (normal ,[DATE]%), and platelet count of 11 K/uL (normal ,[DATE] K/uL). Chemistry results revealed a BUN of 120mg/dL (normal ,[DATE] mg/dL), creatinine 2.5 mg/dL (normal 0XXX,[DATE].10 mg/dL), and GFR of 20 ml/min (normal > 60 ml/min). A stool hemoccult, a test for gastro-intestinal (GI) bleeding, was positive. The resident received two units of IV fluids and her blood pressure dropped. She received two units of blood and her blood pressure stabilized. She was admitted to the Intensive Care Unit for [MEDICAL CONDITION] and [MEDICAL CONDITION]. The ER report read "I think that she has a very poor prognosis and death would not be surprising based on the poor presentation here in the Emergency Department." Record review revealed the resident was admitted to the Intensive Care Unit on [DATE] at 5PM. Orders included laboratory monitoring, oxygen, chest X-ray, blood cultures, urinalysis, IV fluids, and medications including folate, [MEDICATION NAME] (supplements), solu-[MEDICATION NAME] (corticosteroid), [MEDICATION NAME] (anti-[MEDICAL CONDITION]), [MEDICATION NAME] (GI bleeding, reflux), [MEDICATION NAME] (narcotic [MEDICATION NAME]), and [MEDICATION NAME] (antibiotic). Blood cultures were positive for pseudomonas aeruginosa (bacterial infection). The Summary of Hospital Course revealed physician notes which read in part "patient is profoundly cachectic, chronically ill appearing white female who presented from the nursing home with [MEDICAL CONDITION] and decreased level of consciousness with evidence of mouth pain and dried blood on her lips. She complains of severe mouth pain. Shortly after arrival she became progressively hypotensive and unresponsive...She was noted to be markedly anemic, [MEDICAL CONDITION], and neutropenic (low white blood cells)." An addendum dated [DATE] read "patient medical list was reviewed and currently is apparently taking [MEDICATION NAME] on a daily basis as well as [MEDICATION NAME]. Not on folic acid. Indication for therapy unclear at this point. Will administer IV folate and followup level. Certainly may be contributing to the mucositis and severe pancytopenia present on admission." The Assessment/Plan read in part "acute [MEDICAL CONDITIONS]/sepsis - blood pressure low. Leukopenic (low white blood cells). Etiology [MEDICAL CONDITION] unclear at [MEDICAL CONDITION] - question if related to medication effect...oral [MEDICAL CONDITION]/sores, metabolic acidosis, [MEDICAL CONDITION], cachexia, chronic [MEDICAL CONDITION], deconditioning." The hospital Death Summary read "Preliminary Cause of Death:[MEDICAL CONDITION] syndrome secondary to leukopenia/pancytopenia secondary to [MEDICATION NAME]." The Final [DIAGNOSES REDACTED]." The resident expired on [DATE] at 1:00AM. In an interview on [DATE] at 3:16PM, medication aide #1 stated the procedure for giving oral medications was to first check the MAR, check the medication in the cart, remove the medication from the cart, then double check the medication against the MAR to be sure the right medication and dose were given. After the medication was given, she initialed the entry on the MAR. If a medication was not given for any reason, she initialed the MAR, and circled her initials. For medications ordered weekly, a square box was made around the day on the MAR that the medication was due or the days it was not given were "X'd" out. The med aide reviewed the [MEDICATION NAME] order on resident 170's MAR. She acknowledged she had initialed it as given on [DATE] but stated "I don't remember if I gave it or not." Her initials were circled on [DATE] indicating the medication was not given. She had noticed the [MEDICATION NAME] was not supposed to be given but every seven days and reported it to the nurse. She also reported the resident's complaint of mouth pain at that time. In an interview on [DATE] at 3:43PM, nurse #1 stated the procedure for giving medication was to check the order on the MAR, check the medication label versus the MAR, pour and give the medication, and then sign the MAR. For medication ordered weekly, the MAR was marked with a square box on the day it was due and X'd out the other days. The nurse that took the original order was responsible for marking the current MAR. Two nurses checked the new MARS for accuracy before the first of the month and were responsible for marking the boxes and X's for medications not given daily. Nurse #1 reviewed the [MEDICATION NAME] order on resident 170's MAR. The nurse acknowledged she had initialed it on [DATE] but then crossed it out. She had also worked on [DATE] and left the entry for [MEDICATION NAME] blank. The nurse stated there was no [MEDICATION NAME] in the cart and she did not give it. The nurse stated she should have circled her initials and indicated a reason on the back of the MAR. She did not realize the [MEDICATION NAME] was ordered only every seven days. She did not report the resident was out of medication or call the pharmacy. The nurse stated she knew [MEDICATION NAME] was given for arthritis but was not aware that it was usually given only once weekly. In an interview on [DATE] at 4:07PM, medication aide #2 stated when she gave medications, she checked the MAR for accuracy, then checked the drug label, and then checked the drug label against the MAR again. For medications not ordered daily, the MAR was marked with an X on the days it was not given and marked with a box on the day it was given. The nurse was responsible for marking the appropriate days on the MAR. The nurses also checked the new MARS twice against the old MARS and new orders. The med aide reviewed the [MEDICATION NAME] order on resident 170's MAR and acknowledged she had given it on [DATE], [DATE], and [DATE]. She stated "it was an oversight." In an interview on [DATE] at 4:29PM, medication aide #3 stated she was trained to read the MAR, check the dose, route, and patient name versus the medication label. She removed the medication from the cart and checked it again versus the MAR before administering the medication. For medication not ordered daily, the MARS were usually X'd out on the days it was not given. The nurses marked the X's on the MARS and also checked them monthly for accuracy. The med aide reviewed the [MEDICATION NAME] order on resident 170's MAR and acknowledged she had given it on [DATE] and [DATE]. The med aide offered no explanation why she gave it daily. In a telephone interview on [DATE] at 5:15PM, the attending physician stated the resident was referred to a rheumatologist due to her severe [MEDICAL CONDITION] arthritis. The rheumatologist ordered [MEDICATION NAME] once weekly. The physician stated he observed one sore on the resident's lateral tongue on [DATE]. When he assessed her two days later, her whole mouth was affected and he sent her to the emergency room for evaluation. The physician stated the facility had notified him of the medication error. The resident was supposed to get [MEDICATION NAME] once weekly but he was unsure how much she had actually received. An interview was conducted on [DATE] at 10:11AM with one of the nurses (nurse #2) responsible for checking resident 170's October MAR. Nurse #2 stated the new MARS came to the facility on the 21st of each month. Two nurses checked for new orders daily and added them to the new MARS. The MARS were checked again on the last day of the month to ensure all new orders had been added and the MARS were correct. For unusual dosages such as weekly administration, the MARS were X' out on the days the medication was not to be given. The nurse stated she checked the resident's October MAR to be sure it was correct but did not mark or X out the days [MEDICATION NAME] was not to be given. She stated the nurse giving the medication was responsible for marking the MAR. In an interview on [DATE] at 11:44AM, nurse #3 stated a nursing assistant had asked her to look at resident #170 on [DATE]. The resident complained of mouth pain and had blood on her lower lip. The nurse applied a cool washcloth to the resident's lip. The physician was notified, the [MEDICATION NAME] was held, and an IV fluid was started. On [DATE], nurse #3 noted documentation that the resident hadn't been eating or drinking well. She thought it could be due to the medication. She checked the resident's MAR and discovered that the [MEDICATION NAME] was signed as given daily instead of weekly. The nurse checked the resident ' s vital signs and called the physician. The physician ordered stat labs and then sent the resident to the hospital. Nurse #3 stated the MARS and physicians' orders were checked at the end of the month to be sure they matched. For medication ordered weekly, the nurse doing the first MAR check was supposed to mark the next month's MAR with a box on the days the medication was to be given. The nurse was supposed to X out or draw a line through the other days on the MAR. In an interview on [DATE] at 4:33PM, the Director of Nursing (DON) stated the staff was trained to thoroughly read the MARS and confirm the accurate medication, dose, time, and route. The DON stated two nurses checked the MAR for accuracy at the end of the month. For weekly medications, the nurses marked the MARS with an X or drew a line through the days it was not to be given. The nurses that checked the new MARS at the end of the month were responsible for marking them. If a new order was started after the first of the month, the nurse taking the order was responsible for marking the MAR. The DON stated she expected the staff to observe the five rights of medication administration. She expected them to check the MAR versus the label and the medication. If staff was unfamiliar with the indication, dosage, or side effects of a medication, she expected them to research the information from one of the available references, or ask other nursing staff and/or the pharmacy. Her expectation was for the nurses that checked the monthly MARS to mark them to ensure that medications ordered less than daily were given correctly. The DON stated she considered the daily administration of [MEDICATION NAME] for resident #170 to be a significant medication error. In a telephone interview on [DATE] at 4:05PM, the physician that treated resident 170 in the ICU stated she had multiple contributing factors, including her age, chronic diseases, and debility. The physician stated the [MEDICATION NAME] may have contributed to the resident's pancytopenia. He stated adverse reactions to [MEDICATION NAME] were possible at usual doses and it would take days for the medication to clear after it was stopped. The physician stated he wasn't sure the amount of [MEDICATION NAME] the resident received would be considered an overdose but that it certainly contributed to her condition and death. The Administrator was notified of the Immediate Jeopardy on [DATE] at 5:55PM. The facility provided a credible allegation of compliance on [DATE] at 4:30PM. The allegation of compliance indicated: On [DATE] Resident # 6758 received an order for [REDACTED]. Resident #6758 was administered [MEDICATION NAME] per physician's order [REDACTED]. Resident #6758 was assessed by the licensed Nurse on [DATE] and was noted to have a blood pressure of ,[DATE] and difficulty swallowing in which all 8pm blood pressure medications were held and the MD was notified in person of Resident's change in condition by the licensed Nurse. On [DATE] the MD assessed the Resident and wrote an order for [REDACTED]. Resident #6758 was reassessed on [DATE] by the licensed Nurse and complained of sore mouth and sore throat, ? [MEDICATION NAME] ,[DATE] was administered by the license Nurse. On [DATE] Resident # 6758 lips were assessed by the licensed Nurse and the MD, new orders were received to hold [MEDICATION NAME] and [MEDICATION NAME], hold/stop [MEDICATION NAME] 25mcg patch change Q 72 hours, and IV ? normal saline @ 70 cc per hour. On [DATE] resident #6758 blood pressure, mouth, and mental status was assessed by the licensed Nurse and the MD and the RP was notified of Resident ' s change in condition, new order was received to send to ER for evaluation. On [DATE] at 1023 am Resident was sent to the ER for evaluation. The Director of Nursing was informed the morning of [DATE] the resident was deceased . All staff involved were drug tested [DATE]. All results came back negative. The nurse was re-educated, drug tested and suspended on [DATE] and remains suspended at this time. The medication aides were re-educated. The facility has suspended use of medication aides. All medication aides are working as certified nursing assistants giving direct patient care. All other Residents prescribed [MEDICATION NAME] initial orders were reviewed by the Director of Nursing for accuracy of transcription on to the MAR, blocking of the MAR for every seven day administration and to ensure the accuracy of the next scheduled dose of the medication on [DATE]. There were no doses scheduled to be given at the time of the audit. Noted issues were corrected as identified on [DATE]. Physical Assessments were completed on Residents on [MEDICATION NAME] by licensed nurses and labs obtained by [DATE]. The determination was made by the Director of Nursing after review of the medication administration record (MAR) that the orders were transcribed correctly to the MAR. The medication error was the direct result of the licensed/certified staff not following the six rights of medication administration (right resident, right medication, right dose, right route, right method, right time) resulting in the medication being administered incorrectly. The medication administration record not being blocked off for medication to be given every seven days was a contributing factor to the medication error. The dispensing pharmacy has identified the following medications as being at high risk for medication errors and has taken steps in the dispensing and labeling process to minimize administration error potential: 1. [MEDICATION NAME]- Effective [DATE] the following changes for dispensing [MEDICATION NAME] will be implemented. Beginning with the medication delivery on [DATE]: -Package all [MEDICATION NAME] orders in bingo packaging each time the drug is dispensed from the pharmacy -Send only one week supply each time the drug is dispensed from the pharmacy. -In addition to cautionary wording, **NOTE DOSE AND FREQUENCY!!!*** in sig (directions), place a stop sign shaped caution auxiliary label on the packaging that reads "HIGH ALERT CAUTION" -Move [MEDICATION NAME] to high risk station in pharmacy -Have Registered Pharmacist double check final product in addition to initial review each time the drug is dispensed from the pharmacy. 2. Concentrated liquid [MEDICATION NAME] and [MEDICATION NAME]: 1) A "stop-sign shaped" red auxiliary label that reads "High Alert. Double-Check" affixed to each bottle dispensed to a resident or for the emergency drug kit 2) A mini-monograph with conversion grid dispensed with each bottle. This handout is printed on bright pink/red paper. 3) The following statement is added to each concentrated [MEDICATION NAME] and [MEDICATION NAME] prescription label and MAR, "Double-check dose. Use calibrated syringe." 4) Calibrated oral dosing syringe is dispensed bottle. 3. For [MEDICATION NAME] products exclamation points are placed before the medication name on the MAR/product label 4. "Tall Man" letters are used for sound alike and look alike drug names on the MAR/product label (per the ISMP - institute for safe medication practice - suggested list). [MEDICATION NAME], for the Residents continuing to receive the medication have been returned to the pharmacy upon receipt of the [DATE] delivery. Validating of [MEDICATION NAME] doses occurred by 2 licensed Nurses prior to Administration until new packaging was available. Signage to alert staff of Residents receiving [MEDICATION NAME] and the need to verify dose with a second Nurse was inserted in the Resident's Medication Record. The new packaging arrived in the facility on [DATE]. Medications in the old packaging have been returned to the pharmacy. As a precautionary measure on [DATE] the facility temporarily suspended the use of Medication Aides pending medication administration retraining and a medication pass audit by the Pharmacy Consultant or an Administrative Nurse. The retraining of certified medication aides will include, but will not be limited to: ? the six rights of medication administration ? the importance of reading and understanding medication labels and orders ? being aware of special instructions/alerts on packaging and MARs to include those for medications with unusual dosing schedules or those that could be potentially toxic, for example *****!!!!!!! or a stop sign. ? infection control All Medication Administration Records were audited by licensed Nurses to include the Supervisors with oversight by the Director of Nursing on [DATE] to ensure medications that were ordered less than daily were blocked off on the MAR and are being administered as ordered. Noted issues were corrected as identified. Verification of corrections was completed on [DATE]. In-services were started by the Staff Facilitator, RN on [DATE] for all licensed Nurses and Medication Aides on the six rights of medication administration, blocking the MAR for medications given less than daily by the nurse that takes off the telephone order to the MAR or by the nurses co-signing the monthly orders, notification of MD and RP of significant change in condition. Staff will be in-serviced prior to beginning their shift, to include staff on vacation and those that only work weekends by an Administrative Nurse. In-service was started on [DATE] by Staff Facilitator for licensed nurses and Medication Aides on signs and symptoms of [MEDICATION NAME] Toxicity. Staff will be in-serviced prior to beginning their shift, to include staff on vacation and those that only work weekends. Nurses hired after [DATE] will be in-serviced during their orientation process by the Staff Facilitator related to the Six Rights of Medication Administration, Blocking the MAR for Medications given less than daily, Notification of MD and RP of significant change in condition and the Signs and Symptoms of [MEDICATION NAME] toxicity. In-service was started on [DATE] by the Staff Facilitator for the certified Nursing Assistants on change in Resident conditions that need to be reported to the Nurse. Staff will be in-serviced prior to beginning their shift, to include staff on vacation and those that only work weekends. Nursing Assistants hired after [DATE] will be in-serviced during their orientation process by the Staff Facilitator related to the Changes in Resident conditions that need to be reported to the Nurse. An Interview Tool has been developed related to in-servicing material covered with Nurses and Medication Aides related to the Six Rights of Medication Administration, Blocking the MAR for Medications given less than daily, Notification of MD and RP of significant change in condition and the Signs and Symptoms of [MEDICATION NAME] toxicity. Implementation of the interview tool will occur on [DATE]. All nurses will be interviewed by an Administrative Nurse prior to the beginning of their scheduled shift. The Staff Facilitator or Administrative nurse will use the interview tool on one nurse per shift for 4 weeks, then one nurse daily for 4 weeks. Results of interviews will be reviewed weekly by the Quality Improvement Committee. On [DATE] a review of all current MARs was initiated by licensed nurses to include MDS Nurses, QI Nurse, Treatment Nurses and ADON with assistance and oversight by Director of Nursing to include comparison of October MAR to the September MAR and telephone orders to ensure medications are being administered as ordered. Medication used less than daily were reviewed to ensure the MAR was blocked off. Issues were corrected as identified during the review by the licensed Nurse. Corrections were completed on [DATE]. Beginning [DATE] the licensed Nurses reviewed nurse notes on all Residents from [DATE] to [DATE] ensure there are no acute issues that have not been addressed. A general assessment was completed on each Resident by a licensed Nurse to ensure Residents did not have a change in condition that warranted the notification of the MD and/or RP. Identified issues were addressed as indicated by the licensed Nurse. On [DATE] Medication Administration audits were started for all licensed Nurses and were completed by [DATE]. The medication audits consist of the use of a Medication Pass Audit Form developed by the pharmacy which consists of observation of multiple medications and requiring a less than 5% error rate to pass. Concerns were addressed by the auditing Nurse at the time of the observation. Nurses with a Med Pass error rate of 5% or greater received a second Med Pass Audit by an Administrative Nurse. Nurses hired after [DATE] will receive a Med Pass audit within 2 weeks of completion of the Orientation process. The Med Pass audit will be completed by an Administrative Nurse. Beginning [DATE], all telephone orders will be reviewed by the Administrative Nurse to ensure accurate transcription and blocking of the MARS for medications given less than daily on the medication administration record using copies of the telephone orders daily x 14 days, 3 x weekly x 6 weeks and then as determined necessary by the QI team. Beginning [DATE] MARs will be reviewed by the Administrative Nurse using a current census to ensure medications that ware given less than daily are blocked off on the MAR and are being administered as ordered daily x 14 days, 3 x weekly 6 weeks and then as determined necessary by the QI team Beginning [DATE] the MARs of residents taking [MEDICATION NAME] will be reviewed by the Administrative Nurses using a current census to ensure accurate administration of the medication daily x 14 days, 3 x weekly x 6 weeks and then as determined necessary by the QI team. Beginning with the November MAR, the MAR change over will incorporate a third check by two licensed Nurses on the first day of the month to ensure accuracy of the November MAR and to ensure all medications given less than daily have been blocked off on the MAR. MARs will continue to be signed off by two Nurses, the first Nurse will do the initial check when MARs arrive and the second check will be on the last day of the month prior to change over. Two licensed Nurses will audit 100% of MARs monthly x 3 months by performing a check of the hard copy MAR from the previous month and comparing it to the hard copy MAR for the current month and also incorporating the telephone orders in the third check. The two Nurses completing the third check will sign off on each hard copy and use a current census as the audit tool to show completion of the audit. Audit will be completed by the end of the first day of the new month. Results of the audit will be reviewed and addressed weekly by the Director of Nursing or the designee. The results will be compiled and forwarded

Based on record review and staff interviews, the facility failed to ensure residents were free from an excessive dosage of [MEDICATION NAME], an anti-neoplastic agent, for 1 of 3 sampled residents receiving [MEDICATION NAME] for the treatment of [REDACTED]. The resident was sent to the emergency room for evaluation on [DATE]. She was determined to have [MEDICATION NAME] toxicity and was admitted to the intensive care unit of the hospital. The resident expired on [DATE] at 1:00AM. The Immediate Jeopardy began on [DATE] at 10AM. The facility was informed of the Immediate Jeopardy on [DATE] at 5:55PM. Immediate Jeopardy was removed on [DATE] at 5:59PM, after the facility provided a credible allegation of compliance. The facility remained out of compliance at a scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) for the facility to complete employee training and to monitor its corrective action. Findings include: Resident #170 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the resident's minimum data set ((MDS) dated [DATE] revealed she was cognitively intact. The MDS revealed the resident had no signs or symptoms of a swallowing disorder. Record review of laboratory results dated [DATE] revealed a complete blood count (CBC) with hemoglobin (Hg) 13 g/dl (grams/deciliter) (normal ,[DATE] g/dL), hematocrit 38.7% (normal ,[DATE]%), and platelets 125 K/uL (thousand/microliter) (normal ,[DATE] K/uL). Results of a basic metabolic panel dated [DATE] revealed blood urea nitrogen (BUN) 92 mg/dL (milligram/deciliter) (normal ,[DATE] mg/dL), creatinine 2.43 mg/dL (normal 0XXX,[DATE].10 mg/dL), and estimated glomerular filtration rate (GFR) of 19 ml/min (milliliter/minute) (normal > 60 ml/min). BUN, creatinine, and GFR are indicators of renal function. Record review of the rheumatologist's progress notes dated [DATE] revealed a [DIAGNOSES REDACTED]." Review of the resident's clinical record revealed physician orders [REDACTED]. [MEDICATION NAME] is an anti-neoplastic agent indicated for the treatment of [REDACTED]. The manufacturer's product information for [MEDICATION NAME] read in part: "Warnings - Deaths have been reported with the use of [MEDICATION NAME] in the treatment of [REDACTED]. Such patients require especially careful monitoring for toxicity. Potentially fatal opportunistic infections may occur with [MEDICATION NAME] therapy. Precautions - [MEDICATION NAME] has the potential for serious toxicity. Toxic effects may be related in frequency and severity to dose or frequency of administration but have been seen at all doses. The clinical pharmacology of [MEDICATION NAME] has not been well studied in older individuals. Due to diminished hepatic and renal function, relatively low doses should be considered, and these patients should be closely monitored for early signs of toxicity. Geriatric use - post-marketing experience suggests that the occurrence of bone marrow suppression, [MEDICAL CONDITION], and pneumonitis may increase with age. Renal - [MEDICATION NAME] may cause renal damage that may lead to acute [MEDICAL CONDITION]. Overdosage - symptoms commonly reported following oral overdose include those symptoms and signs reported at pharmacologic doses, particularly hematologic and gastrointestinal reactions. For example, [DIAGNOSES REDACTED] (low white blood cells), [MEDICAL CONDITIONS], pancytopenia (low white blood cells, red blood cells, and platelets), bone marrow suppression, mucositis, stomatitis, oral ulceration, nausea, vomiting, and [MEDICAL CONDITION]. There have been reports of death following overdose. In these cases, events such [MEDICAL CONDITION] or septic shock, [MEDICAL CONDITION], and [MEDICAL CONDITIONS] were also reported." Review of the resident's September medication administration record (MAR) revealed a handwritten entry dated [DATE] for [MEDICATION NAME] 2.5mg 4 tablets by mouth every 7 days. Review of the MAR revealed 4 tablets of [MEDICATION NAME] were given on Wednesday [DATE] and Wednesday [DATE] at 10AM. Review of the provider pharmacy's delivery sheet revealed 16 [MEDICATION NAME] 2.5mg tablets were delivered to the facility for resident #170 on [DATE]. The resident's October MAR read "[MEDICATION NAME] tab 2.5mg 4=10 mg by mouth every 7 days ***Note Dose and Frequency!!***" There was no blocking or other marking on the MAR that noted the weekly administration times. The medication was due to be given on Wednesday [DATE] and Wednesday [DATE]. Review of the MAR revealed [MEDICATION NAME] was given at 10AM `on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], as indicated by the med aides' and nurse's initials. The entry for [DATE] was initialed and marked through with an "X" with no explanation on the back of the MAR. Entries for [DATE] and [DATE] were blank with no explanations on the back of the MAR. The entry for [DATE] was initialed and circled, indicating the medication was not given. Review of the October MAR revealed the 8PM doses of [MEDICATION NAME] (antihypertensive) and [MEDICATION NAME] (anti-arrhythmic) were held on [DATE], [DATE], and [DATE] due to low blood pressure. Review of nursing notes dated [DATE] at 9:49AM revealed the resident refused her scheduled medications due to swallowing issues. Her [MEDICATION NAME] and [MEDICATION NAME] were held due to low blood pressure. The nurse assessed the resident and called the physician. The physician ordered [MEDICATION NAME] and [MEDICATION NAME] oral suspension (antifungal agents). Review of nursing notes dated [DATE] at 7:26AM revealed the resident complained of sore mouth and throat. She refused all morning meds except one-half of a [MEDICATION NAME] ,[DATE] (narcotic [MEDICATION NAME]). Review of nursing notes dated [DATE] at 4:41PM revealed the resident was found with dried frank red blood to her lips with complaints of pain. The dried blood was cleansed away which revealed several open areas to the bottom lip. Pressure was applied to stop the bleeding and a lip moisturizer was applied. Record review revealed physician orders [REDACTED]. The physician added [MEDICATION NAME] (narcotic [MEDICATION NAME]) for the resident's ulcerative stomatitis, held her [MEDICATION NAME] (corticosteroid) and [MEDICATION NAME] (arthritis medication), and started ? normal saline solution intravenously (IV) at 70 ml/hr (milliliter/hour). Record review revealed an Incident Report dated [DATE] at 9:30AM for resident #170. The report read "resident has order for [MEDICATION NAME] 10mg every 7 days, on MAR signed for every day for 7 days. Predisposing factors - staff related. MD notified." Record review revealed physician orders [REDACTED]. When the staff was unable to obtain an adequate blood sample for the labs, the physician sent the resident to the emergency room for evaluation. Nursing notes dated [DATE] at 10:20AM revealed the resident was sent to the emergency room with [MEDICAL CONDITION] and bleeding mouth sores. Record review of the hospital emergency room (ER) record revealed the resident presented with [MEDICAL CONDITION] and altered mental status. The physician noted some dried blood on her lips and was told she was being treated for [REDACTED]. The physician note read "she seems to understand my questions and will nod her head yes or no to appropriate questions. When she initially arrives, as mentioned, seems to be alert certainly to her name and to where she is, i.e. the hospital." When the physician asked if she hurt, the resident said "my mouth hurts." The physical examination in the ER revealed pulse of 70, respirations 16, blood pressure initially ,[DATE], temperature 95.4, and oxygen saturation of 90% on nasal cannula. A cardiac monitor, urinary catheter, occult blood test, and laboratory monitoring were ordered. Hematology results revealed a white blood count (WBC) of 2.1 K/mm3 (thousand/cubic millimeter) (normal 4.5 - 13.5 M/mm3), Hg 7.5 g/dL (normal ,[DATE] g/dL), hematocrit 22.8% (normal ,[DATE]%), and platelet count of 11 K/uL (normal ,[DATE] K/uL). Chemistry results revealed a BUN of 120mg/dL (normal ,[DATE] mg/dL), creatinine 2.5 mg/dL (normal 0XXX,[DATE].10 mg/dL), and GFR of 20 ml/min (normal > 60ml/min). A stool hemoccult, a test for gastro-intestinal (GI) bleeding, was positive. The resident received two units of IV fluids and her blood pressure dropped. She received two units of blood and her blood pressure stabilized. She was admitted to the Intensive Care Unit for [MEDICAL CONDITION] and [MEDICAL CONDITION]. The ER report read "I think that she has a very poor prognosis and death would not be surprising based on the poor presentation here in the Emergency Department." Record review revealed the resident was admitted to the Intensive Care Unit (ICU) on [DATE] at 5PM. Orders included laboratory monitoring, oxygen, chest X-ray, blood cultures, urinalysis, IV fluids, and medications including folate, [MEDICATION NAME] (supplements), solu-[MEDICATION NAME] (corticosteroid), [MEDICATION NAME] (anti-[MEDICAL CONDITION]), [MEDICATION NAME] (GI bleeding, reflux), [MEDICATION NAME] (narcotic [MEDICATION NAME]), and [MEDICATION NAME] (antibiotic). Blood cultures were positive for pseudomonas aeruginosa (bacterial infection). The Summary of Hospital Course revealed physician notes which read in part "patient is profoundly cachectic, chronically ill appearing white female who presented from the nursing home with [MEDICAL CONDITION] and decreased level of consciousness with evidence of mouth pain and dried blood on her lips. She complains of severe mouth pain. Shortly after arrival she became progressively hypotensive and unresponsive...She was noted to be markedly anemic, [MEDICAL CONDITION], and neutropenic (low white blood cells)." An addendum dated [DATE] read "patient medical list was reviewed and currently is apparently taking [MEDICATION NAME] on a daily basis as well as [MEDICATION NAME]. Not on folic acid. Indication for therapy unclear at this point. Will administer IV folate and followup level. Certainly may be contributing to the mucositis and severe pancytopenia present on admission." The Assessment/Plan read in part "acute [MEDICAL CONDITIONS]/sepsis - blood pressure low. Leukopenic. Etiology [MEDICAL CONDITION] unclear at present [MEDICAL CONDITION] - question if related to medication effect...oral [MEDICAL CONDITION]/sores, metabolic acidosis, [MEDICAL CONDITION], cachexia, chronic [MEDICAL CONDITION], deconditioning." The hospital Death Summary read "Preliminary Cause of Death:[MEDICAL CONDITION] syndrome secondary to leukopenia/pancytopenia secondary to [MEDICATION NAME]." The Final [DIAGNOSES REDACTED]." The resident expired on [DATE] at 1:00AM. In an interview on [DATE] at 3:16PM, medication aide #1 stated the procedure for giving oral medications was to first check the MAR, check the medication in the cart, remove the medication from the cart, then double check the medication against the MAR to be sure the right medication and dose were given. After the medication was given, she initialed the entry on the MAR. If a medication was not given for any reason, she initialed the MAR, and circled her initials. For medications ordered weekly, a square box was made around the day on the MAR that the medication was due or the days it was not given were "X'd" out. The med aide reviewed the [MEDICATION NAME] order on resident 170's MAR. She acknowledged she had initialed it as given on [DATE] but stated "I don' remember if I gave it or not." Her initials were circled on [DATE] indicating the medication was not given. She had noticed the [MEDICATION NAME] was not supposed to be given but every seven days and reported it to the nurse. She also reported the resident's complaint of mouth pain at that time. In an interview on [DATE] at 3:43PM, nurse #1 stated the procedure for giving medication was to check the order on the MAR, check the medication label versus the MAR, pour and give the medication, and then sign the MAR. For medication ordered weekly, the MAR was marked with a square box on the day it was due and X'd out the other days. The nurse that took the original order was responsible for marking the current MAR. Two nurses checked the new MARS for accuracy before the first of the month and were responsible for marking the boxes and X's for medications not given daily. Nurse #1 reviewed the [MEDICATION NAME] order on resident 170's MAR. The nurse acknowledged she had initialed it on [DATE] but then crossed it out. She had also worked on [DATE] and left the entry for [MEDICATION NAME] blank. The nurse stated there was no [MEDICATION NAME] in the cart and she did not give it. The nurse stated she should have circled her initials and indicated a reason on the back of the MAR. She did not realize the [MEDICATION NAME] was ordered only every seven days. She did not report the resident was out of medication or call the pharmacy. The nurse stated she knew [MEDICATION NAME] was given for arthritis but was not aware that it was usually given only once weekly. In an interview on [DATE] at 4:07PM, medication aide #2 stated when she gave medications, she checked the MAR for accuracy, then checked the drug label, and then checked the drug label against the MAR again. For medications not ordered daily, the MAR was marked with an X on the days it was not given and marked with a box on the day it was given. The nurse was responsible for marking the appropriate days on the MAR. The nurses also checked the new MARS twice against the old MARS and new orders. The med aide reviewed the [MEDICATION NAME] order on resident 170's MAR and acknowledged she had given it on [DATE], [DATE], and [DATE]. She stated "it was an oversight." In an interview on [DATE] at 4:29PM, medication aide #3 stated she was trained to read the MAR, check the dose, route, and patient name versus the medication label. She removed the medication from the cart and checked it again versus the MAR before administering the medication. For medication not ordered daily, the MARS were usually X'd out on the days it was not given. The nurses marked the X's on the MARS and also checked them monthly for accuracy. The med aide reviewed the [MEDICATION NAME] order on resident 170's MAR and acknowledged she had given it on [DATE] and [DATE]. The med aide offered no explanation why she gave it daily. In a telephone interview on [DATE] at 5:15PM, the attending physician stated the resident was referred to a rheumatologist due to her severe [MEDICAL CONDITION] arthritis. The rheumatologist ordered [MEDICATION NAME] once weekly. The physician stated he observed one sore on the resident's lateral tongue on [DATE]. When he assessed her two days later, her whole mouth was affected and he sent her to the emergency room for evaluation. The physician stated the facility had notified him of the medication error. The resident was supposed to get [MEDICATION NAME] once weekly but he was unsure how much she had actually received. An interview was conducted on [DATE] at 10:11AM with one of the nurses (nurse #2) responsible for checking resident 170's October MAR. Nurse #2 stated the new MARS came to the facility on the 21st of each month. Two nurses checked for new orders daily and added them to the new MARS. The MARS were checked again on the last day of the month to ensure all new orders had been added and the MARS were correct. For unusual dosages such as weekly administration, the MARS were X'd out on the days the medication was not to be given. The nurse stated she checked the resident's October MAR to be sure it was correct but did not mark or X out the days [MEDICATION NAME] was not to be given. She stated the nurse giving the medication was responsible for marking the MAR. In an interview on [DATE] at 11:44AM, nurse #3 stated a nursing assistant had asked her to look at resident #170 on [DATE]. The resident complained of mouth pain and had blood on her lower lip. The nurse applied a cool washcloth to the resident's lip. The physician was notified, the [MEDICATION NAME] was held, and an IV fluid was started. On [DATE], nurse #3 noted documentation that the resident hadn't been eating or drinking well. She thought it could be due to the medication. She checked the resident's MAR and discovered that the [MEDICATION NAME] was signed as given daily instead of weekly. The nurse checked the resident ' s vital signs and called the physician. The physician ordered stat labs and then sent the resident to the hospital. Nurse #3 stated the MARS and physicians' orders were checked at the end of the month to be sure they matched. For medication ordered weekly, the nurse doing the first MAR check was supposed to mark the next month's MAR with a box on the days the medication was to be given. The nurse was supposed to X out or draw a line through the other days on the MAR. In an interview on [DATE] at 4:33PM, the Director of Nursing (DON) stated the staff was trained to thoroughly read the MARS and confirm the accurate medication, dose, time, and route. The DON stated two nurses checked the MAR for accuracy at the end of the month. For weekly medications, the nurses marked the MARS with an X or drew a line through the days it was not to be given. The nurses that checked the new MARS at the end of the month were responsible for marking them. If a new order was started after the first of the month, the nurse taking the order was responsible for marking the MAR. The DON stated she expected the staff to observe the five rights of medication administration. She expected them to check the MAR versus the label and the medication. If staff was unfamiliar with the indication, dosage, or side effects of a medication, she expected them to research the information from one of the available references, or ask other nursing staff and/or the pharmacy. Her expectation was for the nurses that checked the monthly MARS to mark them to ensure that medications ordered less than daily were given correctly. In a telephone interview on [DATE] at 4:05PM, the physician that treated resident 170 in the ICU stated she had multiple contributing factors, including her age, chronic diseases, and debility. The physician stated the [MEDICATION NAME] may have contributed to the resident's pancytopenia. He stated adverse reactions to [MEDICATION NAME] were possible at usual doses and it would take days for the medication to clear after it was stopped. The physician stated he wasn't sure the amount of [MEDICATION NAME] the resident received would be considered an overdose but that it certainly contributed to her condition and death. The Administrator was notified of the Immediate Jeopardy on [DATE] at 5:55PM. The facility provided a credible allegation of compliance on [DATE] at 4:30PM. The allegation of compliance indicated: On [DATE] Resident # 6758 received an order for [REDACTED]. Resident #6758 was administered [MEDICATION NAME] per physician's orders [REDACTED]. Resident #6758 was assessed by the licensed Nurse on [DATE] and was noted to have a blood pressure of ,[DATE] and difficulty swallowing in which all 8pm blood pressure medications were held and the MD was notified in person of Resident's change in condition by the licensed Nurse. On [DATE] the MD assessed the Resident and wrote an order for [REDACTED]. Resident #6758 was reassessed on [DATE] by the licensed Nurse and complained of sore mouth and sore throat, ? [MEDICATION NAME] ,[DATE] was administered by the license Nurse. On [DATE] Resident # 6758 lips were assessed by the licensed Nurse and the MD, new orders were received to hold [MEDICATION NAME] and [MEDICATION NAME], hold/stop [MEDICATION NAME] 25mcg patch change Q 72 hours, and IV ? normal saline @ 70 cc per hour. On [DATE] resident #6758 blood pressure, mouth, and mental status was assessed by the licensed Nurse and the MD and the RP was notified of Resident's change in condition, new order was received to send to ER for evaluation. On [DATE] at 1023 am Resident was sent to the ER for evaluation. The Director of Nursing was informed the morning of [DATE] the resident was deceased . All staff involved were drug tested [DATE]. All results came back negative. The nurse was re-educated, drug tested and suspended on [DATE] and remains suspended at this time. The medication aides were re-educated. The facility has suspended use of medication aides. All medication aides are working as certified nursing assistants giving direct patient care. All other Residents prescribed [MEDICATION NAME] initial orders were reviewed by the Director of Nursing for accuracy of transcription on to the MAR, blocking of the MAR for every seven day administration and to ensure the accuracy of the next scheduled dose of the medication on [DATE]. There were no doses scheduled to be given at the time of the audit. Noted issues were corrected as identified on [DATE]. Physical Assessments were completed on Residents on [MEDICATION NAME] by licensed nurses and labs obtained by [DATE]. The determination was made by the Director of Nursing after review of the medication administration record (MAR) that the orders were transcribed correctly to the MAR. The medication error was the direct result of the licensed/certified staff not following the six rights of medication administration (right resident, right medication, right dose, right route, right method, right time) resulting in the medication being administered incorrectly. The medication administration record not being blocked off for medication to be given every seven days was a contributing factor to the medication error. The dispensing pharmacy has identified the following medications as being at high risk for medication errors and has taken steps in the dispensing and labeling process to minimize administration error potential: 1. [MEDICATION NAME]- Effective [DATE] the following changes for dispensing [MEDICATION NAME] will be implemented. Beginning with the medication delivery on [DATE]: -Package all [MEDICATION NAME] orders in bingo packaging each time the drug is dispensed from the pharmacy -Send only one week supply each time the drug is dispensed from the pharmacy. -In addition to cautionary wording, **NOTE DOSE AND FREQUENCY!!!*** in sig (directions), place a stop sign shaped caution auxiliary label on the packaging that reads "HIGH ALERT CAUTION" -Move [MEDICATION NAME] to high risk station in pharmacy -Have Registered Pharmacist double check final product in addition to initial review each time the drug is dispensed from the pharmacy. 2. Concentrated liquid [MEDICATION NAME] and [MEDICATION NAME]: 1) A "stop-sign shaped" red auxiliary label that reads "High Alert. Double-Check" affixed to each bottle dispensed to a resident or for the emergency drug kit 2) A mini-monograph with conversion grid dispensed with each bottle. This handout is printed on bright pink/red paper. 3) The following statement is added to each concentrated [MEDICATION NAME] and [MEDICATION NAME] prescription label and MAR, "Double-check dose. Use calibrated syringe." 4) Calibrated oral dosing syringe is dispensed bottle. 3. For [MEDICATION NAME] products exclamation points are placed before the medication name on the MAR/product label 4. "Tall Man" letters are used for sound alike and look alike drug names on the MAR/product label (per the ISMP - institute for safe medication practice - suggested list). [MEDICATION NAME], for the Residents continuing to receive the medication have been returned to the pharmacy upon receipt of the [DATE] delivery. Validating of [MEDICATION NAME] doses occurred by 2 licensed Nurses prior to Administration until new packaging was available. Signage to alert staff of Residents receiving [MEDICATION NAME] and the need to verify dose with a second Nurse was inserted in the Resident' Medication Record. The new packaging arrived in the facility on [DATE]. Medications in the old packaging have been returned to the pharmacy. As a precautionary measure on [DATE] the facility temporarily suspended the use of Medication Aides pending medication administration retraining and a medication pass audit by the Pharmacy Consultant or an Administrative Nurse. The retraining of certified medication aidees will include, but will not be limited to: ? the six rights of medication administration ? the importance of reading and understanding medication labels and orders ? being aware of special instructions/alerts on packaging and MARs to include those for medications with unusual dosing schedules or those that could be potentially toxic, for example *****!!!!!!! or a stop sign. ? infection control All Medication Administration Records were audited by licensed Nurses to include the Supervisors with oversight by the Director of Nursing on [DATE] to ensure medications that were ordered less than daily were blocked off on the MAR and are being administered as ordered. Noted issues were corrected as identified. Verification of corrections was completed on [DATE]. In-services were started by the Staff Facilitator, RN on [DATE] for all licensed Nurses and Medication Aides on the six rights of medication administration, blocking the MAR for medications given less than daily by the nurse that takes off the telephone order to the MAR or by the nurses co-signing the monthly orders, notification of MD and RP of significant change in condition. Staff will be in-serviced prior to beginning their shift, to include staff on vacation and those that only work weekends by an Administrative Nurse. In-service was started on [DATE] by Staff Facilitator for licensed nurses and Medication Aides on signs and symptoms of [MEDICATION NAME] Toxicity. Staff will be in-serviced prior to beginning their shift, to include staff on vacation and those that only work weekends. Nurses hired after [DATE] will be in-serviced during their orientation process by the Staff Facilitator related to the Six Rights of Medication Administration, Blocking the MAR for Medications given less than daily, Notification of MD and RP of significant change in condition and the Signs and Symptoms of [MEDICATION NAME] toxicity. In-service was started on [DATE] by the Staff Facilitator for the certified Nursing Assistants on change in Resident conditions that need to be reported to the Nurse. Staff will be in-serviced prior to beginning their shift, to include staff on vacation and those that only work weekends. Nursing Assistants hired after [DATE] will be in-serviced during their orientation process by the Staff Facilitator related to the Changes in Resident conditions that need to be reported to the Nurse. An Interview Tool has been developed related to in-servicing material covered with Nurses and Medication Aides related to the Six Rights of Medication Administration, Blocking the MAR for Medications given less than daily, Notification of MD and RP of significant change in condition and the Signs and Symptoms of [MEDICATION NAME] toxicity. Implementation of the interview tool will occur on [DATE]. All nurses will be interviewed by an Administrative Nurse prior to the beginning of their scheduled shift. The Staff Facilitator or Administrative nurse will use the interview tool on one nurse per shift for 4 weeks, then one nurse daily for 4 weeks. Results of interviews will be reviewed weekly by the Quality Improvement Committee. On [DATE] a review of all current MARS was initiated by licensed nurses to include MDS Nurses, QI Nurse, Treatment Nurses and ADON with assistance and oversight by Director of Nursing to include comparison of October MAR to the September MAR and telephone orders to ensure medications are being administered as ordered. Medication used less than daily were reviewed to ensure the MAR was blocked off. Issues were corrected as identified during the review by the licensed Nurse. Corrections were completed on [DATE]. Beginning [DATE] the licensed Nurses reviewed nurse notes on all Residents from [DATE] to [DATE] ensure there are no acute issues that have not been addressed. A general assessment was completed on each Resident by a licensed Nurse to ensure Residents did not have a change in condition that warranted the notification of the MD and/or RP. Identified issues were addressed as indicated by the licensed Nurse. On [DATE] Medication Administration audits were started for all licensed Nurses and were completed by [DATE]. The medication audits consist of the use of a Medication Pass Audit Form developed by the pharmacy which consists of observation of multiple medications and requiring a less than 5% error rate to pass. Concerns were addressed by the auditing Nurse at the time of the observation. Nurses with a Med Pass error rate of 5% or greater received a second Med Pass Audit by an Administrative Nurse. Nurses hired after [DATE] will receive a Med Pass audit within 2 weeks of completion of the Orientation process. The Med Pass audit will be completed by an Administrative Nurse. Beginning [DATE], all telephone orders will be reviewed by the Administrative Nurse to ensure accurate transcription and blocking of the MARS for medications given less than daily on the medication administration record using copies of the telephone orders daily x 14 days, 3 x weekly x 6 weeks and then as determined necessary by the QI team. Beginning [DATE] MARS will be reviewed by the Administrative Nurse using a current census to ensure medications that ware given less than daily are blocked off on the MAR and are being administered as ordered daily x 14 days, 3 x weekly 6 weeks and then as determined necessary by the QI team Beginning [DATE] the MARS of residents taking [MEDICATION NAME] will be reviewed by the Administrative Nurses using a current census to ensure accurate administration of the medication daily x 14 days, 3 x weekly x 6 weeks and then as determined necessary by the QI team. Beginning with the November MAR, the MAR change over will incorporate a third check by two licensed Nurses on the first day of the month to ensure accuracy of the November MAR and to ensure all medications given less than daily have been blocked off on the MAR. MARs will continue to be signed off by two Nurses, the first Nurse will do the initial check when MARs arrive and the second check will be on the last day of the month prior to change over. Two licensed Nurses will audit 100% of MARs monthly x 3 months by performing a check of the hard copy MAR from the previous month and comparing it to the hard copy MAR for the current month and also incorporating the telephone orders in the third check. The two Nurses completing the third check will sign off on each hard copy and use a current census as the audit tool to show completion of the audit. Audit will be completed by the end of the first day of the new month. Results of the audit will be reviewed and addressed weekly by the Director of Nursing or the designee. The results will be compiled and forwarded to the Quality Improvement Committee for weekly review of identification of trends, development of action plans and to determine the need and /or frequency of continuing QI monitoring. On [DATE] at 5:59PM, the credible allegation of compliance was validated by observations, interviews, and record review. The facility provided evidence of in-service training for all nursing staff and medication aides. In-services included medication administration, special precautions, dosage, packaging, MAR blocking, and side effects

Based on observations, record review, staff and resident interviews, the facility failed to recognize and implement treatment interventions for 1 of 1 sampled residents (Resident #1) who experienced frequent loose stools after receiving multiple antibiotics and continued to receive a stool softener. Findings include: The facility's Standing PRN (as needed) Medication Order, which was undated and referred to as the diarrhea protocol by staff, included orders for diarrhea. #1 indicated that the rectum was to be checked for stool. #2 indicated [MEDICATION NAME] (medication given for loose stools) 1 teaspoon or 1 capsule could be given three times daily for 24 hours. #3 indicated to obtain "[MEDICAL CONDITION]" ([MEDICAL CONDITION]) [MEDICATION NAME] and toxins. Resident #1 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. According to hospital discharge records of 01/27/12, Resident #1 was [MEDICATION NAME](an antibiotic) 500 milligrams (mg) daily for 7 days. A nurse's note of 01/30/12 at 3:36 PM indicated Resident #1 was [MEDICATION NAME] a urinary tract infection [MEDICAL CONDITION]. Resident #1's Admission Minimum Data Set (MDS) assessment of 02/03/12 indicated she had moderate cognitive impairment. She needed extensive assistance with bed mobility, transfer, dressing, toilet use and hygiene. She needed total assistance with bathing. She was incontinent of both bowel and bladder. The February 2012 physician's orders [REDACTED]. According to the February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Upon further review of the February 2012 MAR, there was no documentation of administration of [MEDICATION NAME] during the same 02/01/12 through 02/26/12 time period. A physician's telephone order of 02/06/12 indicated Resident #1 was to receive [MEDICATION NAME] (an antibiotic) 150 mg 2 tablets by mouth three times daily [MEDICATION NAME] (an antibiotic) mg twice daily for hip infection. A clarification physician's telephone order of 02/08/12 indicated Resident #1 was to take [MEDICATION NAME] for 10 days. A nurse's note of 02/10/12 at 9:37 AM indicated Resident #1 had tested positive [MEDICAL CONDITION] in her left hip wound. A physician's telephone order of 02/12/12 for Resident #1 indicated she was to receive [MEDICATION NAME] 300 mg (an antibiotic) twice daily for 10 days for [MEDICAL CONDITION] infection of her left hip wound. A physician's telephone order of 02/13/12 indicated to discontinue [MEDICATION NAME] mg. Resident #1 was seen by the physician on 02/13/12. According to his progress note, she had developed [MEDICAL CONDITION] infection to her left hip wound. He noted to continue the isolation, discontinue [MEDICATION NAME] was to receive [MEDICATION NAME] ( an antibiotic) 300 mg twice daily for 10 days. According to the bowel movement record for February 2012 provided by the facility, Resident #1 had a large formed bowel movement on 02/12/12. She did not have a bowel movement on 02/13/12, 02/14/12, 02/15/12, 02/16/12 or 02/17/12 per the bowel movement record. A nurse's note of 02/16/12 at 9:05 PM indicated Resident #1 had a bowel movement and had no complaints of discomfort. A nurse's note of 02/17/12 at 3:10 PM indicated Resident #1 was given Milk of Magnesia (for constipation). Resident #1 was documented as having a large formed bowel movement on 02/18/12 per the February 2012 bowel movement record. The February 2012 bowel movement record indicated Resident #1 had a large and small formed stool on 02/19/12. The February 2012 MAR indicated [REDACTED]. Review of the February 2012 bowel movement record for Resident #1 revealed she experienced both medium and large loose bowel movements on a daily basis from 02/20/12 through 02/26/12. According to the February 2012 bowel movement record, Resident #1 had a large loose bowel movement as well as a medium loose bowel movement on 02/20/12. A nurse's note of 02/20/12 at 6:26 AM indicated Resident #1 was alert. There was no mention of the loose bowel movements. The February 2012 MAR indicated [REDACTED]. A nurse's note of 02/20/12 at 3:31 PM indicated Resident #1 was alert with no mention of the loose bowel movements. According to the February 2012 bowel movement record, Resident #1 had 2 large loose bowel movements, a medium loose bowel movement, and a medium formed bowel movement on 02/21/12. The February 2012 MAR indicated [REDACTED]. A nurse's note of 02/22/12 at 10:19 PM indicated Resident #1 was resting in bed with no complaints and was alert as well as oriented. There was no mention of loose bowel movements. A physician's progress note of 02/22/12 indicated Resident #1 was seen. There was no mention of Resident #1's loose bowel movements. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record for Resident #1 indicated she had 2 large loose bowel movements on 02/22/12. A physician's progress note of 02/23/12 indicated Resident #1 had been seen. There was no mention of her loose bowel movements. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record indicated Resident #1 had 4 large loose bowel movements on 02/23/12. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record indicated Resident #1 had 3 large loose bowel movements on 02/24/12. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record indicated Resident #1 had 2 large loose bowel movements on 02/25/12. A physician's telephone order of 02/26/12 for Resident #1 indicated to check stool for "c diff toxins" ([MEDICAL CONDITION] toxins) and start [MEDICATION NAME] (an antibiotic given for[DIAGNOSES REDACTED]) 500 mg three times daily for 10 days. The February 2012 MAR indicated [REDACTED]. It was noted that there was a line drawn with a date of 02/26/12 and the medication was discontinued. The February 2012 bowel movement record indicated Resident #1 had 4 large loose bowel movements on 02/26/12. A nurse's note of 02/27/12 at 6:58 AM indicated Resident #1 was seen by the physician and the [MEDICAL CONDITION] protocol had been started related to loose stools. It was noted that Resident #1 had an elevated temperature of 101 degrees Fahrenheit at 1:00 AM and was medicated with Tylenol. Her temperature was rechecked at 6:30 AM and found to be 99.1 degrees Fahrenheit. This was communicated to the physician. There was no physician progress notes [REDACTED]. A nurse's note of 02/27/12 at 7:51 AM indicated the physician was notified at 7:15 AM of Resident #1 having an elevated temperature during the night with an elevated heart rate. New orders were received to send her to the emergency room for evaluation to rule [MEDICAL CONDITION]. She left the facility at 7:45 AM. A physician's telephone order of 02/27/12 indicated to send Resident #1 to the emergency room for further evaluation of loose stools, increased heart rate and temperature. Upon review of the February 2012 MAR for Resident #1, there was no entry or any documentation found that Resident #1 had received any doses of [MEDICATION NAME] for the month of February. The discharge [DIAGNOSES REDACTED].#1 included [MEDICAL CONDITION] (c diff), systemic [MEDICAL CONDITION] response syndrome, urinary tract infection [MEDICAL CONDITION], acute [MEDICAL CONDITION] (resolved), and dehydration (resolved). She developed diarrhea and became dehydrated due to the diarrhea. Upon arrival to emergency room she was very dehydrated. Her stool tested positive for [MEDICAL CONDITION] toxin. Resident #1 was observed in bed on 03/12/12 at 12:20 PM. There was an isolation cart sitting just outside her doorway. Resident #1 was interviewed on 03/13/12 at 12:15 PM. The resident stated she was feeling better since she came back from the hospital and was glad the "diarrhea" had resolved. When questioned as to whether the nurses were aware of her loose stools, she stated that they were aware but she had not complained. An interview was conducted with nurse #1 on 03/14/12 at 3:00 PM. She stated Resident #1 was alert and oriented. She stated she had bouts of "diarrhea" and had been on multiple antibiotics. When questioned about her loose stools, she responded that the "diarrhea" had started out slowly but then every stool she had was loose. Nurse #1 stated she did not notice the foul odor that was typical of [MEDICAL CONDITION]. She stated Resident #1 began to be confused and was not eating well. She stated her family was concerned and thought she had a urinary tract infection. Nurse #1 added that the urine specimen had been negative. She commented that Resident #1 had been sent out for evaluation and came back positive for [MEDICAL CONDITION]. She added that prior to the "diarrhea", Resident #1 [MEDICAL CONDITION] in her wound. When questioned as to nursing interventions for loose stools/diarrhea, she stated there was a standing order in place for residents with loose stools. Nurse #1 added that [MEDICATION NAME] could be given and if the diarrhea/loose stools did not resolve, staff were to notify the physician. An interview was conducted with Nurse #2 on 03/14/12 at 4:55 PM. She stated she remembered Resident #1 having problems with "diarrhea" for about 2 days during the week before she was sent out. She added that she had been off for a few days and when she came back to work Resident #1 had been out to the hospital. Nurse #2 stated she was told that a stool specimen had been collected and was positive for [MEDICAL CONDITION] prior to her going out to the hospital. She added she thought Resident #1 had received at least 2 doses of antibiotics prior to her going out. When questioned about how she would know that a resident was having diarrhea/loose stools, she stated the nurse aides sometimes would inform the nurse and sometimes they would not. She added that the aides use the computer charting system to input their documentation in regards to bowel movements. Nurse #2 stated if she was told about diarrhea/loose stools she would give medication for it. Nurse #2 commented that she herself had just found out how one would acquire [MEDICAL CONDITION]. Resident #1's physician (Physician #1) was interviewed on 03/14/12 at 5:15 PM. He stated Resident #1 had been on antibiotics for some time and because of the length of time she had been on them, she developed [MEDICAL CONDITION]. He also stated that dehydration usually resulted from the diarrhea. He commented that he had been out for a period of time and another physician (physician #2) had covered for him. Physician #1 stated that Physician #2 had sent her out to the hospital for hydration and treatment. Nurse #1 was interviewed again on 03/15/12 at 9:45 AM. She stated she had remembered giving [MEDICATION NAME] to Resident #1 once but she had not documented it. She stated she remembered it because she had worked a double that day and had gone in to assist NA#1 in providing incontinent care for loose stools. Nurse #1 stated the nurses received an alert list which included all the residents who did not have bowel movements. She added that she did not routinely go into the computer system to see what resident's bowel habits were because she did not know how to access the information. Upon review of the February 2012 bowel movement record, she agreed that on 02/21/12 the diarrhea protocol should have been initiated and the [MEDICATION NAME] should have been started. Nurse #1 added that the aides usually would tell her if a resident was having issues with their bowels. NA#2 was interviewed on 03/15/12 at 10:25 AM. She stated she had worked with Resident #1 during the time she was having bowel issues. She reported that Resident #1 [MEDICAL CONDITION] and then developed [MEDICAL CONDITION]. She stated to her all stools had a foul odor and she was familiar with signs of [MEDICAL CONDITION]. She stated she did have "diarrhea" and she had reported it to the nurse but didn't know if anything was given for it. NA#2 commented that she had documented all of her stools in the nurse aide charting computer system. During an interview with the Director of Nurses (DON), on 03/15/12 at 10:50 AM, she stated her expectation would be for staff to initiate the diarrhea protocol (standing orders) if a resident had several days of loose stools. She stated while they were having the diarrhea/loose stools, she would expect to see some type of intervention like holding stool softeners to see if the diarrhea would resolve. The DON stated she would expect staff to notify the physician if there was no rationale found for that resident having diarrhea or loose stools. She also commented that if the protocol was initiated and was not affective in resolving the problem, the staff should notify the physician and obtain direction. The DON stated the nurse aides document their information into the computer and all nurses have the ability to access that information. She added that there was an alert built into the computer program that would trigger residents who had not had bowel movements but there was nothing to alert that residents were having diarrhea. Nurse Aide #1 (NA#1) was interviewed on 03/15/12 at 11:50 AM. NA#1 reported that she had worked with Resident #1 during the time she had diarrhea/loose stools. She stated sometimes residents have loose stools and it didn't always mean there was a problem. She added that if the resident had more than one loose stool on her shift she would tell the nurse. NA#1 commented that she had reported that Resident #1 had loose stools to the nurse. She stated Resident #1 drank plenty of fluids when she worked with her. She stated she documented the bowel movements in the computer system. During another interview with the DON, on 03/15/12 at 1:20 PM, she reported that she had spoken with all of the staff who had worked with Resident #1 about her diarrhea/loose stools and none of them remembered if they had given [MEDICATION NAME] or not. A telephone interview was conducted with Physician #2 on 03/15/12 at 1:40 PM. He stated he did not remember when staff informed him about the diarrhea/loose stools but she had developed [MEDICAL CONDITION] and was sent out for evaluation. Nurse #3 was interviewed on 01/15/12 at 3:00 PM. She stated if a resident reported to her that they were having diarrhea she would talk with the nurse aides to confirm. She stated if the resident had more than a couple loose stools she would give [MEDICATION NAME]. When questioned about Resident #1, she stated she could not remember if she had diarrhea/loose stools or not. Nurse #3 added that the nurses could go into the computer system to check to see what the bowel movement history was on any of the residents. She commented that the diarrhea protocol included administration of [MEDICATION NAME] and if within 24 hours the diarrhea had not resolved, staff were to notify the physician. Nurse #3 stated after reviewing the February 2012 bowel movement record for Resident #1 that someone should have initiated the diarrhea protocol (the standing orders). She commented that when Resident #1 had the 3 large loose stools on 02/21/12 nursing should have administered the [MEDICATION NAME]. Nurse #2 was interviewed again on 03/15/12 at 3:25 PM. She stated if a resident had one or more loose stools she would initiate the diarrhea protocol (standing orders). She stated all of the residents had standing orders for [MEDICATION NAME] for diarrhea. Nurse #2 added that if the [MEDICATION NAME] was given, the nurse would need to write it on the MAR indicated [REDACTED]. She stated she remembered giving [MEDICATION NAME] to Resident #1 on one occasion but she did not document it. Nurse #2 commented that if the resident continued to have diarrhea 24 hours after the initiation of the protocol, she would notify the physician.

Based on observations, record review, staff and resident interviews, the facility failed to assess a change in condition for 1 of 1 sampled residents (Resident #1) who experienced a change in bowel movements and continued to receive a stool softener while experiencing frequent loose stools. Findings include: The facility's Standing PRN (as needed) Medication Order, which was undated and referred to as the diarrhea protocol by staff, included orders for diarrhea. #1 indicated that the rectum was to be checked for stool. #2 indicated [MEDICATION NAME] (medication given for loose stools) 1 teaspoon or 1 capsule could be given three times daily for 24 hours. #3 indicated to obtain "[MEDICAL CONDITION]" ([MEDICAL CONDITION]) [MEDICATION NAME] and toxins. Resident #1 was admitted to the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. According to hospital discharge records of 01/27/12, Resident #1 was [MEDICATION NAME](an antibiotic) 500 milligrams (mg) daily for 7 days. A nurse's note of 01/30/12 at 3:36 PM indicated Resident #1 was [MEDICATION NAME] a urinary tract infection [MEDICAL CONDITION]. Resident #1's Admission Minimum Data Set (MDS) assessment of 02/03/12 indicated she had moderate cognitive impairment. She needed extensive assistance with bed mobility, transfer, dressing, toilet use and hygiene. She needed total assistance with bathing. She was incontinent of both bowel and bladder. The February 2012 physician's orders [REDACTED]. According to the February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Upon further review of the February 2012 MAR, there was no documentation of administration of [MEDICATION NAME] during the same 02/01/12 through 02/26/12 time period. A physician's telephone order of 02/06/12 indicated Resident #1 was to receive [MEDICATION NAME] (an antibiotic) 150 mg 2 tablets by mouth three times daily [MEDICATION NAME] (an antibiotic) mg twice daily for hip infection. A clarification physician's telephone order of 02/08/12 indicated Resident #1 was to take [MEDICATION NAME] for 10 days. A nurse's note of 02/10/12 at 9:37 AM indicated Resident #1 had tested positive [MEDICAL CONDITION] in her left hip wound. A physician's telephone order of 02/12/12 for Resident #1 indicated she was to receive [MEDICATION NAME] 300 mg (an antibiotic) twice daily for 10 days for [MEDICAL CONDITION] infection of her left hip wound. A physician's telephone order of 02/13/12 indicated to discontinue [MEDICATION NAME] mg. Resident #1 was seen by the physician on 02/13/12. According to his progress note, she had developed [MEDICAL CONDITION] infection to her left hip wound. He noted to continue the isolation, discontinue [MEDICATION NAME] was to receive [MEDICATION NAME] ( an antibiotic) 300 mg twice daily for 10 days. According to the bowel movement record for February 2012 provided by the facility, Resident #1 had a large formed bowel movement on 02/12/12. She did not have a bowel movement on 02/13/12, 02/14/12, 02/15/12, 02/16/12 or 02/17/12 per the bowel movement record. A nurse's note of 02/16/12 at 9:05 PM indicated Resident #1 had a bowel movement and had no complaints of discomfort. A nurse's note of 02/17/12 at 3:10 PM indicated Resident #1 was given Milk of Magnesia (for constipation). The February 2012 MAR indicated [REDACTED]. Resident #1 was documented as having a large formed bowel movement on 02/18/12 per the February 2012 bowel movement record. The February 2012 bowel movement record indicated Resident #1 had a large and small formed stool on 02/19/12. The February 2012 MAR indicated [REDACTED]. Review of the February 2012 bowel movement record for Resident #1 revealed she experienced both medium and large loose bowel movements on a daily basis from 02/20/12 through 02/26/12. According to the February 2012 bowel movement record, Resident #1 had a large loose bowel movement as well as a medium loose bowel movement on 02/20/12. A nurse's note of 02/20/12 at 6:26 AM indicated Resident #1 was alert. There was no mention of the loose bowel movements. The February 2012 MAR indicated [REDACTED]. A nurse's note of 02/20/12 at 3:31 PM indicated Resident #1 was alert with no mention of the loose bowel movements. According to the February 2012 bowel movement record, Resident #1 had 2 large loose bowel movements, a medium loose bowel movement, and a medium formed bowel movement on 02/21/12. The February 2012 MAR indicated [REDACTED]. A nurse's note of 02/22/12 at 10:19 PM indicated Resident #1 was resting in bed with no complaints and was alert as well as oriented. There was no mention of loose bowel movements. A physician s progress note of 02/22/12 indicated Resident #1 was seen. There was no mention of Resident #1's loose bowel movements. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record for Resident #1 indicated she had 2 large loose bowel movements on 02/22/12. A physician's progress note of 02/23/12 indicated Resident #1 had been seen. There was no mention of her loose bowel movements. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record indicated Resident #1 had 4 large loose bowel movements on 02/23/12. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record indicated Resident #1 had 3 large loose bowel movements on 02/24/12. The February 2012 MAR indicated [REDACTED]. The February 2012 bowel movement record indicated Resident #1 had 2 large loose bowel movements on 02/25/12. A physician's telephone order of 02/26/12 for Resident #1 indicated to check stool for "c diff toxins" ([MEDICAL CONDITION] toxins) and start [MEDICATION NAME] (an antibiotic given for[DIAGNOSES REDACTED]) 500 mg three times daily for 10 days. The February 2012 MAR indicated [REDACTED]. It was noted that there was a line drawn with a date of 02/26/12 and the medication was discontinued. The February 2012 bowel movement record indicated Resident #1 had 4 large loose bowel movements on 02/26/12. A nurse's note of 02/27/12 at 6:58 AM indicated Resident #1 was seen by the physician and the [MEDICAL CONDITION] protocol had been started related to loose stools. It was noted that Resident #1 had an elevated temperature of 101 degrees Fahrenheit at 1:00 AM and was medicated with Tylenol. Her temperature was rechecked at 6:30 AM and found to be 99.1 degrees Fahrenheit. This was communicated to the physician. There was no physician progress notes [REDACTED]. A nurse's note of 02/27/12 at 7:51 AM indicated the physician was notified at 7:15 AM of Resident #1 having an elevated temperature during the night with an elevated heart rate. New orders were received to send her to the emergency room for evaluation to rule [MEDICAL CONDITION]. She left the facility at 7:45 AM. A physician's telephone order of 02/27/12 indicated to send Resident #1 to the emergency room for further evaluation of loose stools, increased heart rate and temperature. The discharge [DIAGNOSES REDACTED].#1 included [MEDICAL CONDITION] (c diff), systemic [MEDICAL CONDITION] response syndrome, urinary tract infection [MEDICAL CONDITION], acute [MEDICAL CONDITION] (resolved), and dehydration (resolved). She developed diarrhea and became dehydrated due to the diarrhea. Upon arrival to emergency room she was very dehydrated. Her stool tested positive for [MEDICAL CONDITION] toxin. Resident #1 was observed in bed on 03/12/12 at 12:20 PM. There was an isolation cart sitting just outside her doorway. Resident #1 was interviewed on 03/13/12 at 12:15 PM. The resident stated she was feeling better since she came back from the hospital and was glad the "diarrhea" had resolved. When questioned as to whether the nurses were aware of her loose stools, she stated that they were aware but she had not complained. An interview was conducted with nurse #1 on 03/14/12 at 3:00 PM. She stated Resident #1 was alert and oriented. She stated she had bouts of "diarrhea" and had been on multiple antibiotics. When questioned about her loose stools, she responded that the "diarrhea" had started out slowly but then every stool she had was loose. Nurse #1 stated she did not notice the foul odor that was typical of [MEDICAL CONDITION]. She stated Resident #1 began to be confused and was not eating well. She stated her family was concerned and thought she had a urinary tract infection. Nurse #1 added that the specimen had been negative. She commented that Resident #1 had been sent out for evaluation and came back positive for [MEDICAL CONDITION]. She added that prior to the "diarrhea", Resident #1 [MEDICAL CONDITION] in her wound. When questioned as to nursing interventions for loose stools/diarrhea, she stated there was a standing order in place for residents with loose stools. Nurse #1 added that [MEDICATION NAME] could be given and if the "diarrhea" did not resolve, staff were to notify the physician. An interview was conducted with Nurse #2 on 03/14/12 at 4:55 PM. She stated she remembered Resident #1 having problems with "diarrhea" for about 2 days during the week before she was sent out. She added that she herself had been off for a few days and when she came back to work Resident #1 had been out to the hospital. Nurse #2 stated she was told that a stool specimen had been collected and was positive for [MEDICAL CONDITION] prior to her going out to the hospital. She added she thought Resident #1 had received at least 2 doses of antibiotics prior to her going out. When questioned about how she would know that a resident was having diarrhea, she stated the nurse aides sometimes would inform the nurse and sometimes they would not. She added that the aides use the computer to input their documentation in regards to bowel movements. Nurse #2 stated if she was told about diarrhea or loose stools she would give medication for it. Nurse #2 commented that she herself had just found out how one would acquire [MEDICAL CONDITION] (C Diff). Resident #1's physician (Physician #1) was interviewed on 03/14/12 at 5:15 PM. He stated Resident #1 had been on antibiotics for some time and because of the length of time she had been on them, she developed [MEDICAL CONDITION]. He also stated that dehydration usually resulted from the diarrhea. He commented that he had been out for a period of time and another physician (physician #2) had covered for him. Physician #1 stated that Physician #2 had sent her out to the hospital for hydration and treatment. Nurse #1 was interviewed again on 03/15/12 at 9:45 AM. She stated she had remembered giving [MEDICATION NAME] to Resident #1 once but she had not documented it. She stated she remembered it because she had worked a double that day and had gone in to assist NA#1 in providing incontinent care for loose stools. Nurse #1 stated the nurses received an alert list which included all the residents who did not have bowel movements. She added that she did not routinely go into the computer system to see what resident's bowel habits were because she did not know how to access the information. Upon review of the February 2012 bowel movement record, she agreed that on 02/21/12 the diarrhea protocol should have been initiated and the [MEDICATION NAME] should have been started. Nurse #1 added that the aides usually would tell her if a resident was having issues with their bowels. NA#2 was interviewed on 03/15/12 at 10:25 AM. She stated she had worked with Resident #1 during the time she was having bowel issues. She reported that Resident #1 [MEDICAL CONDITION] and then developed [MEDICAL CONDITION]. She stated to her all stools had a foul odor and she was familiar with signs of [MEDICAL CONDITION]. She stated she did have "diarrhea" and she had reported it to the nurse but didn't know if anything was given for it. NA#2 commented that she had documented all of her stools in the nurse aide charting computer system. During an interview with the Director of Nurses (DON), on 03/15/12 at 10:50 AM, she stated her expectation would be for staff to initiate the diarrhea protocol if a resident had several days of loose stools. She stated while they were having the diarrhea/loose stools, she would expect to see some type of intervention like holding stool softeners to see if the diarrhea would resolve. The DON stated she would expect staff to notify the physician if there was no rationale found for that resident having diarrhea or loose stools. She also commented that if the protocol was initiated and was not affective in resolving the problem, the staff should notify the physician and obtain direction. The DON stated the nurse aides document their information into the computer and all nurses have the ability to access that information. She added that there was an alert built into the computer program that would trigger residents who had not had bowel movements but there was nothing to alert that residents were having diarrhea. Nurse Aide #1 (NA#1) was interviewed on 03/15/12 at 11:50 AM. NA#1 reported that she had worked with Resident #1 during the time she had diarrhea. She stated sometimes residents have loose stools and it didn't always mean there was a problem. She added that if the resident had more than one on her shift she would tell the nurse. NA#1 commented that she had reported that Resident #1 had loose stools to the nurse. She stated Resident #1 drank plenty of fluids when she worked with her. She stated she documented the bowel movements in the nurse aide charting computer system. During another interview with the DON, on 03/15/12 at 1:20 PM, she reported that she had spoken with all of the staff who had worked with Resident #1 about her diarrhea/loose stools and none of them remembered if they had given [MEDICATION NAME] or not. A telephone interview was conducted with Physician #2 on 03/15/12 at 1:40 PM. He stated he did not remember when staff informed him about the diarrhea/loose stools but she had developed [MEDICAL CONDITION] and was sent out for evaluation. Nurse #3 was interviewed on 01/15/12 at 3:00 PM. She stated if a resident reported to her that they were having diarrhea she would talk with the nurse aides to confirm. She stated if the resident had more than a couple loose stools she would give [MEDICATION NAME]. When questioned about Resident #1, she stated she could not remember if she had diarrhea/loose stools or not. Nurse #3 added that the nurses could go into the computer system to check to see what the bowel movement history was on any of the residents. She commented that the diarrhea protocol included administration of [MEDICATION NAME] and if within 24 hours the diarrhea had not resolved, staff were to notify the physician. Nurse #3 stated after reviewing the February 2012 bowel movement record for Resident #1 that someone should have initiated the diarrhea protocol (the standing orders). She commented that when Resident #1 had the 3 large loose stools on 02/21/12 nursing should have administered the [MEDICATION NAME]. Nurse #2 was interviewed again on 03/15/12 at 3:25 PM. She stated if a resident had one or more loose stools she would initiate the diarrhea protocol (standing orders). She stated all of the residents had standing orders for [MEDICATION NAME] for diarrhea. Nurse #2 added that if the [MEDICATION NAME] was given, the nurse would need to write it on the MAR indicated [REDACTED]. She stated she remembered giving [MEDICATION NAME] to Resident #1 on one occasion but she did not document it. Nurse #2 commented that if the resident continued to have diarrhea 24 hours after the initiation of the protocol, she should notify the physician.