Every finding on record at Windsor Rehabilitation and Healthcare Center

Based on record review and staff, Pharmacist, Medical Director and Physician interviews, the facility failed to clarify and resolve a discrepancy with an order for carvedilol (medication in the class of alpha and beta blockers used to treat conditions affecting the heart and blood vessels) which resulted in a significant medication error for 1 of 5 residents reviewed for unnecessary medications (Resident #7).Findings included:Resident #7's hospital Discharge summary dated [DATE] revealed her discharge medications included carvedilol 25 milligrams (mg) by mouth twice daily.Resident #7 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and heart failure.A physician's order for Resident #7 with a start date of 12/3/25 revealed carvedilol 25 mg by mouth twice daily for essential hypertension.Resident #7's December 2025 Medication Administration Record (MAR) revealed documentation indicating carvedilol 25 mg was administered to Resident #7 twice daily from 12/3/25 through 12/4/25.A Report of Consultation document completed by Resident #7's Cardiologist dated 12/5/25 included a handwritten portion completed and signed by Physician #2 which revealed Resident #7 had coronary and peripheral artery disease (narrowing or blockage of the arteries in the heart and legs, pelvic area or arms). The recommendation was to increase Resident #7's carvedilol to 37.5 mg twice daily and to check Resident #7's blood pressure with a goal of systolic (the hearts contraction phase measuring peak pressure in the arteries) blood pressure of 110 (mmHg-millimeters of mercury) to 130 (mmHg-millimeters of mercury). A printed portion of the document titled After Visit Summary Instructions revealed increase carvedilol to 3.125 milligrams twice daily. An additional printed portion titled Your Medication List revealed carvedilol 25 mg take 1.5 tablets (37.5 mg total) by mouth in the morning and 37.5 mg by mouth in the evening.A physician's order for Resident #7 with a start date of 12/5/25 entered by Nurse #12 revealed carvedilol 3.125 mg twice daily by mouth for hypertension.On 1/7/26 at 10:10 AM in an interview Nurse #12 stated recalled being assigned to Resident #7 on 12/5/25 when Resident #7 returned from her appointment with her Cardiologist (heart specialist physician). She reported as the nurse assigned to Resident #7, it was her duty to review the consultation report documents that returned with Resident #7 and to enter any new orders. She stated she saw the handwritten portion completed by Physician #2, and noticed the discrepancy between what he hand wrote, what was printed in the instructions portion, and what was printed in the medication list portion. Nurse #12 reported it was her understanding she was supposed to use what was printed in the instructions portion to enter the medication order. She indicated she knew she should have called a provider to clarify the discrepancy before she entered the order. She stated she normally would have called Physician #2's office, but it had been late in the evening, and she had not.Resident #7's December 2025 MAR revealed documentation indicating carvedilol 3.125 mg was administered to her twice daily from 12/5/25 at 8:00 PM through 12/31/25 at 8:00 PM. Resident #7's January 2026 MAR revealed documentation indicating carvedilol 3.125 mg was administered to her twice daily from 1/1/26 at 8:00 AM through 1/7/2 at 8:00 AM.Resident #7's blood pressure readings from 12/3/25 through 12/31/25 revealed Resident #7's blood pressure was checked twice daily. Resident #7's systolic blood pressure (SBP is the top number in a blood pressure reading indicating the pressure in the arteries when the heart beats with normal adult SBP being less than 120) ranged from a low of 100 to a high of 180. Resident #7's diastolic blood pressure (DBP is the lower number in a blood pressure reading, measuring the pressure in your arteries when your heart rests between beats with normal adult DBP being between 60 and 80) ranged from a low of 48 to a high of 94.Resident #7's blood pressure reading from 1/1/26 through 1/7/26 revealed Resident #7's blood pressure was checked twice daily. Resident #7's SBP ranged from a low of 111 to a high of 172. Her DBP ranged from a low of 55 to a high of 87.On 1/7/26 at 10:25 AM a telephone interview with Physician #2 indicated he was Resident #7's Cardiologist. He stated he recommended an increase in the dose of Resident #7's carvedilol at her appointment on 12/5/25 because Resident #7's blood pressure had not been well controlled. Resident #7's twice daily documented blood pressure and pulse readings for December 2025 and January 2026 were reviewed with Physician #2 via telephone. Physician #2 stated that while these readings were not optimal, they weren't terrible either. He reported while he did not feel that receiving the lower dose of 3.125 mg of carvedilol twice daily since 12/5/25 had caused Resident #7 any harm, it was very important that she begin receiving the correct dose of 37.5 mg of carvedilol twice daily now.On 1/7/26 at 10:36 AM in a return telephone call Physician #2 stated he was now very concerned about Resident #7 going from 3.125 mg of carvedilol twice daily to 37.5 mg of carvedilol twice daily. He stated because she had been receiving the much lower dose for so long, there could be potentially adverse consequences to Resident #7 which included a sudden drop in heart rate and blood pressure. Physician #2 reported he would need to provide titration orders to the Director of Nursing (DON) for a gradual increase in Resident #7's carvedilol from 3.125 mg twice daily to the goal of 37.5 mg twice daily.On 1/7/26 at 10:40 AM an interview with the DON indicated Nurse #12 should have immediately clarified Resident #7's carvedilol order when she saw the discrepancy in the document. The DON stated Physician #2 had just given her verbal telephone orders for increasing Resident #7's carvedilol to 12.5 mg twice daily for one week, 25 mg twice daily for one week, then 37.5 mg twice daily continuously after that and for monitoring Resident #7's heart rate and blood pressure twice daily. She reported she would consider this a significant medication error.On 1/7/26 at 11:35 AM a telephone interview with Pharmacist #2 indicated she completed Resident #7's initial medication regime review on 12/8/25. She reported she noted the discrepancy between Resident #7's initial admission carvedilol dose of 25 mg twice daily, the recommendation by Physician #2 on 12/5/25 to increase Resident #7's carvedilol to 37.5 mg twice daily, and the facility's order for a significantly decreased dose of carvedilol 3.125 mg twice daily. Pharmacist #2 stated she had sent a recommendation to the DON to clarify this discrepancy on 12/8/25. She reported carvedilol was a medication that required gradual dose titration. She stated Resident #7 going from carvedilol 25 mg twice daily to 3.125 mg twice daily could have had significant adverse effects such as heart rate changes and increased blood pressure consequences.On 1/7/26 at 2:12 PM a telephone interview with the Medical Director indicated it was a problem that the Cardiology visit summary was not accurate. He stated he did not feel Resident #7 experienced any harm as a result of this problem. He reported although carvedilol was a medication that required gradual titration up or down as it could affect heart rate, he did not feel it had been clinically significant in Resident #7's case. The Medical Director stated someone from the facility should have picked up on the discrepancy and contacted a provider for clarification.On 1/8/26 at 8:38 AM an interview with the Administrator indicated there were providers on call for the facility at all times. She stated Nurse #12 should have immediately called a provider for clarification when she noted a discrepancy.

Based on observations, record review and staff and Nurse Practitioner (NP) interviews, the facility failed to: 1.) to follow their infection control practices and procedures for Contact Precautions when Nurse Aide (NA) #1 entered resident's room under contact precautions without wearing a gown or gloves to pick up a meal tray 2.) follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when NA #2 provided a bed bath without wearing a gown and when NA #2 left dirty linens on the floor of the resident's room instead of placing them in a bag and later picked them up and held them against her body. 3.) follow CDC guidance for testing residents exposed to covid 4.) to implement their infection control policies and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident receiving enteral feedings when Nurse #2 failed to don (to put on) personal protective equipment (PPE) to include a gown. The deficient practice was identified for 4 of 17 staff observed for infection control practices (NA #1, NA #2, Nurse #2, and the previous Assistant Director of Nursing). Findings included: 1. The policy regarding contact precautions, dated October 2018, stated staff and visitors were required to perform hand hygiene and don disposable gloves and a gown upon entering the residents' room and remove them before exiting the room, performing hand hygiene upon exit. Observation of Resident #54's room door on 1/4/26 at 12:41 PM revealed signage titled Contact Precautions. The signage instructed everyone to perform hand hygiene and don gloves and a gown before entering the room and discard the gown and gloves before exiting the room and to then perform hand hygiene. Further observation revealed Nurse Aide (NA) #1 entered Resident #54's room without performing hand hygiene or donning gloves or a gown, picking up the residents' meal tray, exiting the room and placing the tray on the meal tray cart without follow-up hand hygiene. During an interview with NA #1 on 1/4/26 at 12:43 PM, she stated she had received training on infection control and contact precautions when she returned to work in December 2025. NA #1 acknowledged she should have performed hand hygiene, donned a gown and gloves before entering Resident #54's room and performed hand hygiene when leaving the room. She explained that Resident #54 was not her assigned resident and she was in a hurry, so she didn't look for the sign. On 1/4/26 at 12:49 PM, the Director of Nursing (DON) stated she and the Assistant Director of Nursing (ADON) provided infection control training, including contact precautions, to all new hires. The DON confirmed NA #1 should have performed hand hygiene and donned a gown and gloves before entering Resident #54's room and performed hand hygiene after exiting the room. She indicated that these precautions were implemented for the protection of both the staff and other residents. During an interview with the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist (IP), on 1/4/26 at 12:57 PM, she stated NA #1 should have performed hand hygiene and donned a gown and gloves before entering Resident #54's room and should have performed hand hygiene after exiting the room. The facility had implemented contact precautions for Resident #54 due to a communicable disease. Contact precautions protected both the resident from any disease-causing microorganisms the NA could have introduced into the room and protected the NA from carrying disease-causing microorganisms from the resident to other residents and staff in the facility. The ADON added that she reminded nursing staff about contact precautions at least weekly and there was no reason for them to be unaware, as signs posted on the door stated hand hygiene and a gown and gloves were required before entering the room and hand hygiene was required upon exit. She confirmed NA #1 had received this training upon hire. In an interview with the Administrator on 1/4/26 at 2:54 PM, she stated that NA #1 should have noticed the contact precaution sign on Resident #54's door and followed the recommendations to perform hand hygiene and wear a gown and gloves before she entered the room and to perform hand hygiene upon exit. During an interview with the Nurse Practitioner on 1/6/26 at 2:55 PM, she stated that contact precautions were implemented for Resident #54 due to a diagnosis of a communicable disease. She added that contact precautions protected both the resident and staff from disease-causing microorganisms and prevented the spread of infections throughout the facility. 2. The policy regarding Enhanced Barrier Precautions (EBP) stated staff and visitors were required to perform hand hygiene and don a gown and gloves only for high-contact resident care with examples that included bathing/dressing and handling linens. Observation of Resident #24's door revealed signage for EBP on 1/5/26 at 10:21 AM. The signage indicated that staff providing high contact care to Resident #24 were required to wear gowns and gloves for high contact care such as bathing/dressing or changing linens. Further observation revealed a hanging organizer in Resident #24's room, to the left of the door, that contained Personal Protective Equipment (PPE) including gowns and gloves. After knocking on the door and receiving a reply, the door to Resident #24's room was opened and entered on 1/5/26 at 10:21 AM. NA #2 was observed in Resident #24's room wearing gloves and no gown and handling what appeared to be soiled linens. NA #2 dropped the linens onto a pile on the floor at the end of the resident's bed. When asked if she had been providing care, she stated she had just given the resident a bed bath. When asked if she had been wearing a gown, she questioned whether one was needed in that room as she did not think Resident #24 required EBP. When directed to the EBP sign on the door, she replied Oh, I didn't even notice because I was in a hurry and this resident always rushes me. I guess I should have been wearing a gown. While discussing the gown, NA #2 picked the pile of linen up off the floor, held it against her body, carried it across the room and dropped it on the floor next to the trash can by the door. NA #2 then took her personal fleece jacket off of a chair, while still wearing dirty gloves, and put her jacket on. When asked if the linens should be on the floor, she stated she just set them there for a minute while she put on her jacket. When asked if the soiled linen had been on the floor at the end of the bed, she stated Oh, yeah. NA #2 went on to say that soiled linens should not be on the floor and that she should have put them directly into a plastic bag when removed from the resident or bed. NA #2 indicated she had had training on EBP and handling soiled linen when she was hired about 5 months ago. During an interview with the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist (IP), on 1/5/26 at 10:30 AM, she stated NA #2 should have been wearing a gown while providing a bed bath to Resident #24 and handling his soiled linens. The facility had implemented EBP for Resident #24 due to a chronic wound. EBP protected both the resident from any disease-causing microorganisms the NA could have introduced into the room and protected the NA from carrying disease-causing microorganisms from the resident to other residents and staff in the facility. The ADON added that she reminded nursing staff about wearing EBP at least weekly and there was no reason for them to be unaware, as signs posted on the door stated a gown and gloves were required during close contact care such as bed baths and handling dirty linens. She further stated that staff were not to place soiled linens anywhere except in a plastic bag immediately after removing them from the resident or the bed and confirmed NA #2 had received this training upon hire. During an interview with the Director of Nursing (DON) on 1/5/26 at 10:34 AM she stated that NA #2 received education on checking resident room doors for precaution signs and following the recommended guidelines, including the safe handling of soiled linen. NA #2 should have worn a gown and gloves while performing a bed bath and handling soiled linens, and the linens should have been placed directly into a plastic bag. These measures were intended to prevent disease-causing microorganisms from transferring between the NA and the resident spreading to other residents in the facility. In an interview with the Administrator on 1/5/26 at 10:50 AM, she stated that NA #2 should have noticed the EBP sign on Resident #24's door and followed the recommendations to wear a gown and gloves. She added that NA #2 should have placed soiled linens directly into a plastic bag rather than on the floor to prevent disease-causing microorganisms from spreading throughout the room and being tracked into the facility. During an interview with the Nurse Practitioner on 1/6/26 at 2:45 PM, she stated that EBP was implemented for Resident #24 due to a chronic wound. She added that EBP protected both the resident and staff from disease-causing microorganisms and prevented the spread of infections throughout the facility. 3. Review of the Centers for Disease Control and Prevention (CDC) recommendations titled Infection Control Guidance: SARS-CoV-2 dated 6/24/24 revealed the CDC recommended asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Review of the policy and procedure for the facility titled Guidance and Protocol-COVID-19 dated 5/16/23 revealed when a resident was exposed to COVID-19, test immediately but generally not earlier than 24 hours after the exposure. Resident #76 was admitted to the facility on [DATE]. Review of a grievance for Resident #76 dated 9/5/25 revealed the resident felt he should be tested for COVID since his roommate had tested positive on 9/2/25. He was tested on [DATE] as a response to the grievance and was negative. During an interview on 1/5/26 at 2:57 PM the Assistant Director of Nursing stated she was a floor nurse during Resident #76's stay in the facility. Resident #76's roommate tested positive for COVID on 9/2/25. She stated if a resident was exposed to COVID the resident should be tested no sooner than 24 hours after exposure but as soon as possible and she would have tested Resident #76 prior to 9/5/25. The Assistant Director of Nursing explained she was not over infection control at that time, it was the Previous Assistant Director of Nursing. She concluded Resident #76 should have been tested prior to 9/5/25 according to their policy which reflects the CDC guidance for nursing homes. During an interview on 1/6/26 at 11:57 AM the previous Assistant Director of Nursing stated she remembered Resident #76 and she was over infection control in September 2025 and she was new to infection control at that time. She stated the previous Administrator told her they do not test for COVID unless a resident was symptomatic. She stated she was surprised by this because the other places she had worked had tested the entire hall after a resident ended up being positive for COVID. She stated Resident #76 was eventually tested but could not remember the specific details around why he was tested. During an interview on 1/6/26 at 1:51 PM the Director of Nursing stated she was not working for the facility at the time of this occurrence. Upon reviewing the timing of Resident #76's testing, and the fact that he had to complete a grievance to get tested after his initial exposure to COVID on 9/2/25, the Director of Nursing stated the previous infection preventionist did not follow their COVID testing policy which reflected the CDC guidance for nursing home testing. She concluded she would expect COVID testing to be completed according to their policy and CDC guidance. 4. Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions and last revised in October 2018 read in part; Enhanced Barrier Precautions (EBP), appropriate notification is placed above the residents bed so personnel and visitors are aware of the need for enhanced barrier precautions, the signage informs the staff of instructions for personal protective equipment (PPE) use while providing high contact care. The policy also stated in part, EBP requires the use of gown and gloves for high contact resident care activities in the resident room such as feeding tube. On 1/7/26 at 12:20 PM during an observation of enteral nutrition (delivers liquid nutrients and fluids directly into the gastrointestinal (GI) tract via a tube bypassing the mouth and throat) Nurse #2 entered Resident #8's room which had an EBP sign posted on the exterior of the door, to administer nutrition via gastrostomy tube (a hollow tube inserted directly through the skin of the abdomen into the stomach to deliver nutrition, hydration and medication). Nurse #2 performed hand hygiene prior to entering the room and donned (put on) a clean pair of gloves but did not don a gown. Nurse #2 administered nutrition using a feeding syringe (a large 2-part syringe used to administer nutrition) through a gastrostomy tube. An interview was conducted with Nurse #2 on 1/7/26 at 12:30 PM. She stated she forgot to don a gown during the enteral feeding activity, she went on to say she should have worn a gown. An interview with the Director of Nursing (DON) was conducted on 1/7/26 at 12:45 PM. She stated Nurse #2 should have worn a gown while providing enteral nutrition when an EBP sign was posted. An interview with the Administrator was held on 1/7/26 at 12:55 PM. She stated she expected Nurse #2 to wear a gown while providing enteral nutrition to a resident in a room where there was an EBP sign posted.

Based on record review and staff interviews, the facility failed to have a complete and accurate Treatment Administration Record (TAR) and failed to have a complete and accurate Medication Administration Record (MAR) for 4 of 19 residents reviewed for medical record accuracy (Resident #76, Resident #36, Resident #54, and Resident #51).Findings included: 1. Resident #76 was admitted to the facility on [DATE]. Review of Resident #76's physician orders revealed on 8/26/25 the resident had an order entered for his surgical left foot incision to be cleansed with Dakin's (a dilute solution bleach solution used as an antiseptic for wounds), pat dry, collagen particles Dakin's moistened gauze and abdominal gauze roll every day and as needed for wound care. Please read over the highlighted and revise- does not make sense. Review of Resident #76's TAR for September 2025 revealed there was no documented wound care on 9/2/25, 9/8/25, 9/13/25, 9/15/25, and 9/17/25. Review of Resident #76's wound care notes from 8/27/25 through 9/18/25 revealed his wound was decreasing in size and the wound care physician documented the wound as improving. During a telephone interview on 1/6/25 at 8:20 AM the previous Wound Care Nurse who was responsible for wound care for Resident #76 on 9/2/25, 9/8/25, 9/15/25, and 9/17/25 stated she completed wound care on those days but did not document it. During an interview on 1/5/26 at 3:56 PM the Assistant Director of Nursing who was responsible for wound care for Resident #76 on 9/13/25 stated she was covering the medication aide on 9/13/25 and did complete the wound care according to orders. She stated until it was just brought to her attention, she thought she had documented her wound care on the TAR but must have forgotten to document it. During an interview on 1/6/26 at 9:13 AM the Director of Nursing stated if wound care was completed it should be documented on the TAR to ensure the accuracy of their medical records. During an interview on 1/6/26 at 9:20 AM the Administrator stated her expectation was when wound care was completed, the wound care would be documented on the TAR to ensure the accuracy of their medical records. 2. Resident #36 was admitted to the facility on [DATE]. Resident #36's physician orders dated 4/28/25 revealed: -For the left leg with lymphedema: staff cleaned the leg with soap and water, applied triamcinolone, then applied a special gauze with Calamine, followed by rolled gauze and an ace wrap from the base of the toes to one inch below the knee, two times a week on Mondays and Thursdays. -For the right leg with lymphedema: staff cleaned the leg with soap and water, applied triamcinolone, then applied special gauze with Calamine, followed by rolled gauze and an ace wrap from the base of the toes to one inch below the knee, two times a week on Mondays and Thursdays. Review of the Treatment Administration Record (TAR) for August 2025 revealed Resident #36's treatments for the right and left leg were not marked completed as ordered on 8/21/25. Review of the TAR for September 2025 revealed Resident #36's treatments for the right and left leg were not marked completed as ordered on 9/8/25. During a telephone interview on 1/6/25 at 8:20 AM, Nurse #11 stated she completed the treatment orders for Resident #36 in August and September 2025 but forgot to mark them as complete on the TAR. She confirmed she was assigned to Resident #36 on the days in August and September that were not marked as complete. Nurse #11 further stated she always completed her treatments as assigned. Review of the TAR for November 2025 revealed Resident #36's treatments for the right and left leg were not marked completed as ordered on 11/24/25. During an interview on 1/6/25 at 9:10 AM, Nurse #8 stated she completed the treatments for Resident #36 on 11/24/25 but forgot to mark the task complete on the TAR. Review of the TAR for December 2025 revealed Resident #36's treatments for the right and left leg were not marked completed as ordered on 12/25/25. During an interview on 1/5/26 at 4:35 PM, the Assistant Director of Nursing (ADON) stated she was assigned to provide treatments for Resident #36 in 12/25/25. She added she provided the treatments but forgot to mark them as completed on the TAR. During an interview on 1/6/26 at 9:15 AM, the Director of Nursing (DON) stated staff should document treatments complete when they finish the task. An interview with the Administrator was conducted on 1/6/26 at 9:25 AM. She stated she would have expected the treatments to be documented as complete when the tasks were completed in real time. 3. Resident #54's physician orders revealed an order dated 8/13/25 for Lispro insulin 3 units to be administered subcutaneously 3 times a day with meals. Resident #54's Electronic Medication Administration Record (EMAR) for November 2025 revealed no nurse signature that indicated Lispro insulin 3 units was administered the following dates and times: - 11/20/25 at 8:30 AM, 12:00 PM, and 5:30 PM. - 11/21/25 at 8:30 AM - 11/29/25 at 5:30 PM In a telephone interview with Nurse #4 on 1/6/26 at 2:06 PM who was scheduled to work on 11/21/25 at 8:30 AM and 11/29/25 at 5:30 PM, she stated she did not recall those particular days, however, if she did not give insulin the EMAR should have been coded with a reason why. Nurse #4 added that she must have forgotten to sign the EMAR which left the boxes blank. During a telephone interview with Nurse #5 on 1/7/26 at 12:45 PM, she stated that she had been responsible for Resident #54 on 11/20/25 during the 7:00 AM to 7:00 PM shift. She explained that if the EMAR lacked a signature or code, it was because she had forgotten to sign it. Nurse #5 added that she did not recall a time she was not able to give insulin to Resident #54. In the final interview with the DON on 1/8/26 at 10:00 AM, she stated that there was no reason for Nurse #4 and Nurse #5 to have forgotten to sign the EMAR for Resident #54's insulin, as the resident name would have shown up as red when a medication had not been signed off as given, and green once it had been administered. She further stated that the EMAR system was set up this way to help nurses know which medications had been signed for and which had not. In an interview with the Administrator on 1/8/26 at 10:08 AM, she stated she was unaware there were medications unsigned for in Resident #54's EMAR. She further stated the EMAR system was set up to help nurses remember to give and sign off medications by highlighting the resident name with red if not signed off and green when it was signed off. 4. Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (DM II). A physician's order for Resident #51 with a start date of 10/22/25 and a discontinue date of 12/12/25 revealed Ozempic (semaglutide- medication for management of DM II and weight loss) (1 mg (milligram)/dose) subcutaneous solution pen injector 2 mg/1.5ml. Inject 1 mg subcutaneously (under the skin) one time a day every 7 days related to DM II. Ozempic (1 mg/dose) subcutaneous solution pen injector 2 mg/1.5ml (semaglutide) Inject 1 mg subcutaneously one time a day every 7 days related to DM II. Resident #51's October 2025 Medication Administration Record (MAR) revealed documentation on 10/23/25 at 9:30 AM by Nurse #7 indicating she administered Resident #51's Ozempic per the physician's order. On 1/6/26 at 9:46 in a telephone interview Nurse #7 stated she recalled being assigned to care for Resident #51 on 10/23/25 on the 7AM to 3PM shift. She reported her documentation on 10/23/25 at 9:30 AM indicating that she administered Resident #51's Ozempic was an error. She reported she recalled looking for the medication but not being able to find it. On 1/6/26 at 12:12 PM an interview with the Director of Nursing (DON) indicated that Nurse #7 should not have documented on Resident #51's MAR on 10/23/25 that she administered Ozempic 1 mg subcutaneously to Resident #51 if she had not actually administered it. On 1/8/26 at 8:38 AM an interview with the Administrator indicated that Nurse #7 should not have documented on Resident #51's MAR on 10/23/25 that she administered Ozempic 1 mg subcutaneously to Resident #51 if she had not actually administered it.

Based on record review and staff interviews, the facility failed to protect the residents' right to be free from misappropriation of money from their personal funds' accounts for 3 of 4 residents reviewed for misappropriation of property (Residents #51, #8, and #37).The findings included:a. Resident #51 was admitted to the facility 4/13/23. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 was cognitively intact. An interview with Resident #51 on 1/4/26 at 2:17 PM revealed she recalled that in November 2025 her personal funds of $50.00 were not available when requested. She added after asking several times for her funds she did eventually receive the funds on another day.b. Resident #8 was admitted to the facility on [DATE].The annual MDS assessment dated [DATE] revealed Resident #8 was cognitively intact.On 1/6/26 at 10:55 AM an interview was conducted with Resident #8. He stated the facility had a personal funds account for him and didn't recall a time when he did not receive his funds when requested.c. Resident #37 was admitted to the facility on [DATE].The annual MDS assessment dated [DATE] revealed Resident #37 was cognitively intact.An interview was conducted with Resident #37 on 1/5/26 at 11:30 AM. He stated he was told by the Business Office Manager the facility did not have the cash available to give him the $30.00 he requested from his personal funds on 11/4/25. He stated he had to wait until the 6th day of the month to receive his money. He indicated he received his funds after speaking with the previous Administrator as she gave him cash from her own funds. He did not recall the reason why his funds were not available upon request.An initial allegation report was submitted to the North Carolina Department of Health and Human Services Division of Health Service Regulation by the previous Administrator on 11/5/25 at 4:06 PM. The allegation of misappropriation of resident property was made on 11/4/25 when Residents #51, #8, and #37 alleged that they did not receive their personal funds when requested. The local law enforcement office was notified on 11/6/25 at 2:15 PM.The facility investigation report that was completed by the previous Administrator on 11/7/25 revealed on 11/4/25 residents had requested funds from their personal trust accounts from the previous Administrative Assistant. The previous Administrative Assistant had stated she placed the funds in envelopes with all 3 residents' names (Residents #51, #8, and #37) listed on the outside of the envelope. She then placed the envelopes inside her file cabinet and walked away. The file cabinet was left unattended and unlocked and when she returned the envelopes were empty. The previous Administrative Assistant was suspended and later that day on 11/4/25 her employment was terminated. A telephone interview on 1/6/26 at 2:30 PM with the previous Administrative Assistant revealed on 11/4/25 she had put the residents' personal funds in individual envelopes with cash in her desk and then went outside to supervise residents who were smoking. When she returned to her desk, the cash was gone. The previous Administrative Assistant did recall putting cash in labeled envelopes for Residents #51 ($50.00), #8 ($50.00), and #37 ($30.00).Attempts to interview the previous Administrator were unsuccessful.Attempts to interview the law enforcement officer that took the report on 11/4/25 regarding the misappropriation of resident funds was unsuccessful.An interview was held on 1/6/26 at 11:00 AM with the Business Office Manager. She stated that the previous Administrative Assistant told her on 11/4/25 she had placed Residents #51's, #8's, and #37's requested personal funds in separate envelopes labeled with their names in her desk drawer and then went outside, leaving the desk unattended and unlocked. The Business Office Manager stated she did not believe there was a system breakdown with the personal funds accounts that caused the funds unavailability but rather a bad employee. An interview was conducted on 1/6/26 at 11:20 AM with the Social Services Director. She stated that since the 11/4/25 incident of misappropriation of residents' personal funds, she had been tasked with dispersing personal funds to residents upon request. An interview with the Regional Business Office Manager was conducted on 1/6/26 at 2:00 PM. She stated in November 2025 she was in the facility when the allegation of misappropriation of residents' personal funds occurred. The Regional Business Office Manager reported she spoke with the previous Administrative Assistant on 11/4/25. She indicated when she asked the previous Administrative Assistant why the funds were not available upon the residents' request, the previous Administrative Assistant told her she had put the money in envelopes to be dispersed to residents, but when she returned to her desk, the envelopes were empty. The Regional Business Office Manager added that the facility requested funds from the corporate office and restored the resident accounts.An interview was conducted on 1/6/26 at 3:45 PM with the Administrator. She revealed she would expect the Business Office Manager or designee to administer and disperse residents' funds when requested. She added that the Administrative Assistant that was employed when the allegation of misappropriation of personal funds occurred on 11/4/25 was no longer employed by the facility. She went on to say the procedure for personal funds had been changed since this incident on 11/4/25 and stated the current Administrative Assistant was no longer involved in the personal funds' procedures for the residents.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of medications for 1 of 5 residents reviewed for medication administration (Resident #51).Findings included:Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2. Resident #51's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD, the last day of the assessment period) of 9/25/25 revealed she received insulin injections on 7 of the last 7 days.A review of Resident #51's September 2025 Medication Administration Record (MAR) revealed documentation of liraglutide (a non-insulin injectable medication for diabetes mellitus type 2) subcutaneous solution pen injector 1.8 milligrams (mg) subcutaneously (under the skin) one time a day for diabetes mellitus type 2 was administered at 8:00 AM daily from 9/18/25 through 9/25/25.On 1/13/26 at 2:04 PM a telephone interview with MDS Nurse #1 indicated she coded the medication section of Resident #51's MDS assessment dated [DATE]. She reported she coded insulin injections for 7 of 7 days because Resident #51 received liraglutide injections daily during this period. MDS Nurse #1 stated she had a reference sheet she found that she went by when coding medications and liraglutide was listed under insulins.On 1/13/26 at 2:07 PM a telephone interview with the Director of Nursing indicated MDS Nurse #1 coded Resident #51 as receiving insulin on the MDS assessment dated [DATE] because she had received liraglutide injections for her diabetes. She reported MDS assessments should be coded to accurately reflect the medications residents received.On 1/13/26 at 2:09 PM a telephone interview with the Administrator indicated residents' MDS assessments should be coded accurately.

Based on record review and resident, staff, Medical Director and Nurse Practitioner (NP) interviews the facility failed to administer medication as ordered by the physician for 1 of 5 residents reviewed for medication administration (Resident #51).Findings included:Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (DM II). Resident #51's quarterly Minimum Data Set (MDS) assessment dated 9/25 25 revealed she was cognitively intact.A physician's order for Resident #51 with a start date of 10/22/25 and a discontinue date of 12/12/25 revealed Ozempic (semaglutide- medication for management of DM II and weight loss) (1 mg (milligram)/dose) subcutaneous (under the skin) solution pen injector 2 mg/1.5ml. Inject 1 mg subcutaneously one time a day every 7 days related to DM II.On 1/5/26 at 3:15 PM an interview with Resident #51 indicated she was originally supposed to receive her first dose of Ozempic on 10/23/25, but she didn't receive her first dose until December. She reported since this had been resolved, she had begun getting her injections weekly.A pharmacy packing slip proof of delivery received via email communication with Pharmacist #1 on 1/6/26 at 10:09 AM revealed a confirmation signature on 10/22/25 at 12:34 AM by Nurse #10 that she received Ozempic 4mg/3ml for Resident #51 from the pharmacy.On 1/6/26 at 2:21 PM in a telephone interview Nurse #10 stated she did not recall what happened on 10/22/25. She reported that if her signature appeared on the proof of delivery slip on 10/22/25, this would indicate she received the medication from the pharmacy. She stated she did not usually work with Resident #51, so she would have given the medication to the nurse assigned to Resident #51 at that time.On 1/6/26 at 3:26 PM an interview with the Assistant Director of Nursing (ADON) indicated she was assigned to care for Resident #51 on 10/22/25 when her Ozempic medication was delivered from the pharmacy. She reported she recalled receiving the medication from Nurse #10, and she placed the medication into the medication refrigerator because Resident #51 had not been due for a dose on her shift.Resident #51's October 2025 Medication Administration Record (MAR) revealed documentation on 10/23/25 at 9:30 AM by Nurse #7 indicating she administered Resident #51's Ozempic per the physician's order.On 1/6/26 at 9:46 in a telephone interview Nurse #7 stated she recalled being assigned to care for Resident #51 on 10/23/25 on the 7AM to 3PM shift. She reported her documentation on 10/23/25 at 9:30 AM indicating that she administered Resident #51's Ozempic was an error. She reported she recalled looking for the medication but not being able to find it. She stated she should have called the pharmacy that day to find out why the medication had not been available, but she had gotten distracted and had forgotten.Resident #51's October 2025 Medication Administration Record (MAR) further revealed documentation on 10/30/25 at 9:30 AM by Nurse #4 indicating she did not administer Resident #51's Ozempic per the physician's order and to see the progress note.There was no corresponding nursing progress note for 10/30/25 to indicate why the medication was not given.On 1/5/2026 at 4:27 PM in a telephone interview Nurse #4 stated she recalled caring for Resident #51 on 10/30/25 on the 7AM to 3PM shift. She reported when she went to administer Resident#51's Ozempic medication that morning, it had not been available. She indicated she had looked everywhere, including in the medication room. She stated there had been other days when Resident #51 was due to receive this medication, but it had not been available. She stated she called the pharmacy at one point and had been told that a 28-day supply of the medication had been sent to the facility on [DATE], and no more could be sent. She stated she had not notified anyone that the medication had not been available. Nurse #4 reported she did not know why she had not done this.Resident #51's November 2025 Medication Administration Record (MAR) revealed documentation on 11/6/25 at 9:30 AM by Nurse #8 indicating that she administered Resident #51's Ozempic per the physician's order.On 1/6/26 at 8:09 AM an interview with Nurse #8 indicated she really couldn't recall exactly what happened on 11/6/25. She reported her documentation of Resident #51's MAR on 11/6/25 indicated that she had administered Resident #51's Ozempic per the physician's order. She stated she did not recall where she had gotten Resident #51's Ozempic medication or what she did with the pen after administering it to Resident #51.Resident #51's November 2025 Medication Administration Record (MAR) further revealed documentation on 11/13/25 at 9:30 AM by Nurse #4 indicating that she had not administered Resident #51's Ozempic per the physician's order.A nursing progress note dated 11/13/25 at 2:40 PM written by Nurse #4 indicated she had spoken to the pharmacy regarding Resident #51's Ozempic medication not being available for administration. Resident #51 had last received a dose of the medication on 11/6/25. The pharmacy had advised that a 28-day dose of the medication had been sent on 10/22/25, and a new 28-day supply could not be sent until 11/17/25. Nurse #4 reported this to Resident #51.Resident #51's November 2025 Medication Administration Record (MAR) further revealed documentation on 11/20/25 at 9:30 AM by Nurse #3 indicating that she had not administered Resident #51's Ozempic per the physician's order and to see the progress note.There was no corresponding nursing progress note for 11/20/25 to indicate why the medication was not given.On 1/6/26 at 4:24 PM in a telephone interview Nurse #3 stated she recalled caring for Resident #51 on 11/20/25 on the 7AM to 3PM shift. She reported Resident #51's Ozempic medication had not been available for her to administer. She stated she recalled calling the pharmacy on 11/20/25, and being told the medication would be sent. Nurse #3 reported she didn't know what happened after this. Resident #51's November 2025 Medication Administration Record (MAR) further revealed documentation on 11/27/25 at 9:30 AM by Nurse #4 indicating that she had not administered Resident #51's Ozempic per the physician's order and to see the progress note.There was no corresponding nursing progress note for 11/27/25 to indicate why the medication was not given.Resident #51's December 2025 Medication Administration Record (MAR) further revealed documentation on 12/4/25 at 9:30 AM by Nurse #9 indicating that she had not administered Resident #51's Ozempic per the physician's order and to see the progress note.There was no corresponding nursing progress note for 12/4/25 to indicate why the medication was not given.Attempts at telephone interview with Nurse #9 were not successful.A nursing progress note dated 12/5/25 at 11:51 PM written by Nurse #4 revealed Resident #51 reported to her that she had not been receiving her Ozempic medication and would like for someone to tell her what the status was. Resident #51 was her own Responsible Party (RP). Nurse #4 would continue to monitor this.On 1/6/26 at 8:20 AM an interview with the ADON indicated she was familiar with Resident #51. She stated she recalled an issue where nurses including Nurse #4 had been documenting that Resident #51's Ozempic medication had not been available, but had not notified her, the Director of Nursing, or a provider. The ADON stated she had initially become aware of the issue when she saw it documented on the 24-hour Nursing Report sheet by Nurse #4. She stated she thought this had been sometime in November or December 2025. She indicated as soon as she became aware there was an issue, she checked all the medication carts, and the medication refrigerator and could not locate the medication. The ADON reported she had no idea what could have happened to the Ozempic that was delivered by the pharmacy for Resident #51 on 10/22/25. She stated she had immediately notified the Nurse Practitioner (NP) and called the pharmacy to see how they could get the medication. On 1/7/26 at 12:31 PM an interview with the NP indicated as soon as she was notified by the facility that Resident #51 had not received her Ozempic as ordered, she addressed the issue. On 1/6/26 at 9:18 AM in a telephone interview Pharmacist #1 stated the first 28-day supply of Ozempic was set to the facility on [DATE]. Pharmacist #1 went on to say the next fill for the medication would have been due on 11/13/25, but due to the high cost of the medication, a preauthorization for filling the medication had been sent to the facility but had not been received back. He reported that due to the pharmacy not receiving this authorization back, there had been a delay in filling the Ozempic prescription for Resident #51, and the next supply had not been sent to the facility until 12/11/25.On 1/6/26 at 10:45 AM in a telephone interview the facility's Medical Director stated he had been made aware that Resident #51 had not been receiving her Ozempic as ordered by the Nurse Practitioner (NP). He stated there had been no harm to Resident #51 as a result of this incident because she had not experienced any blurred vision, recurrent urinary tract infections, or hospitalizations. On 1/6/26 at 12:12 PM an interview with the Director of Nursing (DON) indicated her understanding of the situation was that nurses were documenting Resident #51's Ozempic medication was not available but had not notified a provider of this. She reported it seemed some nurses had contacted the pharmacy, but they had not reported any issue with getting Resident #51's Ozempic to herself, or the ADON so the issue could be resolved. The DON stated if an ordered medication was not available, medication carts and all medication storage areas should be searched, the medication should be obtained from the back-up supply if available or the nurse should call the pharmacy for a refill and ask when it would arrive. She went on to say the nurse should also notify her or the nurse manager on call to let them know if there were issues. In a follow up interview on 1/8/26 at 8:06 AM the DON stated the preauthorization for filling Resident #51's Ozempic prescription would have been sent by the pharmacy to a facility fax machine. She reported she did not know what happened to this authorization form, as there was not a process in place regarding which fax machine they were set to, who retrieved them, or for getting them to her so she could follow-up.On 1/8/26 at 8:38 AM an interview with the Administrator indicated nurses should have communicated with the DON or ADON when Resident #51's Ozempic was not available. She indicated pharmacy communications and pre-authorizations should be followed up on. She stated as a result of the lack of communication, medication doses were missed, and it just became a cyclical issue.

Based on record review, and Medical Director, Nurse Practitioner (NP), staff and Responsible Party (RP) interviews, the facility failed to notify the physician/medical provider when an ordered medication was unavailable for administration (Resident #51) and failed to notify the resident's RP when a deep tissue pressure injury (DTI) developed on his right heel (Resident #78) for 2 of 3 residents reviewed for notification of changes (Resident #51 and Resident #78).Findings included: 1. Resident #51 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (DM II). Resident #51's quarterly Minimum Data Set (MDS) assessment dated 9/25 25 revealed she was cognitively intact. A physician's order for Resident #51 with a start date of 10/22/25 and a discontinue date of 12/12/25 revealed Ozempic (semaglutide- medication for management of DM II and weight loss) (1 mg (milligram)/dose) subcutaneous (under the skin) solution pen injector 2 mg/1.5ml. Inject 1 mg subcutaneously one time a day every 7 days related to DM II. A pharmacy packing slip proof of delivery received via email communication with Pharmacist #1 on 1/6/26 at 10:09 AM revealed a confirmation signature on 10/22/25 at 12:34 AM by Nurse #10 that she received Ozempic 4mg/3ml for Resident #51 from the pharmacy. Resident #51's October 2025 Medication Administration Record (MAR) revealed documentation on 10/30/25 at 9:30 AM by Nurse #4 indicating she did not administer Resident #51's Ozempic per the physician's order. On 1/5/2026 at 4:27 PM in a telephone interview Nurse #4 stated she recalled caring for Resident #51 on 10/30/25 on the 7AM to 3PM shift. She reported when she went to administer Resident#51's Ozempic medication that morning, it had not been available. She indicated she had looked everywhere, including in the medication room. She stated there had been other days when Resident #51 was due to receive this medication, but it had not been available. She stated she had not notified anyone including Resident #51's medical provider that the medication had not been available. Nurse #4 reported she did not know why she had not done this. Resident #51's November 2025 Medication Administration Record (MAR) further revealed documentation on 11/20/25 at 9:30 AM by Nurse #3 indicating that she had not administered Resident #51's Ozempic per the physician's order. On 1/6/26 at 4:24 PM in a telephone interview Nurse #3 stated she recalled caring for Resident #51 on 11/20/25 on the 7AM to 3PM shift. She reported Resident #51's Ozempic medication had not been available for her to administer. She stated she had not notified a provider that Resident #51's Ozempic had not been available for administration on 11/20/25. She could not say why. Resident #51's November 2025 MAR further revealed documentation on 11/27/25 at 9:30 AM by Nurse #4 indicating that she had not administered Resident #51's Ozempic per the physician's order. Resident #51's December 2025 MAR revealed documentation on 12/4/25 at 9:30 AM by Nurse #9 indicating that she had not administered Resident #51's Ozempic per the physician's order. Attempts at telephone interview with Nurse #9 were not successful. On 1/6/26 at 8:20 AM an interview with the Assistant Director of Nursing (ADON) indicated she was familiar with Resident #51. She stated she recalled an issue where nurses including Nurse #4 had been documenting that Resident #51's Ozempic medication had not been available but had not notified a provider. The ADON reported Nurse #4, and the other nurses had not followed the proper protocol when the medication had not been available to administer to Resident #51, which would have been to immediately notify a medical provider to see if any alternate medications or other orders were required. On 1/7/26 at 12:31 PM an interview with the NP indicated a medical provider should have been made aware immediately when Resident #51's Ozempic was not available. On 1/6/26 at 10:45 AM in a telephone interview the facility's Medical Director stated there had been no harm to Resident #51 as a result of this incident because she had not experienced any blurred vision, recurrent urinary tract infections, or hospitalizations. The Medical Director reported he would have expected for a medical provider to be notified immediately when Resident #51's Ozempic medication was not available so alternate medication and monitoring orders could have been provided. He stated when the NP notified him of the issue, she assured him that Resident #51 was back on track. On 1/6/26 at 12:12 PM an interview with the Director of Nursing (DON) indicated her understanding of the situation was that nurses were documenting Resident #51's Ozempic medication was not available but had not notified a medical provider of this. She indicated if the medication was unavailable for administration a provider should be notified immediately for alternative medications or further interventions. On 1/8/26 at 8:38 AM an interview with the Administrator indicated nurses should have notified a provider immediately when Resident #51's Ozempic was not available. 2. Resident #78 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #78 was severely cognitively impaired and had one unhealed pressure ulcer. Resident #78's wound progress note dated 5/22/25 indicated that care had been reestablished at that time due to the development of a new DTI on the resident's right heel, measuring 3.5 cm (centimeters) x 3.5 cm x 0 centimeters cm. The plan included applying skin prep (creates a protective film on intact skin) to the heel once daily and offloading pressure. It was also documented that the plan had been discussed with both the staff and the resident. The progress note was signed by the Wound Care Nurse Practitioner. Resident #78's medical record did not reveal documentation indicating the previous wound care nurse contacted Resident #78's RP. Attempts to reach the Wound Care Nurse Practitioner for interview were unsuccessful. Attempts to interview the previous Wound Care Nurse about whether Resident #76's RP was notified of the new DTI on his right heel were unsuccessful. Resident #78's physician orders indicated the following: On 5/23/25, Nurse #1 entered an order to apply skin prep to the right heel daily and as needed for a DTI, and to offload pressure. On 6/2/25, an additional order was entered by Nurse #1 for Prevalon boots (special boots designed to offload pressure from the feet) to be worn while the resident was in bed. Attempts to contact Nurse #1 for interview were unsuccessful. In a telephone interview with Resident #78's RP on 1/4/26 at 10:59 AM, she stated that no one had notified her that the resident had developed a DTI on his right heel. She added that she had not learned of the pressure wound until he had been transferred to the hospital in September 2025. An interview was conducted with the Assistant Director of Nursing (ADON) on 1/6/26 at 12:36 PM. She stated that she had worked as a staff nurse in May 2025 and explained that when a new skin issue was identified, the process was for the nurse to contact the physician or the on-call provider to obtain orders and to notify the resident or the responsible party (RP), if applicable. The ADON reviewed Resident #78's medical record and did not find documentation that his RP was notified of the DTI on his right heel. In an interview with the Director of Nursing (DON) on 1/7/26 she stated that after reviewing Resident #78's medical record, she noted there was no documentation indicating that his RP had been notified of the (DTI) to his right heel. In an interview with the interim Administrator on 1/8/25 at 10:50 AM, she stated she had been unaware that residents' RPs were not being informed of new skin concerns, such as DTIs. The Administrator added that RPs should be notified of new skin concerns after the physician was called and orders for treatment were obtained. She reported that the nurse should document the notification in the medical record.

Based on record review and staff, Pharmacist, Medical Director, Nurse Practitioner and Physician interviews, the facility failed to ensure the attending physician was informed of the pharmacy recommendation to clarify a physician's order for carvedilol (medication in the class of alpha and beta blockers used to treat conditions affecting the heart and blood vessels) for 1 of 5 residents reviewed for unnecessary medications (Resident #7).Findings included:Resident #7 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure) and heart failure.A Report of Consultation document from Resident #7's Cardiologist dated 12/5/25 included a handwritten portion completed and signed by Physician #2 which revealed Resident #7 had coronary and peripheral artery disease (narrowing or blockage of the arteries in the heart and legs, pelvic area or arms). The recommendation was to increase Resident #7's carvedilol to 37.5 mg twice daily and to check Resident #7's blood pressure with a goal of systolic (the hearts contraction phase measuring peak pressure in the arteries) blood pressure of 110 (mmHg-millimeters of mercury) to 130 (mmHg-millimeters of mercury). A printed portion of the document titled After Visit Summary Instructions revealed increase carvedilol to 3.125 milligrams twice daily. An additional printed portion titled Your Medication List revealed carvedilol 25 mg take 1.5 tablets (37.5 mg total) by mouth in the morning and 37.5 mg by mouth in the evening.A physician's order for Resident #7 with a start date of 12/5/25 entered by Nurse #12 revealed carvedilol 3.125 mg twice daily by mouth for hypertension.The pharmacist recommendation for Resident #7 dated 12/8/25 written by Pharmacist #2 revealed Physician #2 increased Resident #7's carvedilol on 12/5/25. Resident #7's carvedilol went from 25 mg twice daily to 3.125 mg daily on her Medication Administration Record (MAR). This was a big decrease in carvedilol. Clarify the carvedilol dose and order on her MAR. There was no indication this had been reviewed by a medical provider.On 1/7/26 at 11:35 AM a telephone interview with Pharmacist #2 indicated she completed Resident #7's initial medication regime review (MRR) on 12/8/25. She reported she noted the discrepancy between Resident #7's initial admission carvedilol dose of 25 mg twice daily, the recommendation by Physician #2 on 12/5/25 to increase Resident #7's carvedilol to 37.5 mg twice daily, and the facility's order for a significantly decreased dose of carvedilol 3.125 mg twice daily. Pharmacist #2 stated she had sent a recommendation to the DON to clarify this discrepancy by email on 12/8/25. On 1/7/25 at 12:54 PM an interview with the Director of Nursing (DON) indicated she would have received the Consultant Pharmacist's Progress Note admission MRR for 12/8/25 on 12/8/25 or a few days later in her email. She reported she did not check her email daily and had not been aware of the recommendation to clarify the physician's order for Resident #7's carvedilol until 1/7/26. She reported it would have been her responsibility to provide this clarification recommendation to the provider for review, but she had not gone through these reviews for December 2025 yet.On 1/7/26 at 12:31 PM an interview with the Nurse Practitioner (NP) indicated she did not receive any pharmacy recommendations from the facility. She reported these would be handy to have. The NP stated if she had been given Resident #7's pharmacy recommendation from 12/8/25, she would have addressed it.On 1/7/26 at 2:12 PM a telephone interview with the Medical Director indicated he received the pharmacy recommendations from facilities if they gave them to him. He reported he had not received the recommendation from 12/8/25 for Resident #7. He stated this should have been provided to him within a few days of the facility's receiving it so he could have addressed it. The Medical Director indicated it should not have taken a month.On 1/8/26 at 8:38 AM an interview with the Administrator indicated there should be a be an effective process in place for addressing pharmacy recommendations.

Based on observations and staff interviews, the facility failed to keep medications in a locked treatment cart for 1 of 2 treatment carts observed (Treatment Cart #1).Findings included:During observation on 1/5/26 at 8:32 AM Treatment Cart #1 was observed with the locking mechanism in the unlocked position on the 100-hall outside of a resident's room. The face of the cart was pointed at a resident's room and the resident's room door was open. The privacy curtain was pulled around the resident as well as the Wound Care Nurse. The transport driver was approximately 15 feet away from the unlocked treatment cart and there were no other individuals observed. The surveyor was able to step between the resident's doorway and the unlocked treatment cart without touching the treatment cart. The Wound Care Nurse was behind the privacy curtain and could not be seen by the surveyor. At 8:35 AM the Wound Care Nurse returned to the treatment cart from behind the privacy curtain. During an interview on 1/5/26 at 8:35 AM the Wound Care Nurse stated she was unable to visualize the unlocked treatment cart while in the resident's room and did not know the surveyor was standing there. Upon observing Treatment Cart #1 she stated it was unlocked and should be locked when unattended. The Wound Care Nurse confirmed the treatment cart was out of her sight while she was providing care. During observation on 1/5/26 at 8:36 AM the contents of Treatment Cart #1 were observed to include A&D ointment (a topical emollient that contains vitamin A and vitamin D to treat diaper rash, dry skin, and skin irritation), Manuka Honey (a gel treatment for wound care, offering antibacterial, anti-inflammatory, and healing properties), Chymosin topical (a skin barrier ointment that provides protection and relief from irritation, commonly used for diaper rash, minor cuts, and other skin conditions), Cadexomer Iodine Gel 10 grams/0.35 ounce (a sterile antimicrobial dressing formulation of Cadexomer Iodine), Diclofenac Gel diclofenac sodium topical gel 1% (a nonsteroidal anti-inflammatory drug (NSAID) that helps reduce inflammation and pain when applied to the skin), Triamcinolone cream 0.5% (a topical corticosteroid used to treat various inflammatory skin conditions such as eczema, psoriasis, dermatitis, and rashes), Collagenase Santyl ointment 250 units/gram (a sterile enzymatic debriding ointment used to help clean and remove dead tissue from wounds, such as ulcers and severe burns), triamcinolone acetonide cream 0.1% (a topical corticosteroid used to treat various inflammatory skin conditions such as eczema, dermatitis, psoriasis, and rashes. It works by reducing itching, redness, and swelling associated with these conditions), nystatin topical powder (an antifungal medication used to treat fungal or yeast infections of the skin, particularly those caused by the Candida species), and Dyna-hex 4 Chlorhexidine Gluconate 4% solution (a Chlorhexidine Gluconate 4% solution used as an antiseptic for skin disinfection and surgical scrubs). During an interview on 1/5/26 8:41 AM the Director of Nursing stated any time any treatment or medication cart was out of view of the nurse, it should be locked.

Based on record review and staff interview, the facility failed to ensure a consent was documented prior to administering the Influenza vaccination for 1 of 5 residents reviewed for vaccination status (Resident #80).Findings included:Resident #80 was admitted to the facility on [DATE].Review of Resident #80's Medication Administration Record for September 2025 revealed she received the Influenza vaccine on 9/22/25.Review of Resident #80's only immunization consent form in her medical record dated 11/20/25 revealed Resident #80 left the Influenza vaccination selection blank and did not sign consent for the Influenza vaccine. During an interview on 1/8/26 at 10:18 AM the Director of Nursing stated there was no consent on file for Resident #80 regarding the flu vaccination for 9/22/25. She further stated consents should always be acquired prior to administration of a vaccine and maintained in the resident's medical record.

Based on record review, staff and Nurse Practitioner (NP) interview, the facility failed to obtain consent and inform the resident's Responsible Party (RP) of the risks and benefits of psychotropic medications prior to initiation or the treatment alternatives available. The deficient practice was identified for 1 of 5 residents reviewed for unnecessary medications (Resident #54). Findings included: Resident #54 was admitted to the facility on [DATE] with diagnoses that included stroke and non-Alzheimer's dementia. Review of Resident #54's physician orders revealed:- Mirtazapine (antidepressant) 7.5 mg, 1 tablet to be given by mouth at bedtime for depression with a start date of 10/7/25. - Trazodone (antidepressant) oral tablet 100 milligram (mg), 1 tablet to be given by mouth in the afternoon for depression with a start date of 11/13/25. Resident #54's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired, had no behaviors and received antidepressant medications. Resident #54's Medication Administration Record for January 2026 revealed the Mirtazapine and Trazodone were initialed by a nurse indicating they had been administered daily. Resident #54's medical record revealed no information indicating her RP was informed in advance of the risks and benefits of initiating treatment with Trazodone and Mirtazapine or the treatment alternatives available or that consent was obtained. Attempts to reach Resident #54's RP were unsuccessful. In an interview with the Assistant Director of Nursing (ADON) on 1/7/26 at 3:44 PM she stated she was unsure who was responsible for obtaining consent for the use of psychotropic medications. During an interview with the Director of Nursing (DON) on 1/7/26 at 3:53 PM she stated that she had been aware that some consents for psychotropic medications were not signed because the Social Worker (SW) had previously been responsible for obtaining the consents, but nursing had not always informed the SW when a new psychotropic medication was ordered. During an interview with the SW on 1/7/26 at 4:02 PM, she stated she had been responsible for obtaining consents for psychotropic medication until recently. The SW explained that nursing staff were expected to notify her whenever a new psychotropic medication order was issued; however, this did not always occur, resulting in some missed consents. In an interview with the Nurse Practitioner (NP) on 1/7/26 at 4:15 PM, she stated nursing staff were responsible for obtaining consent for the use of newly prescribed psychotropic medications. During an interview with the Administrator on 1/8/26 at 9:54 AM, she stated she had not been aware Resident #54 lacked a signed consent for the psychotropic medications Trazodone and Mirtazapine. She further stated that she had been aware consents should have been obtained prior to the implementation of the medications.

Based on interviews with residents and staff, the facility failed to ensure residents' right to receive mail delivered on Saturdays. This had the potential to affect 67 of 67 residents in the facility. The findings included: During a Resident Council meeting on 1/6/26 at 1:00 PM, members reported that mail was not delivered on Saturdays. Residents present included #71, #14, #19, #56, and #62. They stated that the Activities Director delivered mail Monday through Friday and only on Saturdays if she was in the facility. An interview was conducted on 1/6/26 at 1:16 PM with the Activities Director and she stated that on weekends, the manager on duty retrieved mail from the outdoor mailbox and placed it in the Business Office Manager's office. However, mail was not delivered to residents' rooms on Saturdays. The mail was given to her on Monday for delivery to residents. An interview was conducted with the Business Office Manager on 1/6/26 at 1:25 PM and she confirmed that weekend managers retrieved mail but did not distribute it because they were unsure which mail belonged to residents. She stated that managers gave the mail to her, and she passed it to the Activities Director on Mondays for delivery. An interview was conducted with the Administrator on 1/6/26 at 1:30 PM, she stated that her expectation was for staff to deliver mail Monday through Saturday, including Saturdays, by the manager on duty.

Based on record reviews, staff interviews, and a resident interview, the facility failed to protect a resident's right to be free from resident-to-resident physical abuse when Resident #3 struck Resident #4, resulting in a bruise to the right side of the face. This occurred for 1 of 3 residents reviewed for abuse (Resident #4). Findings included:Resident #3 was readmitted to the facility on [DATE].Documentation on an annual Minimum Data Set assessment dated [DATE] revealed Resident #3 was cognitively intact.Resident #4 was admitted to the facility on [DATE].Documentation on a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #4 had moderately impaired cognition.Documentation in a behavior note for Resident #3 dated 8/27/2025 at 2:45 PM written by the Assistant Director of Nursing (ADON) revealed the following information. The ADON heard yelling in the dining room area and went to the dining room. Resident #3 indicated to the ADON that Resident #4 needed help getting through the doorway in his wheelchair from the outside. Resident #4 began to curse and call Resident #3 a racially charged name. As the ADON removed Resident #4 from the doorway, both Resident #3 and Resident #4 began to curse at each other. Resident #3 propelled himself in his wheelchair toward Resident #4 with his hand raised to hit him. The ADON told Resident #3 not to hit Resident #4, but Resident #3 then slapped Resident #4 on the right side of the face. Resident #4 was assisted in his wheelchair to the nursing station.The ADON was interviewed on 10/8/2025 at 12:11 PM. The ADON confirmed Resident #3 struck Resident #4 as she was attempting to pull Resident #3 out of the way. The ADON indicated Resident #4 refused to stop calling Resident #3 a racially charged name so Resident #3 slapped him. The ADON stated afterward the police were called and Resident #4 could not recall the incident. The ADON confirmed Resident #3 was charged with assault and had already made an initial court appearance. The ADON confirmed Resident #4 had a small bruise on the right side of his head after being struck by Resident #3.Resident #3 was interviewed on 10/8/2025 at 11:40 AM. Resident #3 explained that Resident #4 was outside and was trying to get into the building but was stuck in the doorway. Resident #3 further explained that he shouted for help until the ADON came into the dining room and he pointed to Resident #4 to let her know he was the one who needed help. Resident #3 stated that Resident #4 started cursing at him and called him a racially charged named that was very disrespectful. Resident #3 revealed he tried to hit Resident #4 but never made contact because the ADON pulled Resident #4 out of the way. Resident #3 confirmed the police were called but the ADON told the police Resident #3 struck Resident #4. Resident #3 confirmed he had already been to court, and the case had a continuation date. Resident #3 explained that Resident #4 had apologized to him and there were no further issues or problems between the two residents.Resident #4 was interviewed on 10/8/2025 at 11:50 AM. Resident #4 did not recall any incident or occasion for which he was slapped or hit at the facility. Resident #4 denied knowledge of any altercations he had involving Resident #3.The Administrator was interviewed on 10/8/2025 at 2:12 PM. The Administrator stated that after Resident #3 hit Resident #4 the police were called. The Administrator confirmed Resident #3 was charged with assault. The Administrator also confirmed Resident #4 was assessed by a provider, ice was applied to his face, and he was moved to a different hallway away from Resident #3. The Administrator stated Resident #3 and Resident #4 have not had any further issues.

Based on record review, staff interviews, and resident interviews, the facility failed to act in a dignified manner toward (Resident #1) and within hearing distance of (Resident #3) for 2 of 3 residents reviewed for dignity (Resident #1 and Resident #3). Findings included:Resident #1 was admitted on [DATE] and discharged on 9/25/2025.Documentation on an admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 as cognitively intact.Documentation in a behavior note dated 9/24/2025 at 3:29 PM written by the Administrator revealed, Resident [#1] requested to speak with Administrator concerning nursing care. [Resident #1] became very demanding requesting that the nurse who documented his refusal be brought in to see him. The issue had been addressed and taken care of two weeks ago. When suggesting that we move forward with today's plan of care [Resident #1] became belligerent, stating, you don't tell me to move forward. You can just kiss my [vulgar word]. [Resident #1] was then advised that his tone was not acceptable and would not be tolerated. He continued with raising his voice and approached the Administrator in a threatening manner. He was advised to step back because he was too close. He then went to his room. The local authorities were called due to his belligerence. Two officers came in to speak with him regarding his behavior. He was advised that any further acts of aggression could possibly lead to removal.Resident #1 was interviewed on 10/9/2025 at 3:26 PM. Resident #1 confirmed he got into a heated argument with the Administrator on 9/24/2025 in the hallway. Resident #1 stated that all the staff members came out of their offices to watch. Resident #1 stated the Administrator was just as loud as he was and called law enforcement on him. An interview was conducted with the Assistant Director of Nursing (ADON) on 10/8/2025 at 9:55 AM and the following information was obtained regarding the events on the morning of 9/24/2025. The ADON was in her office when she heard loud arguing and she got up to see the source. The Administrator and Resident #1 were in the hallway in the front of the building loudly arguing. Several of the management staff were standing in the hallway watching. The ADON called out to Nurse Aide #5 at the nursing desk to call the police. The ADON stated it was not appropriate behavior for a nursing home.Nurse Aide #5 was interviewed on 10/8/2025 at 3:17 PM. Nurse Aide #5 stated she was standing at the nursing desk and observed the Administrator and Resident #1 hollering at each other. Nurse Aide #5 confirmed that the ADON asked her to call the police to the facility, and she did so.The Activities Director was interviewed on 10/8/2025 at 10:31 AM and the following information was provided. The Activities Director was in the hair salon, located in the front hallway of the building, with Resident #3 on the morning of 9/24/2025. Resident #1 asked the Administrator a question and the Administrator responded that she did not know the answer. It was almost lunch time, and the Administrator and Resident #1 were outside the dining room. Resident #1 was swearing at the Administrator and the Administrator responded that she was not going to let him disrespect her. It was very loud, and the police were called.Documentation in an annual MDS assessment dated [DATE] revealed Resident #3 was coded as cognitively intact.Resident #3 was interviewed on 10/8/2025 at 11:40 AM and provided the following information. Resident #3 stated it was around 10:00 AM or 11:00 AM on 9/24/2025 and he was in the hair salon getting his hair done by the Activity Director. Resident #3 stated he heard it all. There was a back-and-forth verbal exchange between the Administrator and Resident #1. Resident #3 could not recall the exact words that were spoken but Resident #1 was threatening the Administrator and cursing her. Instead of diffusing the situation the Administrator was amping him up. Resident #3 stated it was undignified and unprofessional on both part of both the Administrator and Resident #1.The Rehabilitation Program Manager was interviewed on 10/8/2025 at 1:10 PM and relayed the following information. On 9/24/2025 before lunch the Rehabilitation Program Manager heard louder than normal talking outside the therapy room. The Rehabilitation Program Manager looked out into the hallway from the therapy room door and saw the Administrator, Resident #1, and other staff members standing around watching. It was very noisy out there. The Rehabilitation Program Manager asked the Administrator if she was okay, to which she replied she was fine. The Rehabilitation Program Manager returned to the therapy office and requested the Physical Therapy Assistant go out into the hallway to deescalate the situation because she had a rapport with Resident #1 and the Administrator.The Physical Therapy (PT) Assistant was interviewed on 10/08/2025 at 1:12 PM and provided the following information. The PT Assistant was working on documentation in the physical therapy room. Directly outside the room she could hear fussing and words were said back and forth. The PT Assistant opened the door and looked in the hallway to see the Administrator and Resident #1 having a loud argument. The Rehabilitation Program Manager asked the PT Assistant to remove her. The PT Assistant came out of the door of the physical therapy room, came up behind the Administrator and asked the Administrator to come with her. The PT Assistant led the Administrator out into the parking lot where they walked around the parking lot until the police officers arrived requesting to speak to her. The police, the Administrator and PT Assistant then returned to the facility through the front lobby.The Director of Nursing (DON) was interviewed on 10/8/2025 at 2:46 PM and she provided her observations and recollection of the events of the morning of 9/24/2025. The DON was sitting in her office, which was in the front hallway across from the physical therapy room. The DON heard yelling and a commotion in the hallway, so she went to see what was happening. In the hallway the Administrator was against the wall near the therapy room and Resident #1 was against the opposite wall. Resident #1 was not listening to the Administrator, and it was getting loud. The ADON asked a nurse aide at the nursing desk to call the police. The PT Assistant came out of the therapy room and took the Administrator outside the building. Resident #1 then returned to his room. The DON returned to her office but did note the police arriving shortly thereafter to speak to Resident #1.The Administrator was interviewed on 10/8/2025 at 2:12 PM. The Administrator stated on 9/24/2025 she was told that Resident #1 wanted to speak to her. The Administrator said she saw Resident #1in the dining room and told him she had heard he was looking for her. The Administrator indicated Resident #1 became immediately aggressive, intimidating, and verbally abusive. The Administrator stated she walked into the hallway to avoid being in an enclosed room with Resident #1. The Administrator stated her voice elevated as Resident #1's voice elevated in the hallway. The Administrator stated she was trying to let Resident #1 know that he could not speak to her and the nursing staff in the manner he was speaking. The Administrator indicated that she then returned to her office and Resident #1 returned to his room. The Administrator was questioned about the involvement of the PT Assistant. The Administrator confirmed the PT Assistant took her outside to go for a walk, the police arrived, and she then returned to the building and her office. The Administrator added that she asked the police to talk to Resident # 1, requesting him to not behave in that manner anymore, as he was soon scheduled to leave the facility for home.

Based on observation, record review and staff interview, the facility failed to: a.) follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when Nurse #1 and Nurse Aide (NA) #1 provided wound care without wearing gowns for 2 of 2 staff observed for infection control (Nurse #1 and NA #1) and b.) to implement their policy for EPB for the current 41 of 61 residents that required the precautions due to chronic wounds or indwelling medical devices. The findings included: The facility policy titled Isolation-Categories of Transmission Based Precautions dated October 2018 stated in part: 1. EBP requires the use of gown and gloves only for high contact resident care activities (unless otherwise indicated as part of Standard Precautions). a.) High contact resident care activities: in the resident room to include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. 2. Residents are not restricted to their rooms and do not require placement in a private room. EBP is intended to be in place for the duration of a resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 3. Enhanced Barrier Precautions (EBP) are recommended for residents with indwelling medical devices and wounds who do not otherwise meet the criteria for Contact Precautions, even if they have no history MDRO colonization or infection and regardless of whether others in the facility are known to have MDRO colonization. This is because devices and wounds are risk factors that place these residents at higher risk for carrying or acquiring an MDRO and many residents colonized with an MDRO are asymptomatic or not presently known to be colonized. a.) An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples include but are not limited to, central vascular lines including hemodialysis catheters, indwelling urinary catheters, feeding tubes and tracheostomy tubes. b.) A wound is defined as the care of any skin opening requiring a dressing. However, the intent of EBP is to focus on residents with a higher risk of acquiring an MDRO over a prolonged period of time. This generally includes residents with chronic wounds, and not those with only shorter-lasting wounds such as skin breaks or skin tears covered with a Band Aid or similar dressing. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers. The policy further stated that for EBP, appropriate notification was placed above the resident's bed so personnel and visitors are aware of the need for EBP and the signage informs staff of instructions for PPE use while providing high contact resident care activities. a.) An observation of Nurse #1 and NA #1 providing wound care to Resident #5 was conducted on 5/28/25 at 11:55 AM. There was no signage indicating Resident #5 required EBP for high contact care observed inside or outside of the room. NA #1 was present to assist with repositioning Resident #5. Nurse #1 and NA #1 were observed performing hand hygiene and donning gloves before repositioning Resident #5 and starting wound care. Neither Nurse #1 nor NA #1 donned a gown before providing high contact care to Resident #5. An interview was conducted with Nurse #1 on 5/28/25 at 12:30 PM. Nurse #1 indicated she was the facility's Wound Care Nurse, and she had no residents on her wound care list that required EBP. She indicated that Resident #5 had chronic wounds that she treated daily. Nurse #1 further stated she had not received education about EBP at any time since she was hired in February 2025 and was under the impression EBP was for residents with an infectious disease such as influenza. In an interview with NA #1 on 5/28/25 at 12:35 PM she stated she had not been trained on EBP since she was hired and did not have any residents on EBP. NA #1 was not aware of indications for a resident to be on EBP. b.) Observations of resident rooms in all halls on 5/28/25 revealed no signage indicating any resident required EBP, nor any Personal Protective Equipment (PPE) used for EBP readily available. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/28/25 at 12:11 PM. The ADON indicated she was also the Infection Preventionist for the facility. She stated that there were no residents in the facility that required EBP, that she knew it was a new thing for residents with intravenous lines but hadn't looked into it yet as she just started in February 2025. The ADON revealed she was also responsible for training staff on infection prevention and control but had yet to start a training program. The ADON stated she was unaware that residents with chronic wounds and indwelling medical devices would require EBP with high contact care. In an interview with the Director of Nursing (DON) on 5/28/25 at 12:31 PM she stated the facility had no residents on EBP. She was aware EBP was to be used for residents with chronic wounds and indwelling medical devices and was able to give examples of such. She indicated that Nurse #1 and NA #1 should have been wearing gowns while completing wound care for Resident #5. The DON further stated she was unsure why EBP was not implemented in the facility as she had just started there 4 weeks ago. An interview was conducted with the Administrator on 5/28/25 at 1:38 PM. The Administrator was unable to say why EBP was not implemented in the facility or why Nurse #1 and NA #1 were not wearing gowns while proving high contact care for Resident #5. She was unsure if staff received training on EBP at any time and did not know the regulation. A list of 41 residents that had chronic wounds or indwelling medical devices and required EBP was provided by the Administrator on 5/28/25 at 2:10 PM which included resident's names and the reasons they should have been on EBP prior to 5/28/25.

Based on record review and staff interviews, the facility failed to designate a qualified Infection Preventionist who was certified in infection prevention and control, to be responsible for the facility's Infection Control and Prevention Program. This had the potential to affect 72 of 72 residents in the facility. The findings included: During an interview with the Assistant Director of Nursing (ADON) on 5/28/25 at 12:11 PM the ADON indicated she was also the facility's Infection Preventionist (IP) and stated she was responsible for oversight of infection control duties. The ADON further stated she had worked at the facility since late February 2025 and had completed 13 of the 20 modules needed to obtain IP certification through the Centers for Disease Control and Prevention (CDC) IP program. The ADON was not aware she had to have IP certification to hold the position of IP. In an interview with the Director of Nursing (DON) on 5/28/25 at 1:38 PM she stated she was aware the ADON did not yet have an IP certification and the ADON was working on it through the CDC IP program. The DON further stated she had been encouraging the ADON to complete her certification as soon as possible. The DON was not aware the ADON needed to hold an IP certification to be the facility IP. She thought it was adequate that the ADON was working toward her certification. An interview was conducted with the Administrator on 5/28/25 at 2:14 PM. The Administrator stated she was aware the ADON was also the facility's IP but was unaware the ADON did not yet have her IP certification.

Based on observation, record review, and staff interview, the facility failed to have an effective system in place to train nurses and nurse aides (NAs) and verify their competency with infection control policies for Enhanced Barrier Precautions (EBP). The Assistant Director of Nursing (ADON)/Infection Preventionist (IP) who was responsible for training staff on infection control practices and procedures was unaware that residents with chronic wounds and indwelling medical devices required EBP with high contact care. Nurse #1 and NA #1 failed to follow the infection control policy by providing wound care for a resident with chronic wounds without wearing gowns. The facility had 41 residents that required EBP due to chronic wounds or indwelling medical devices. This deficient practice was identified for 3 of 3 staff (ADON/IP, Nurse #1, and NA #1) reviewed for competency and had the potential to affect other facility residents. Findings included: This tag is cross-referenced to: F880: Based on observation, record review and staff interview, the facility failed to: a.) follow their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a chronic wound when Nurse #1 and Nurse Aide (NA) #1 provided wound care without wearing gowns for 2 of 2 staff observed for infection control (Nurse #1 and NA #1) and b.) to implement their policy for EPB for the 41 residents that required the precautions due to chronic wounds or indwelling medical devices. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/28/25 at 12:11 PM. The ADON revealed she was responsible for training staff on infection prevention but had yet to start a training program. In an interview with the Director of Nursing (DON) on 5/28/25 at 12:31 PM. She indicated she was unaware staff were not trained or competent in the use of EBP. An interview was conducted with the Administrator on 5/28/25 at 1:38 PM. She stated she was unsure if staff received training on EBP at any time.

Based on record review and staff interviews, the facility failed to maintain evidence of grievance investigation and decisions for 3 of 3 residents reviewed for grievances (Resident #1, Resident #2 and Resident #3). Findings included: A review of the facility's grievance policy dated April 2017 stated in part: 4. The investigation and report would include: f.) employee account of the alleged incident and h.) recommendations for corrective action. a.) Resident # 1 was admitted to the facility on [DATE]. A review of the grievance filed by Resident #1 on 1/3/25 revealed she was concerned that third shift Nurse Aides (NA) did not come in and check on her or answer her call bell. Resident #1 was further concerned that she received dry and burnt food from the kitchen. The grievance was not completed, as there was no documentation regarding an investigation, outcome or recommendation for corrective action. b.) Resident #2 was admitted to the facility on [DATE]. A review of the grievance filed by Resident #2 on 12/19/24 indicated she was missing a plaid varsity jacket and had last seen it about 3 weeks before. The grievance was incomplete as it did not include documentation of an investigation, outcome or recommendations for corrective action. c.) Resident #3 was admitted to the facility on [DATE]. Review of the grievance filed by Resident #3 on 12/11/24 revealed he was concerned that the NA assigned to him on 12/10/24 did not assist him with toileting. The grievance was incomplete as it did not include documentation of an investigation, outcome or recommendations for corrective action. An interview was conducted with the Social Worker (SW) on 5/28/25 at 2:10 PM. The SW stated she helped residents fill out the initial information on the grievance form that included the date, time, their name, room number, the department the grievance will go to and their concern. She then gave the grievance form to the pertinent department head, and they did the investigation. After the grievance was investigated, it was given to the Administrator to review and sign, then it came back to her to be filed. The SW was unsure how grievance forms that were not completed ended up filed in her office. In an interview with the Administrator on 5/28/25 at 2:12 PM she stated she was the last stop for grievances. The Administrator revealed she gets the completed form from the responsible department head then checks in with the complainant to ensure the grievance had been resolved.After this she gives the grievance to the SW to be filed. The Administrator was not sure how incomplete grievances ended up going to the SW to be filed.

Based on record review, and resident and staff interviews, the facility failed to maintain a resident's dignity when a resident wore a nightgown and no makeup to an outside appointment making the resident feel angry and unimportant for 1 of 1 resident (Resident # 4) reviewed for dignity and respect. Finding included: Resident #4 was admitted to the facility on [DATE]. The annual [NAME] Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact. An interview with the Transportation Driver at 2:37pm on 5/28/2025 revealed Resident #4 was unaware of her appointment on 5/27/25. He stated that he became aware of the appointment at 4:06am by text message from the Scheduler, after he learned about the appointment, he did call the facility and informed the nurse. Transport driver stated it was the nurse's job to provide verbally communicate appointments to residents. He was aware of Resident #4 was unhappy about wearing her night gown to her doctor's appointment and he tried to console Resident #4 by provided encouragement with positive statements. An interview with Resident #4 on 5/28/2025 at 3:25pm revealed the resident went to a doctor's appointment on 5/27/2025.Resident #4 stated that 2 aids from night shift woke her up and told her about the appointment that was scheduled. Resident #4 stated, she had to wear the night gown and the underwear that she slept in. She stated she did not have time to bathe herself with soap and water, she used wipes instead. Resident #4 revealed if she had known about her appointment that she would have taken a shower, picked out her clothes, brushed her hair piece, and picked out her perfume the night before. Resident #4 stated she would inform 2nd and 3rd shift staff that she had an appointment and to wake her up an hour before she leaves for her appointment. Resident #4 stated if she had time to do her normal morning routine for a doctor's appointment she would have picked out a pair of jogging pants and a logo t-shirt, instead of her night gown, she would also put on her makeup for the appointment. Resident #4 stated that she was angry the whole day and she did not feel important. An interview conducted on 5/28/2025 at 2:19pm with Nurse #7 revealed, Resident #4 liked to go to her appointment with her hair and makeup done. Nurse #7 stated, normally if Resident #4 was aware of her appointments she would inform 3rd shift staff to wake Resident #4 up early. An interview conducted on 5/28/2025 at 9:30am with [NAME] President (VP) of Clinical Services revealed the scheduler has a personal planner that she kept all residents' appointments written down. A review of the appointment schedule revealed Resident #4 had an outside appointment on 5/27/2025 at 9:15am. An interview conducted with the Administrator and VP of Clinical Services at 4:41pm on 5/28/2025 revealed all residents have a right to choose what they want to wear when they go out of the facility.

Based on record review, and staff and family interviews, the facility failed to immediately identify abuse and respond to intervene to protect a resident from physical abuse. Facility staff delayed intervention when Resident #1, a severely cognitively impaired resident, was hit with a belt by a family member resulting in three whip-like marks on her left upper thigh and abdomen and a visit to the emergency room . The facility also failed to notify the state agency within two hours of physical abuse that occurred in the facility. This occurred for 1 (Resident #1) of 3 residents reviewed for adherence to abuse policies and procedures during physical abuse investigations. Findings included: a. Documentation on the undated facility abuse policies and procedures revealed under the heading of identification of abuse, neglect, and exploitation, the facility will identify events, occurrences, patterns, and trends that may constitute: . Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Documentation on the undated facility abuse policies and procedures also revealed in part, When suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occurs, the following procedure will be initiated: All staff, where applicable will: Respond to the needs of the resident and protect him/her from further incident. Resident #1 was admitted to the facility on [DATE] and had diagnoses of a genetic-related intellectual disability and a neurological condition. Documentation on a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and was dependent on staff for all activities of daily living. Resident #1 was not coded as having any moods or behaviors on the MDS assessment. Documentation in a nursing progress note dated 4/23/2025 at 7:18 PM written by Nurse #2 stated, This nurse was standing in (the) hallway in front of [readmission] patient room. As this nurse was standing there, I overheard [Resident #1] yelling. This nurse then overheard the sound of someone hitting someone, and then I overheard [Resident #1] yelling again. This nurse then went to inform, (the) unit manager of what was going on. Nurse #2 was interviewed on 5/6/2025 at 12:02 PM. Nurse #2 confirmed she was assigned to Resident #1 on 4/23/2025 for the 7:00 AM to 7:00 PM shift. Nurse #2 provided the following information. Nurse #2 was in a room near Resident #1's room with another resident when she heard a sound like someone was being hit with a whip and someone calling out in pain. Nurse #2 stopped to listen, and she heard it again, the whipping sound and a cry of pain. Nurse #2 went out into the hallway, and she saw that two of the nurse aides (NA #1 and NA #2) had come out of the resident rooms they were in. Nurse #2 asked the two nurse aides if they had heard that too. Nurse #2 then heard the whipping sound and a cry of pain coming from Resident #1's room for a third time. One of the nurse aides stuck their head into Resident #1's room but then both nurse aides turned around and went back to care for other residents. Nurse #2, without going into Resident #1's room, went down the hall to get the Unit Manager. Nurse #2 found the Unit Manager and told her Resident #1 was getting whooped. Nurse #2 stated she let the Unit Manager handle the situation because she knew it was Resident #1's family member in the room. Nurse #2 stated that the Unit Manager spoke with Resident #1's family member and the family member came out of the room to be escorted off the premises. Nurse #2 explained that she did not immediately go into Resident #1's room when she heard the whipping sound because there was a family member in the room. Nurse #2 further explained that she had been a nurse for a long time and had numerous training sessions on abuse, but she was in shock, and she had never encountered a family member hitting a resident. Nurse #2 admitted that if she saw or heard another resident whipping Resident #1 with a belt she would have gone into the room and intervened immediately. NA #1 was interviewed on 5/6/2025 at 12:42 PM. NA #1 disclosed that she was not assigned to care for Resident #1 on the evening shift on 4/23/2025. NA #1 confirmed she was in a resident's room during the evening mealtime on 4/23/2025 when she heard clapping and hollering. NA #1 stated she went out into the hallway to see what the noise was and along with NA #2 peaked into Resident #1's room. NA #1 indicated the curtain was pulled so she could not see Resident #1 in the first bed but saw the back of what she assumed was a family member in the room. NA #1 reiterated she did not know what was happening, so she returned to assisting another resident with eating. NA #2 was interviewed on 5/6/2025 at 1:54 PM. NA #2 stated she was assigned to care for Resident #1 for the 3:00 PM to 11:00 PM shift on 4/23/2025. NA #2 stated she was in the room next door assisting a resident in eating the evening meal when she heard a smacking or clapping sound. NA #2 indicated she stuck her head out of the room because it was an unusual sound and looked into the doorway of Resident #1's room. NA #2 said the curtain was pulled but Resident #1's family member peaked around the curtain and looked at her. NA #2 said she saw Nurse #2 in the hallway and Nurse #2 said she thought the family member was spanking Resident #1. NA #2 said she reentered the room next door to assist the other resident with eating. NA #2 revealed she did not hear any more noises from Resident #1's room. NA #2 confessed she did not know that the family member hitting Resident #1 was considered abuse. NA #2 was later told that it was considered abuse because it happened within the walls of the facility. The family member of Resident #1 was interviewed on 5/6/2025 at 3:01 PM. The family member revealed the following information. Someone from the facility called the family member and told her Resident #1 was exposing herself. The family member did not plan to go to the facility that day, but she went to the facility to discipline Resident #1. The family member confirmed she hit Resident #1 with her belt three to five times. The Assistant Director of Nursing (ADON) explained to the family member of Resident #1 that she was not allowed to do that in the facility. The family member stated she did not know disciplining Resident #1 with a belt was wrong and considered abuse. The Unit Manager was interviewed on 5/6/2025 at 11:20 AM. The Unit Manager described the following events as happening on the evening of 4/23/2025. The Unit Manager was coming up to the nursing station from another hallway when Nurse #2 approached her at the nursing station stating, Her [family member] is whopping her. The Unit Manager was confused and asked Nurse #2 who and what was going on. Nurse #2 described Resident #1's location and that it sounded like Resident #1 was being whopped. Nurse #2 explained to the Unit Manager she did not go into the room but described what it sounded like. The Unit Manager went down the hall and entered Resident #1's room to see the family member with her hands on her hips and her belt in one of her hands. The Unit Manager asked the family member what was going on and the family member responded by repeating what she said. The Unit Manager asked the family member if she was hitting Resident #1 and the family member responded that Resident #1 was acting out. The Unit Manager explained to the family member of Resident #1 that although they were family members, she was not allowed to hit her with a belt in the facility because the residents were under their care. The Unit Manager asked her to step out of the room. The Unit Manager observed that Resident #1 was on her right side in bed and when she lifted her gown there were raised red marks like she was hit with a belt. The Unit Manager was not told by the family member of Resident #1, but it was assumed she hit her with her belt because of the noise described by Nurse #2. The ADON was interviewed on 5/6/2025 at 12:50 PM. The ADON stated on 4/23/2025 she overheard someone talking in the hallway about the family member of Resident #1 whipping Resident #1 with a belt. The ADON revealed she went down the hallway and saw the family member in the hallway. The ADON asked the family member what happened, and she was told by the family member she was spanking her with a belt to discipline her. The ADON revealed she had to explain that she was not allowed to do that in the facility and walked her to the building door so she could leave. Documentation on a weekly skin assessment dated [DATE] at 6:54 PM revealed Resident #1 as assessed as having Slight redness and whip-like marks to the front of left thigh. Small, red whip-like marks to the left upper abdomen area. Documentation in a nursing progress note dated 4/23/2025 at 8:35 PM revealed the nurse practitioner was made aware of the incident with Resident #1 and requested she be sent out to the emergency room for evaluation. Documentation in the nursing progress notes dated 4/24/2025 at 4:04 AM indicated Resident #1 was transported to the emergency room at 8:50 PM on 4/23/2025 via a stretcher for evaluation and returned to the facility at 9:50 PM on 4/23/2025 with no new orders. A skin assessment performed upon her return to the facility revealed Resident #1 did not have any broken or open skin areas. Documentation in the nursing progress notes dated 4/24/2025 at 4:04 AM stated, Resident [#1] left the facility via stretcher at [8:50 PM] on 4/23/25 and returned to the facility by stretcher at [9:50 PM] with no new orders. Skin assessment by the writer noted to be [within normal limits]. No break in skin. Resident alert and oriented. Pleasant mood. No distress noted. An interview was conducted with the facility Administrator on 5/6/2025 at 1:36 PM. The Administrator stated she expected the staff to intervene immediately if abuse occurred in the facility despite the source or situation. b. Documentation on the undated facility abuse policies and procedures revealed in part, The Director of Nursing, Administrator, or designee will notify the appropriate agencies within specified timeframes: Immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, . Documentation on an initial allegation report revealed the facility became aware of an incident of abuse on 4/23/2025 with the allegation details, It was alleged by staff that [Resident #1's family member], [Family Member Name], physically abused her by beating her with a belt. Details of the physical or mental injury/harm were, [Resident #1] sustained whelps to her lower extremity as a result of the incident. The faxed initial allegation report was sent to the state agency on 4/24/2025 at 10:41 AM. An interview with the facility Administrator was conducted on 5/6/2025 at 3:14 PM. The Administrator stated she was not in the facility when she was called by the Unit Manager notifying her of the allegation Resident #1's family member hit Resident #1 with a belt. The Administrator thought notifying the local police department immediately fulfilled the obligation of notifying the appropriate agencies within 2 hours. The Administrator admitted she came into the facility the next day, 4/24/2025, to fax the state agency of the abuse allegation regarding Resident #1. The Administrator confirmed her first attempt to contact the state agency was on 4/24/2025 at 10:41 AM.

Based on record review, staff interview, and family interview, the facility failed to protect the resident's right to be free from abuse for one (Resident #1) of three residents reviewed for physical abuse. Resident #1, a severely cognitively impaired resident, was hit with a belt by a family member resulting in three whip-like marks on her left upper thigh and abdomen. A reasonable person would be traumatized by being hit with a belt. Findings included: Resident #1 was admitted to the facility on [DATE] and had diagnoses of a genetic-related intellectual disability and a neurological condition. Documentation on a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and was dependent on staff for all activities of daily living. Resident #1 was not coded as having any moods or behaviors on the MDS assessment. Documentation on a care plan dated as initiated [DATE] revealed Resident #1 had an activity of daily living, self-care performance deficit relative to muscle weakness and malignant neuroleptic syndrome, a rare and life-threatening reaction to the use of antipsychotic medication. One of the interventions under this focus area was Resident #1's total dependence on staff for repositioning and turning in bed. There were no focus areas for behaviors on the care plan for Resident #1 before [DATE]. Documentation in a nursing progress note dated [DATE] at 7:18 PM written by Nurse #2 stated, This nurse was standing in (the) hallway in front of [readmission] patient room. As this nurse was standing there, I overheard [Resident #1] yelling. This nurse then overheard the sound of someone hitting someone, and then I overheard [Resident #1] yelling again. This nurse then went to inform, (the) unit manager of what was going on. Nurse #2 was interviewed on [DATE] at 12:02 PM. Nurse #2 confirmed she was assigned to Resident #1 on [DATE] for the 7:00 AM to 7:00 PM shift. Nurse #2 provided the following information. Nurse #2 was in a room near Resident #1's room with another resident when she heard a sound like someone was being hit with a whip and someone calling out in pain. Nurse #2 stopped to listen, and she heard it again, the whipping sound and a cry of pain. Nurse #2 went out into the hallway, and she saw that two of the nurse aides (NA #1 and NA #2) had come out of the resident rooms they were in. Nurse #2 asked the two nurse aides if they had heard that too. Nurse #2 then heard the whipping sound and a cry of pain coming from Resident #1's room for a third time. One of the nurse aides stuck their head into Resident #1's room but then both nurse aides turned around and went back to care for other residents. Nurse #2, without going into Resident #1's room, went down the hall to get the Unit Manager. Nurse #2 found the Unit Manager and told her Resident #1 was getting whooped. Nurse #2 stated she let the Unit Manager handle the situation because she knew it was Resident #1's family member in the room. Nurse #2 stated that the Unit Manager spoke with Resident #1's family member and the family member came out of the room to be escorted off the premises. Nurse #2 entered Resident #1's room and assisted the Unit Manager with a skin assessment. Resident #1 was lying on her right side and had 3 marks on her left hip. Nurse #2 completed a pain assessment and a skin assessment. Nurse #2 explained the red raised marks did not require treatment and Resident #1 did not appear to be in pain. Nurse #2 explained that she did not immediately go into Resident #1's room when she heard the whipping sound because there was a family member in the room. Nurse #2 further explained that she had been a nurse for a long time and had numerous training sessions on abuse, but she was in shock, and she had never encountered a family member hitting a resident. NA #1 was interviewed on [DATE] at 12:42 PM. NA #1 confirmed she was in a resident's room during the evening mealtime on [DATE] when she heard clapping and hollering. NA #1 stated she went out into the hallway to see what the noise was and along with NA #2 peaked into Resident #1's room. NA #1 indicated the curtain was pulled so she could not see Resident #1 in the first bed but saw the back of what she assumed was a family member in the room. NA #1 reiterated she did not know what was happening, so she returned to assisting another resident with eating. NA #2 was interviewed on [DATE] at 1:54 PM. NA #2 stated she was assigned to care for Resident #1 for the 3:00 PM to 11:00 PM shift on [DATE]. NA #2 stated she was in the room next door assisting a resident in eating the evening meal when she heard a smacking or clapping sound. NA #2 indicated she stuck her head out of the room because it was an unusual sound and looked into the doorway of Resident #1's room. NA #2 said the curtain was pulled but Resident #1's family member peaked around the curtain and looked at her. NA #2 said she saw Nurse #2 in the hallway and Nurse #2 said she thought the family member was spanking Resident #1. NA #2 said she reentered the room next door to assist the other resident with eating. NA #2 revealed she did not hear any more noises from Resident #1's room. NA #2 confessed she did not know that the family member hitting Resident #1 was considered abuse. NA #2 was later told that it was considered abuse because it happened within the walls of the facility. NA #2 stated that Resident #1 sometimes resisted care but in general she was a sweet person. The family member of Resident #1 was interviewed on [DATE] at 3:01 PM. The family member revealed the following information. Someone from the facility called the family member and told her Resident #1 was exposing herself. The family member did not want to reveal who called her. The family member did not plan to go to the facility that day, but she went to the facility to discipline Resident #1. The family member confirmed she hit Resident #1 with her belt three to five times. The Assistant Director of Nursing (ADON) explained to the family member of Resident #1 that she was not allowed to do that in the facility. The family member stated she did not know it was wrong and considered abuse. If the family member had known disciplining Resident #1 with a belt would have the consequence of having the police called, it wouldn't have happened. The family member stated she was interviewed by the police and explained to them that she loved Resident #1, goes with her to every medical appointment, and stayed with her in the hospital when she almost died . The family member said she told the police she was not out to hurt Resident #1, but she needed to stop the behavior of undressing. The family member was sorry it happened, but she felt she needed to discipline Resident #1 when she entered the room and found her with her arm out of her gown. The family member confirmed Nurse #1 came into Resident #1's room, asked her what she was doing, and requested she leave. The family member stated other family members have been visiting Resident #1 but that she would not visit Resident #1 until all of this blows over. The family member confirmed she was told she could have supervised visits, but she did not want to do that. Documentation in the nursing progress notes dated [DATE] at 7:12 PM by the Unit Manager stated, This nurse was notified around 6:00 PM by the floor nurse that [Resident #1's family member] was whooping her. This nurse immediately went to [Resident #1's] room and observed [Resident #1] laying in the bed, kind of on her right side and [Resident #1's family member] standing beside the bed with her hands on her hips and a belt in her left hand. I immediately asked what was going on and [Resident #1's family member] responded back to me by repeating what I had just asked her. I then asked her if she was hitting her (Resident #1) with the belt that she was holding and [Resident #1's family member] responded that she (Resident #1) was acting out with behaviors. I then proceeded to tell [Resident #1's family member] that she cannot beat/hit her and that while she is here in this facility, she (Resident #1) is our responsibility. I then asked [Resident#1's family member] what behaviors she is referring to and [Resident #1's family member] stated that [Resident #1] had took her gown off and was naked in the bed. I asked [Resident #1's family member] to step out of the room and then I walked to the nursing station and called my DON (Director of Nursing) and Administrator and was informed to tell [Resident #1's family member] to leave and to call 911. 911 was called and [Resident #1's family member] was walked to the front door by staff. The Unit Manager was interviewed on [DATE] at 11:20 AM. The Unit Manager described the following events as happening on the evening of [DATE]. The Unit Manager was coming up to the nursing station from another hallway when Nurse #2 approached her at the nursing station stating, Her [family member] is whopping her. The Unit Manager was confused and asked Nurse #2 who and what was going on. Nurse #2 described Resident #1's location and that it sounded like Resident #1 was being whopped. Nurse #2 explained to the Unit Manager she did not go into the room but described what it sounded like. The Unit Manager went down the hall and entered Resident #1's room to see the family member with her hands on her hips and her belt in one of her hands. The Unit Manager asked the family member what was going on and the family member responded by repeating what she said. The Unit Manager asked the family member if she was hitting Resident #1 and the family member responded that Resident #1 was acting out. The Unit Manager explained to the family member of Resident #1 that although they were family members, she was not allowed to hit her with a belt in the facility because the residents were under their care. The Unit Manager asked her to step out. The Unit Manager observed that Resident #1 was on her right side in bed and when she lifted her gown there were raised red marks like she was hit with a belt. The family member stood in the hallway and the ADON was talking to her. The Unit Manager then called the Administrator and the Director of Nursing, who were not in the building. The Administrator told the Unit Manager to inform the family member of Resident #1 to leave the building and to call 911. The Unit Manager had the ADON walk the family member of Resident #1 to the front door and instruct her not to return to the building until the Administrator or DON called her. The police came to the building to conduct interviews with Nurse #2, NA #1, NA #2, and herself. Resident #1's family left the facility before the police arrived. The police took pictures of the red marks on Resident #1. The Unit Manager was not told by the family member of Resident #1, but it was assumed she hit her with her belt because of the noise described by Nurse #2. The Unit Manager stated this was an unexpected action from the family member and she had never indicated before this that she would do anything like this to Resident #1. The ADON was interviewed on [DATE] at 12:50 PM. The ADON stated on [DATE] she overheard someone talking in the hallway about the family member of Resident #1 whipping Resident #1 with a belt. The ADON revealed she went down the hallway and saw the family member in the hallway. The ADON asked the family member what happened, and she was told by the family member she was spanking her with a belt to discipline her. The ADON revealed she had to explain that she was not allowed to do that in the facility and walked her to the building door so she could leave. An attempt to interview Resident #1 was made on [DATE] at 12:36 PM. Resident #1 was not able to express her recollection of the events of [DATE]. Documentation on a weekly skin assessment dated [DATE] at 6:54 PM revealed Resident #1 as assessed as having Slight redness and whip-like marks to front of left thigh. Small, red whip-like marks to left upper abdomen area. Documentation on a pain interview dated [DATE] at 7:04 PM revealed Resident #1 was in no pain and had no indicators of pain. Documentation in a nursing progress note dated [DATE] at 8:35 PM revealed the nurse practitioner was made aware of the incident with Resident #1 and requested she be sent out to the emergency room for evaluation. Documentation in the nursing progress notes dated [DATE] at 4:04 AM stated, Resident [#1] left the facility via stretcher at [8:50 PM] on [DATE] and returned to the facility by stretcher at [9:50 PM] with no new orders. Skin assessment by the writer noted to be [within normal limits]. No break in skin. Resident alert and oriented. Pleasant mood. No distress noted. Documentation in Resident #1's care plan was updated on [DATE] with the focus area for the potential for harm injury from others relative to cognitive loss and behaviors of undressing. The goal was for Resident #1 to have no injuries due to harm from others and will remain in a safe environment through the next review. The intervention was supervised visits with a family member in a common area with a staff member present. An interview was conducted with the facility Social Worker on [DATE] at 12:08 PM. The Social Worker revealed Resident #1's family member was very involved in her care both attending medical appointments with her and attending care plan conferences. The Social Worker stated she was shocked when she heard Resident #1's family member hit her with a belt. The Social Worker revealed the Administrator requested she call Resident #1's family member on [DATE] to notify her she would only be allowed to have supervised visits with Resident #1 for a period of time. The Social Worker indicated that to her knowledge Resident #1's family member had not been back to the facility. An interview was conducted with the facility Administrator on [DATE] at 1:36 PM. The facility administrator revealed that Resident #1 tried to get the staff's attention without understanding what she was doing because she had a childlike mind. The Administrator indicated the family member of Resident #1 would say things jokingly that would insinuate she would stop Resident #1 from acting out but family dynamics were not seen as an issue. The Administrator explained Resident #1's family member, who struck her with a belt, would often bring Resident #1's young daughter to the facility to visit her. The police and the facility explained to Resident #1 after the incident that the family member would not be allowed to visit her for a while. Resident #1 became inconsolable on the day of the event because in her mind it meant she would not be able to see her daughter and the family member ever again. The Administrator confirmed the Social Worker called the family member to notify her she would only be allowed 20-minute supervised visits with Resident #1 until it was deemed she was safe. The Administrator stated she expected the staff to intervene immediately if abuse occurred in the facility no matter the source or situation.

Based on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist interview, and psychiatry nurse practitioner interview the facility failed to obtain laboratory tests as ordered and provide laboratory results to the pharmacy as required for antipsychotic medication monitoring for one (Resident #11) of one resident reviewed for laboratory services. Resident #11 had an acute psychotic event after laboratory results were not obtained and faxed to the pharmacy for the renewal of his antipsychotic medication. Resident #11 suffered a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident. Abrupt withdrawal from the medication can cause rebound psychosis (sudden return of psychotic symptoms). Findings included: Resident #11 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. Resident #11 had a physician's order for 200 milligrams (mg) Clozapine, an antipsychotic, to be administered as one tablet by mouth two times a day for paranoid schizophrenia initiated on 7/9/2024. The administration times listed were 8:00 AM and 8:00 PM. Documentation in the manufacturer's label for Clozapine revealed the average elimination half-life of Clozapine after a singe 75 mg dose was 8 hours with a range of 4 to 12 hours, while the average elimination half-life after achieving a steady state with 100 mg twice a day dose, of 12 hours. The abrupt stopping of Clozapine has been associated with agitation and a rapid onset of psychosis. Documentation in the assessment and plan portion of a psychiatry progress note date 9/19/2024 revealed Resident #11's paranoid schizophrenia was chronic and stable. The documentation also indicated Resident #11 was adhering to his medication regimen and indicated a stable mental state. Resident #11 had a physician's order dated as initiated on 9/19/2024 for blood to be drawn for a complete blood count (CBC) and a complete metabolic panel (CMP) on the night shift every 30 days for anemias and vitamin deficiencies to be completed on 10/19/2024 at 7:00 PM. Anemia and vitamin B12 deficiency can be a rare side effect of the medication Clozapine. Documentation on a quarterly Minimum Data Set assessment dated [DATE] coded Resident #11 as cognitively intact with no mood issues or behaviors. Resident #11 was coded as requiring substantial assistance with mobility and transfers. Documentation on the October Medication Administration Record (MAR) revealed on 10/19/2024 at 7:00 PM Nurse #2 completed the order for a CBC and a CMP for Resident #11. There was no evidence in the electronic medical record for Resident #11 of the CBC and CMP laboratory results from 10/19/2024. Nurse #2 was interviewed on 11/22/2024 at 11:01 AM. Nurse #2 explained she worked in the facility on the 7:00 PM to 7:00 AM shift. Nurse #2 acknowledged she checked off on the MAR that Resident #11's CBC and CMP were completed on 10/19/2024, but it was not completed. Nurse #2 further explained the order for laboratory services for Resident #11 involved the nursing staff putting the necessary paperwork into a laboratory book so that when the phlebotomist came to draw blood between midnight and 5:00 AM, they would have the necessary information to do so. Nurse #2 stated that usually the orders for laboratory services for the residents were acknowledged and the information for the laboratory book was completed by the day shift nursing staff. Nurse #2 stated she must have been distracted or just forgot on 10/19/2024 to put the required information into the laboratory book for the phlebotomist who comes to the facility to draw the blood for Resident #11. Nurse #2 stated she did understand the system and process for residents to obtain laboratory services, but she thought this was the first time she had to obtain laboratory services for Resident #11. Resident #11 had an additional physician's order written by Nurse Practitioner (NP) #1 dated 10/22/2024 at 11:17 AM for the medication Clozapine to be held for two days until 10/24/2024 at 11:17 AM. NP #1 was interviewed on 11/22/2024 at 9:52 AM. NP #1 revealed the following information. NP #1 explained the reason the Clozapine was put on hold for Resident #11 on 10/22/2024 was because the pharmacy needed laboratory tests to be sent to them prior to filling another 30-day supply of the medication to Resident #11. The pharmacy requires the CBC because Clozapine puts a resident at higher risk for infections. The requirement for the laboratory tests to be sent to the pharmacy prior to filling the Clozapine for Resident #11 was well known to the facility and there was a reoccurring order for blood to be drawn from Resident #11 for laboratory tests each month ahead of time prior to Resident #11 running out of Clozapine. The problem, as explained by NP #1, was that the laboratory tests for Resident #11 were not drawn as ordered on 10/19/2024 and were then not faxed to the pharmacy. NP #1 explained on 10/22/2024 she entered an additional order for a CBC with differential for Resident #11 to be completed STAT (immediately) when she was notified Resident #11 ran out of his Clozapine. (A CBC with differential measures the number and types of cells in your blood to help diagnose a variety of conditions to include infection.) An interview was conducted with a Pharmacist from the facility's pharmacy on 11/22/2024 at 10:25 AM. The Pharmacist revealed that because of the required laboratory tests, the medication Clozapine was not available for the nurses to remove from an electronic medication dispensing cabinet for Resident #11. The Pharmacist explained the laboratory tests were required before the medication could be dispensed from the pharmacy and there was no other way of obtaining the medication for Resident #11. Documentation in a progress note written by NP #1 on 10/22/2024 at 7:55 PM revealed in part, [Resident #11's] schizophrenia appears controlled with current therapy. Will order lab work as indicated and continue with therapy as prescribed. Obtain STAT (immediate) CBC and CMP. (A CBC and CMP measure the number and types of cells in your blood to help diagnose a variety of conditions to include infection.) Documentation on a lab results report for Resident #11 revealed the collection date was 10/23/2024 at 10:31 AM, received at 10/23/2024 at 10:31 AM, and reported to the physician on 10/23/2024 at 11:15 AM. Documentation on the October Medication Administration Record (MAR) indicated Resident #11 had the medication Clozapine on hold by the practitioner for the 8:00 PM dose on 10/22/2024, the 8:00 AM dose on 10/23/2024, the 8:00 PM dose on 10/23/2024, and the 8:00 AM dose on 10/24/2024. Documentation on the same MAR indicated Resident #11 did not receive the scheduled Clozapine for the 8:00 PM dose on 10/24/2024, the 8:00 AM dose on 10/25/2024, and the 8:00 PM dose on 10/25/2024. Documentation in a physician's progress note for Resident #11 dated 10/25/2024 at 1:00 PM written by Medical Doctor (MD) #1 stated in part, Today, he was quite ornery. He is having acute psychosis event at this point. Very difficult to reconcile, redirect and calm down. He was actually verbally offensive and abusive to many of the staff members as well as me and other residents. The patient became very angry while at the nursing station. Attempted to get out of his wheelchair and I suspect probably attempted to take a swing at a staff member when he fell backward and fell on the ground. We did not move him, but I did assess him the best I could on the floor. He denies complaints at this point. However, I am concerned about his ongoing injury from his fall. He did not strike his head. Neurologically, he had no changes from his fall at this point. Neurological assessment otherwise is his baseline other than psychosis. Brief orthopedic assessment could not be completed after a fall secondary to the patient being stabilized on the ground awaiting EMS [Emergency Medical Services]. His vital signs otherwise are stable at this point. Approximately 15 minutes earlier, he received an IM [intramuscular] injection of Benadryl in his arm to calm him down I believe. Benadryl is an antihistamine that can have a sedative effect. An interview was conducted with the physician for Resident #11, MD #1, on 11/22/2024 at 1:23 PM. MD #1 explained that Resident #11 was rolling around in his wheelchair acting very verbally abusively threatening staff, other residents, and MD #1 on 10/25/2024. MD #1 explained Resident #11 was yelling, cussing, and speaking in tongues and acting in a way he had never seen before for this resident. MD #1 explained that Resident #11 rose up out of his wheelchair and what looked like to him attempted to take a swing at one of the staff members nearby, when he fell hard on the ground. MD #1 explained that Resident #11 did periodically have verbal behaviors but this was something else. MD #1 stated he could not definitively say missing the six doses of Clozapine at the time of the incident and fall on 10/25/2024 was a direct cause of the accident because he was unsure of the half- life of the medication. (The half-life provides an accurate indication of the length of time that the effect of the drug persists in an individual.) MD #1 confirmed there was no reason Resident #11 should have missed getting the required lab work completed and missed doses of Clozapine. Documentation in the nursing progress notes dated 10/25/2024 at 1:46 PM written by Nurse #5 revealed, Nurse called pharmacy to check status of resident's Clozapine oral tablet 200 mg. Pharmacist requested to have copy of labs. Nurse [#5] faxed lab per request. [NP #1] made aware. Nurse #5 was interviewed on 11/25/2024 at 9:52 AM. Nurse #5 stated she was the unit manager, and she was in the office adjacent to the nursing station with NP #1 when Resident #11 fell . Nurse #5 revealed Resident #11 usually had a calm demeanor when he received his medication Clozapine, but when he did not receive his antipsychotic medication, he became almost demonic. Nurse #5 explained that the medication Clozapine required laboratory tests to be completed prior to the pharmacy filling the medication. Nurse #5 further explained the nurses working at the facility should have known Resident #11 required the medication Clozapine and that the laboratory tests must be sent to the pharmacy for the medication to be obtained from the pharmacy. Nurse #5 stated the nurses who were working on the medication cart should have known to call the pharmacy if Resident #11 did not have his Clozapine and the pharmacy would have readily told the nurse the laboratory report was needed. Nurse #5 stated when she saw the manic state Resident #11 was in on 10/25/2024 she called the pharmacy because she surmised, he probably had not received his antipsychotic medication. Nurse #5 indicated after the pharmacy notified her the laboratory report was needed, she immediately faxed the results to the pharmacy, and the pharmacy sent the Clozapine to the facility. Documentation on a SBAR (Situation, Background, Assessment, and Recommendation) communication form and progress note dated 10/25/2024 initiated at 3:15 PM written by Nurse #6 revealed in the nursing assessment, Resident having outburst with behavior toward staff. Documentation in the nursing progress notes dated 10/25/2024 at 3:21 PM written by Nurse #6 stated, Resident up and down the hall in wheel[chair] with noted behavior fussing at staff and other residents. Resident talking to self, having out [bursts] toward others. Resident attempted to stand up to hit at staff when resident fell at nursing station. Resident complained of pain, refused help from staff, [Primary Care Physician] onsite, EMS/Police called to escort resident to [emergency room ]. Resident family aware/unit manager aware. Nurse #6 was interviewed on 11/25/2024 at 11:36 AM. Nurse #6 revealed she was an agency nurse who only periodically worked at the facility. Nurse #6 stated that Resident #11 was in an agitated state rolling around the facility in a wheelchair swearing at everyone around him on 10/25/2024. Nurse #6 indicated she notified the charge nurse, Nurse #5, when during her medication pass administration, she noted Resident #11 did not have his antipsychotic medication, Clozapine. Nurse #6 stated Nurse #5 contacted the pharmacy and was told Resident #11 required laboratory tests to be sent to the pharmacy prior to the distribution of the medication by the pharmacy. Record review of an emergency room visit on 10/25/2024 for Resident #11 revealed resident was uncooperative for an x-ray of his left shoulder with continuous refusals. Resident #11 was administered medications intramuscularly to calm him down enough to perform an x-ray of the left shoulder. The x-ray of the shoulder revealed Resident #11 had a fracture of the long bone, between the shoulder and the elbow. Resident #11 was transferred back to the facility with a long-arm splint and sling for support with the recommendation to follow-up with orthopedics the first of the next week. NP #1 was interviewed on 11/22/2024 at 9:52 AM and the following additional information was provided. NP #1 revealed the CBC with differential was completed as ordered on 10/23/2024, but the results were not faxed to the pharmacy until 10/25/2024, resulting in Resident #11 missing seven doses of his Clozapine until the pharmacy sent another 30- day supply on 10/26/2024. NP #1 indicated the medication Clozapine did not make Resident #11 lucid but did make him manageable, so he was not hollering and yelling all the time. NP #1 stated she was in her office near the nursing station on 10/25/2024 when Resident #11 started yelling obscenities and could be heard threatening everyone around him. NP #1 stated she saw MD #1 step back away from Resident #11, but she did not actually see him fall. NP #1 stated Resident #11 hit the ground so hard it could be heard by everyone. NP #1 explained MD #1 immediately ordered for 911 to be called as Resident #11 needed to be sent out. NP #1 indicated Emergency Medical Services (EMS) arrived very quickly but Resident #11 was so belligerent the police had to be called to assist the EMS workers. NP #1 indicated that after the incident on 10/25/2024 she questioned if the results of the CBC from 10/23/2024 were ever faxed to the pharmacy because Resident #11 was acting like he was not on his psychoactive medication. NP #1 stated at that point someone called the pharmacy to check if they received the laboratory results for Resident #11. An interview was conducted with a pharmacist from the facility's pharmacy on 11/22/2024 at 10:25 AM. The Pharmacist revealed the following information. According to the pharmacy records, Resident #11 ran out of the ordered medication Clozapine on 10/22/2024. The Pharmacist called the facility on 10/22/2024 and notified them of a need for a CBC differential for Resident #11 to be faxed to the pharmacy so that another 30-day supply of the medication could be sent to the facility. The Pharmacist did not have any record of who she spoke to at the facility. The Pharmacist explained the pharmacy requires the blood test CBC with differential every 30 days for a resident on the medication Clozapine to monitor the neutrophil counts in the blood. Residents taking Clozapine can develop dangerously low neutrophil counts. Neutrophils are the cells that fight off infection in the body and if someone had very low levels of neutrophils; he or she can be vulnerable to infections. The required CBC with differential for Resident #11 was not sent to the pharmacy on 10/22/2024. The pharmacy received the CBC with differential dated 10/23/2024 for Resident #11 on 10/25/2024. The pharmacy sent a 30-day supply of the Clozapine to the facility on the morning of 10/26/2024. The Pharmacist stated if the medication Clozapine, used for paranoid schizophrenia, was abruptly stopped there was usually rebound psychosis and increase in behaviors related to Clozapine's short duration of action. Documentation in the Nursing Progress notes dated 10/25/2024 at 5:30 PM written by Nurse #6 revealed, [Resident #11] return from hospital with a [diagnosis] of closed displaced fracture of the surgical neck of the left humerus, unspecified fracture morphology. New order to go to Orthopedics in 3 days. Sling to left arm noted. The humerus is the long bone that runs from the upper shoulder to the elbow. Unspecified fracture morphology means the doctor does not have enough information to describe the exact shape or pattern of a bone fracture. Documentation in a nursing progress note dated 10/29/2024 at 6:07 PM revealed that Resident #11 was sent to the emergency room for a difference in legs and swelling to his knee. Documentation in a discharge summary from the hospital revealed Resident #11 had a hospitalization from [DATE] to 11/6/2024 for surgical repair of a left hip fracture. Additionally, while in the hospital Resident #11 had the additional problem areas and procedures of acute blood loss with transfusion of 2 units of blood and acute pain due to trauma. An interview was conducted with a Nurse Aide (NA) #5 on 11/22/2024 at 12:14 PM. NA #5 revealed she worked on the first (7:00 AM to 3:00 PM) and second (3:00 PM to 11:00 PM) shift routinely. NA #5 indicated she knew the care needs of Resident #11 well. NA #5 stated Resident #11 would occasionally get out of bed with a one person stand and pivot to the wheelchair prior to his fall. NA #5 stated that Resident #11 was a completely different person now and required a mechanical lift to get out of bed, but he no longer wants to get out of bed. NA #5 stated she knew Resident #11 did not like the mechanical lift. Resident #11 was observed on 11/22/2024 to be asleep in bed laying on his right side at 9:46 AM, 11:10 AM, and 1:04 PM. An observation and interview were conducted with Resident #11 on 11/22/2024 at 4:29 PM. Resident #11 was laying on his right side in bed with a sling on his left arm. Resident #11 stated he had consistent pain in his hip, and he longer felt like he could get out of bed. An interview was conducted with MD #1 on 10/25/2024 at 11:22 AM. MD #1 stated he visited with Resident #11 on 11/22/2024 to encourage him to work with therapy. MD #1 stated the mentation of Resident #11 was to just stay in bed and not move at this point. Documentation in a psychiatry progress note dated 11/14/2024 written by NP #2 revealed under the history of present illness portion in part, Patient ran out of his clozapine a few days ago, which led to a resurgence of his delusions and hallucinations. This incident escalated to the point where he attempted to physically confront a doctor, resulting in a fall. Since resuming his medication, his symptoms have subsided, and he is reported to be doing well again. The goal is to prevent such an occurrence in the future by ensuring consistent access to his medication. His current medication regimen will be continued without changes, with a follow-up planned in a few weeks. NP #2 was interviewed on 11/22/2024 at 1:43 PM. NP #2 explained that Clozapine had side effects with one of them being the possibility of a severe decrease in white blood cell counts, although rare was a possibility. NP #2 further explained the pharmacy was required to monitor the neutrophils by receiving the laboratory values of Resident #11 monthly prior to sending the Clozapine to the facility to make sure he was not having any adverse side effects. NP #2 stated it was hard to say if the behaviors of Resident #11 on 10/25/2024 were due to him missing 6 doses of Clozapine over two and a half days. NP #2 stated the half-life of Clozapine was 26 to 36 hours. NP #2 revealed she visited the facility every two weeks and usually the facility staff reported occasional verbal behaviors from Resident #11 and never reported physical behaviors. The Director of Nursing (DON) was interviewed on 10/22/2024 at 10:45 AM. The DON stated she felt the root cause of the failure to obtain the Clozapine medication for Resident #11 began with Nurse #2 not following the physician order and not putting the required information in the laboratory book for the laboratory order to be carried out. The DON stated she felt like an additional root cause was the failure of NP #1 to separate out the orders so that one order was to obtain the laboratory services for Resident #1 and then a second order should have been written to fax the results to the pharmacy. The facility was notified of the immediate jeopardy on 11/22/2024 at 3:39 PM. The facility submitted the following corrective action plan on 11/23/2024: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/22/24 at 8:00 pm, Resident #11's medication could not be administered as ordered by the provider due to it not being available. When the nurse notified the pharmacy of the medication not being available to administer the pharmacy stated the medication required lab work to be completed and faxed to the pharmacy prior to dispensing the medication. On 10/22/24 the provider was notified, and an order was obtained to draw stat lab work on 10/22/24. The results of the labs were received on 10/23/24 in the morning and the provider failed to place a physician order to fax the results to the pharmacy so the medication could be dispensed. On 10/25/24 at 1:26 pm the nurse notified the pharmacy the medication was not available to administer. Upon notifying the pharmacy the pharmacy stated they had not received the lab results to dispense the medication. The provider was notified and stated the lab work had been completed and needed to be faxed to the pharmacy. The lab results were faxed to the pharmacy and received by the pharmacy at 1:42PM. The pharmacy dispensed the medication at 1:59pm. The facility received Resident #11's medication on 10/26/24 at 2:00 am. On 10/26/24 Resident #11's medication of Clozapine was administered at 8:00am to the resident as ordered by the provider. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: An audit of all current residents was completed by the Director of Nursing on 10/23/24 to determine if any other residents required lab work previous to medication distribution from pharmacy. No other residents required lab work prior to medication distribution indicating that there were no other residents affected by the deficient practice of not obtaining lab services as ordered by the provider. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated on 11/8/24 of the new process by the Director of Nursing. When the order appears on the Medication Administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Education was provided by the Director of Nursing to licensed staff and licensed agency staff on 11/12/24 to 11/13/24 that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 11/4/24 the Quality Assurance team (Administrator, Director of Nursing, Assistant Director of Nursing, nurse practitioner, Medical Director, social services director, admissions director and therapy director) met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; when the order appears on the medication administration record the licensed nurse ensured the lab results were faxed to the pharmacy, and the results were received and faxed to pharmacy when applicable. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent an omission of ordered lab services on Monday through Friday with ordered lab work through the weekend reviewed Monday for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months for review and, if warranted, further action. Alleged date of immediate jeopardy removal date and compliance date: 11/14/2024 The facility's correction action plan was validated on 11/26/24. Interviews were conducted with a sample of nurses to verify education was conducted for nurses regarding processing lab results and pharmacy notification of lab results. Documentation of in-service records were reviewed. The initial audit was verified as well as ongoing monitoring audits to ensure labs were obtained were verified to be completed. In an interview with the Director of Nursing on 11/26/24 at 12:00 pm, she stated that nurses had been educated on the process for physician orders for medications that required lab monitoring and the completion of labs, to include to faxing results to the pharmacy where indicated. The providers were also educated on the new process. Resident #11's medical record revealed the resident had received all prescribed doses of Clozapine from 11/14/24 through present. He had an order for labs and a separate order to fax lab results related to the medication, clozapine to the pharmacy every 28 days. The facility's immediate jeopardy removal date and compliance date of 11/14/24 was validated.

Based on observation, record review, resident interview, staff interview, nurse practitioner interview, physician interview, pharmacist, and psychiatry nurse practitioner interview the facility failed to administer 6 doses of a required antipsychotic medication for one (Resident #11) of one resident reviewed for significant medication errors. Resident #11 had an acute psychotic event after missing 6 doses of his antipsychotic medication resulting in a fall with a broken shoulder and hip that required surgical repair, acute blood loss and acute pain. Resident #11 has been bedbound since the incident. Findings included: Resident #11 was admitted to the facility on [DATE] with a diagnosis of paranoid schizophrenia. Resident #11 had a physician's order for 200 milligrams (mg) Clozapine, an antipsychotic, to be administered as one tablet by mouth two times a day for paranoid schizophrenia initiated on 7/9/2024. The administration times listed were 8:00 AM and 8:00 PM. Documentation in the manufacturer's label for Clozapine revealed the average elimination half-life of Clozapine after a singe 75 mg dose, was 8 hours with a range of 4 to 12 hours, while the average elimination half-life after achieving a steady state with 100 mg twice a day dose, of 12 hours. Half-life is the time it takes for the amount of a drug's active substance in the body to reduce by half. Anemia and vitamin B12 deficiency can be a rare side effect of the medication Clozapine. The abrupt stopping of Clozapine has been associated with agitation and a rapid onset of psychosis. Documentation in the assessment and plan portion of a psychiatry progress note date 9/19/2024 revealed Resident #11's paranoid schizophrenia was chronic and stable. The documentation also indicated Resident #11 was adhering to his medication regimen and indicated a stable mental state. Documentation on a quarterly Minimum Data Set assessment dated [DATE] coded Resident #11 as cognitively intact with no moods or behaviors. Resident #11 was coded as requiring set up/cleanup for eating and personal hygiene, but was dependent for toileting, showers/bathing, personal hygiene, and dressing. Resident #11 was coded as requiring substantial assistance with mobility. Resident #11 had a physician's order dated as initiated on 9/19/2024 for blood to be drawn for a complete blood count (CBC) and a complete metabolic panel (CMP) on the night shift every 30 days for anemias and vitamin deficiencies to be completed on 10/19/2024 at 7:00 PM. The pharmacy requires blood tests every 30 days for a resident on the medication Clozapine to monitor the neutrophil counts in the blood. There was no evidence in the electronic medical record of the CBC and CMP test results dated 10/19/2024. Resident #11 had an additional physician's order written by Nurse Practitioner (NP) #1 dated 10/22/2024 at 11:17 AM for the medication Clozapine to be held for 2 days until 10/24/2024. Documentation in a progress note written by NP #1 on 10/22/2024 at 7:55 PM revealed in part, [Resident #11's] schizophrenia appears controlled with current therapy. Will order lab work as indicated and continue with therapy as prescribed. Obtain STAT (immediate) CBC (complete blood count) and CMP (comprehensive metabolic panel). Documentation on a lab results report for Resident #11 revealed the collection date was 10/23/2024 at 10:31 AM, received at 10/23/2024 at 10:31 AM, and reported to the physician on 10/23/2024 at 11:15 AM. Documentation on the October Medication Administration Record (MAR) indicated Resident #11 had the medication Clozapine on hold by the practitioner for the 8:00 PM dose on 10/22/2024, the 8:00 AM dose on 10/23/2024, the 8:00 PM dose on 10/23/2024, and the 8:00 AM dose on 10/24/2024. Documentation on the same MAR indicated Resident #11 did not receive the scheduled Clozapine for the 8:00 PM dose on 10/24/2024, and the 8:00 AM dose on 10/25/2024 indicating an explanation would be in the progress notes. Documentation in the electronic medication administration record (e-MAR) administration notes dated 10/24/2024 at 9:01 PM indicated the medication Clozapine was on order for Resident #11. Documentation in the e-MAR administration notes dated 10/25/2024 at 9:23 AM had no explanation for why the Clozapine dose was not administered to Resident #11. Medication Aide (Med Aide) #1 was interviewed on 11/26/2024 at 9:04 AM. Med Aide #1 confirmed she was assigned to administer medications to Resident #11 on 10/24/2024 and 10/25/2024 on the evening shift. Med Aide #1 recalled that the medication Clozapine was held at one point and then was not available when she was administering medications on the evening shift on 10/24/2024 and 10/25/2024. Med Aide #1 recalled that on the evening shift on 10/24/2024, Resident #11 did not have a good night in that he was acting out with behaviors that made him seem like he was possessed. Med Aide #1 stated she was aware the medication Clozapine required laboratory values monthly and was a very important medication for Resident #11 to take. Med Aide #1 thought she had reported the absence of the medication Clozapine for Resident #11 to a nurse, but she could not remember which nurse or the details of the conversation. Nurse #6 was interviewed on 11/25/2024 at 11:36 AM. Nurse #6 confirmed she was the nurse assigned to administer medication to Resident #11 on the morning of 10/25/2024. Nurse #6 stated she did inform the unit manager (Nurse #5) that the Clozapine for Resident #11 was not available on the morning of 10/25/2024. Nurse #6 stated Nurse #5 contacted the pharmacy and sent the required laboratory report to the pharmacy so that the medication Clozapine would be sent to the facility for Resident #11. NP #1 was interviewed on 11/22/2024 at 9:52 AM. NP #1 revealed the following information. NP #1 was in the facility Monday through Friday as an onsite practitioner. NP #1 explained the reason the Clozapine was put on hold for Resident #11 on 10/22/2024 was because the pharmacy needed laboratory values to be sent to them prior to filling another 30-day supply of the medication to Resident #11. The requirement for the laboratory values to be sent to the pharmacy prior to filling the Clozapine for Resident #11 was well known to the facility and there was a reoccurring order for blood to be drawn from Resident #11 for laboratory values each month. The problem, as explained by NP #1, was that the laboratory tests for Resident #11 were not drawn as ordered on 10/19/2024 and were then not faxed to the pharmacy. NP #1 explained on 10/22/2024 she entered an additional order for a CBC (complete blood count) with differential for Resident #11 to be completed STAT (immediately). (A CBC with differential measures the number and types of cells in your blood to help diagnose a variety of conditions to include anemia, infection, or immunodeficiencies.) Documentation in a physician's progress note for Resident #11 dated 10/25/2024 at 1:00 PM written by Medical Doctor (MD) #1 stated in part, Today, he was quite ornery. He is having acute psychosis event at this point. Very difficult to reconcile, redirect and calm down. He was actually verbally offensive and abusive to many of the staff members as well as me and other residents. The patient became very angry while at the nursing station. Attempted to get out of his wheelchair and I suspect probably attempted to take a swing at a staff member when he fell backward and fell on the ground. We did not move him, but I did assess him the best I could on the floor. He denies complaints at this point. However, I am concerned about his ongoing injury from his fall. He did not strike his head. Neurologically, he had no changes from his fall at this point. Neurological assessment otherwise is his baseline other than psychosis. Brief orthopedic assessment could not be completed after a fall secondary to the patient being stabilized on the ground awaiting EMS (Emergency Medical Services). His vital signs otherwise are stable at this point. Approximately 15 minutes earlier, he received an IM (intermuscular) injection of Benadryl in his arm to calm him down I believe. Benadryl is an antihistamine that can have a sedative effect. An interview was conducted with the physician for Resident #11, MD #1, on 11/22/2024 at 1:23 PM. MD #1 explained that Resident #11 was rolling around in his wheelchair acting very verbally abusively threatening staff, other residents, and MD #1 on 10/25/2024. MD #1 explained Resident #11 was yelling, cussing, speaking in tongues, and acting in a way he had never seen before for this resident. MD #1 explained that Resident #11 rose up out of his wheelchair and what looked like to him attempted to take a swing at one of the staff members nearby, when he fell hard on the ground. MD #1 explained that Resident #11 did periodically have verbal behaviors but this was something else. MD #1 stated he could not definitively say Resident #11 missing the six doses of Clozapine at the time of the incident and fall on 10/25/2024 was a direct cause of the accident because he was unsure of the half-life of the medication. (The half-life provides an accurate indication of the length of time that the effect of the drug persists in an individual.) MD #1 confirmed there was no reason Resident #11 should have missed getting the required lab work completed and missed doses of Clozapine. Documentation in the nursing progress notes dated 10/25/2024 at 1:46 PM written by Nurse #5 revealed, Nurse called pharmacy to check status of resident's Clozapine oral tablet 200 mg. Pharmacist requested to have copy of labs. Nurse [#5] faxed lab per request. [NP #1] made aware. Nurse #5 was interviewed on 11/25/2024 at 9:52 AM. Nurse #5 stated she was the unit manager, and she was in the office adjacent to the nursing station with NP #1 when Resident #11 fell . Nurse #5 revealed Resident #11 usually had a calm demeanor when he received his medication Clozapine, but when he did not receive his antipsychotic medication, he became almost demonic. Nurse #5 explained that the medication Clozapine required lab work to be completed prior to the pharmacy filling the medication. Nurse #5 further explained the nurses working at the facility should know Resident #11 required the medication Clozapine and that the lab work must be sent to the pharmacy for him to obtain it from the pharmacy. Nurse #5 stated the nurses who were working on the medication cart should know to call the pharmacy if Resident #11 did not have his Clozapine and the pharmacy would have readily told the nurse the laboratory report was needed. Nurse #5 stated when she saw the manic state Resident #11 was in on 10/25/2024 she called the pharmacy because she surmised, he probably had not received his antipsychotic medication. Nurse #5 indicated after the pharmacy notified her the laboratory report was needed, she immediately faxed the results to the pharmacy, and the pharmacy sent the Clozapine to the facility. Resident #11 had a physician's order dated 10/25/2024 initiated at 1:46 PM for 50 mg of Benadryl to be injected intramuscularly one time only for agitation for one day and may repeat in one hour if needed. Documentation on a transfer form dated as initiated on 10/25/2024 at 1:57 PM written by Nurse #5 indicated Resident #11 was sent to the hospital because, Resident threw himself on the floor. Documentation on the MAR revealed Resident #11 was administered the ordered dose of Benadryl on 10/25/2024 at 2:30 PM by Nurse #6. Documentation on a SBAR (Situation, Background, Assessment, and Recommendation) communication form and progress note dated 10/25/2024 initiated at 3:15 PM written by Nurse #6 revealed in the nursing assessment, Resident having outburst with behavior toward staff. Documentation in the nursing progress notes dated 10/25/2024 at 3:21 PM written by Nurse #6 stated, Resident up and down the hall in wheel[chair] with noted behavior fussing at staff and other residents. Resident talking to self, having out [bursts] toward others. Resident attempted to stand up to hit at staff when resident fell at nursing station. Resident complained of pain, refused help from staff, [Primary Care Physician] onsite, EMS/Police called to escort resident to ER (emergency room ). Resident family aware/unit manager aware. Nurse #6 was interviewed on 11/25/2024 at 11:36 AM. Nurse #6 explained she was an agency nurse and was not very familiar with Resident #11, but she did recall the day he fell at the nurses' station. Nurse #6 stated Resident #11 was rolling all around the facility in a wheelchair in a very agitated state cursing at everybody he encountered. Nurse #6 confirmed that prior to Resident #11 falling at the nurses' station, she had administered Benadryl to him with an order obtained from NP #1. Nurse #6 stated, in addition she went to the unit manager, Nurse #5, to let her know Resident #11 did not have any more Clozapine for administration. Nurse #6 revealed Resident #11 was cursing at MD #1 when he rose up out of his wheelchair and attempted to hit either MD #1 or herself. Nurse #6 stated Resident #11 fell , but was in such a state he would not allow anyone to assess him or for EMS to transport him to the hospital so, the police were called. Documentation on the October MAR indicated Resident #11 did not receive the scheduled Clozapine for the 8:00 PM dose on 10/25/2024 indicating an explanation would be in the progress notes. Documentation in the e-MAR administration notes dated 10/25/2024 at 10:24 PM indicated the medication Clozapine was on order for Resident #11. Record review of an emergency room visit on 10/25/2024 for Resident #11 revealed resident was uncooperative for an x-ray of his left shoulder with continuous refusals. Resident #11 was administered medications intramuscularly to calm him down enough to perform an x-ray of the left shoulder. The x-ray of the shoulder revealed Resident #11 had a fracture of the long bone, between the shoulder and the elbow. Resident #11 was transferred back to the facility with a long-arm splint and sling for support with the recommendation to follow-up with orthopedics the first of the next week. NP #1 was interviewed on 11/22/2024 at 9:52 AM and additional information was provided. NP #1 revealed the CBC with differential was completed as ordered on 10/23/2024, but the results were not faxed to the pharmacy until 10/25/2024, resulting in Resident #11 missing seven doses of his Clozapine until the pharmacy sent another 30- day supply on 10/26/2024. NP #1 indicated the medication Clozapine did not make Resident #11 lucid but did make him manageable, so he was not hollering and yelling all the time. NP #1 stated she was in her office near the nursing station on 10/25/2024 when Resident #11 started yelling obscenities and could be heard threatening everyone around him. NP #1 stated she saw MD #1 step back away from Resident #11, but she did not actually see Resident #11 fall. NP #1 stated Resident #11 hit the ground so hard it could be heard by everyone. NP #1 explained MD #1 immediately ordered for 911 to be called as Resident #11 needed to be sent out. NP #1 indicated Emergency Medical Services (EMS) arrived very quickly but Resident #11 was so belligerent the police had to be called to assist the EMS workers. An interview was conducted with a pharmacist from the facility's pharmacy on 11/22/2024 at 10:25 AM. The Pharmacist revealed the following information. According to the pharmacy records, Resident #11 ran out of the ordered medication Clozapine on 10/22/2024. The Pharmacist called the facility on 10/22/2024 and notified them a new prescription for the Clozapine and a CBC differential for Resident #11 needed to be faxed to the pharmacy so that another 30-day supply of the medication could be sent to the facility. The Pharmacist did not have any record of who she spoke to at the facility. The pharmacist explained the neutrophil count was the value the Pharmacist was monitoring because residents on Clozapine had an increased risk for infection. (Neutrophils are a type of white blood cell that help the body fight infection and heal from injury.) On 11/22/2024 at 11:20 AM a new prescription for Resident #11 for the Clozapine was sent to pharmacy. The required CBC with differential for Resident #11 was not sent to the pharmacy on 10/22/2024. The pharmacy received the CBC with differential dated 10/23/2024 for Resident #11 on 10/25/2024. The pharmacy sent a 30-day supply of the Clozapine to the facility on the morning of 10/26/2024. The Pharmacist stated if the medication Clozapine, used for paranoid schizophrenia, was abruptly stopped there was usually rebound psychosis and increase in behaviors related to Clozapine's short duration of action. Documentation in the Nursing Progress notes dated 10/25/2024 at 5:30 PM written by Nurse #6 revealed, [Resident #11] return from hospital with a [diagnosis] of closed displaced fracture of the surgical neck of the left humerus (the long bone that runs from upper shoulder to the elbow), unspecified fracture morphology. (Unspecified fracture morphology means the doctor does not have enough information to describe the exact shape or pattern of a bone fracture.) New order to go to Orthopedics in 3 days. Sling to left arm noted. Documentation in the nursing progress notes dated 10/30/2024 at 9:10 AM written by the Director of Nursing revealed Resident #11 was transferred to another hospital after a diagnosis of a hip fracture was obtained in a local emergency room . The note further went on to explain the responsible party for Resident #11 was contacted to update health information regarding Resident #11 and discuss the likelihood of Resident #11 sustaining the hip fracture when he fell on [DATE] because Resident #11 had not had any other falls. Documentation in a discharge summary from the hospital revealed Resident #11 had a hospitalization from [DATE] to 11/6/2024 for surgical repair of a left hip fracture. Additionally, while in the hospital Resident #11 had the problem areas and procedures of acute blood loss with transfusion of 2 units of blood and acute pain due to trauma. An interview was conducted with a Nurse Aide (NA) #5 on 11/22/2024 at 12:14 PM. NA #5 revealed she worked on the first (7:00 AM to 3:00 PM) and second (3:00 PM to 11:00 PM) shift routinely. NA #5 indicated she knew the care needs of Resident #11 well. NA #5 stated Resident #11 would occasionally get out of bed with a one person stand and pivot to the wheelchair prior to his fall. NA #5 stated that Resident #11 was a completely different person now and would require a mechanical lift to get out of bed, but he no longer wants to get out of bed. NA #5 stated she knew Resident #11 did not like the mechanical lift. Resident #11 was observed on 11/22/2024 to be asleep in bed laying on his right side 9:46 AM, 11:10 AM, and 1:04 PM. An observation and interview were conducted with Resident #11 on 11/22/2024 at 4:29 PM. Resident #11 was laying on his right side in bed with a sling on his left arm. Resident #11 stated he had consistent pain in his hip, and he longer felt like he could get out of bed. An interview was conducted with MD #1 on 10/25/2024 at 11:22 AM. MD #1 stated he visited with Resident #11 on 11/22/2024 to encourage him to work with therapy. MD #1 stated the mentation of Resident #11 was to just stay in bed and not move at this point. Documentation in a psychiatry progress note dated 11/14/2024 written by NP #2 revealed under the history of present illness portion in part, Patient ran out of his Clozapine a few days ago, which led to a resurgence of his delusions and hallucinations. This incident escalated to the point where he attempted to physically confront a doctor, resulting in a fall. Since resuming his medication, his symptoms have subsided, and he is reported to be doing well again. The goal is to prevent such an occurrence in the future by ensuring consistent access to his medication. His current medication regimen will be continued without changes, with a follow-up planned in a few weeks. NP #2 was interviewed on 11/22/2024 at 1:43 PM. NP #2 stated it was hard to say if the behaviors of Resident #11 on 10/25/2024 were due to him missing 6 doses of Clozapine over two and a half days. NP #2 stated the half-life of Clozapine was 26 to 36 hours. NP #2 revealed she visited the facility every two weeks and usually the facility staff reported occasional verbal behaviors from Resident #11 and never reported physical behaviors. The Director of Nursing was interviewed on 10/22/2024 at 10:45 AM. The Director of Nursing acknowledged the facility initially failed to obtain the needed laboratory report required by the pharmacy for the dispensing of the medication Clozapine on 10/19/2024. The DON also acknowledged NP #1 failed to give a separate order for the faxing of the laboratory report to the pharmacy after it was obtained on 10/23/2024, further delaying the dispensing of the medication Clozapine to Resident #11. The facility was notified of the immediate jeopardy on 11/22/2024 at 3:39 PM. The facility submitted the following corrective action plan on 11/23/2024: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: On 10/22/24 at 8:00 pm. Resident #11's medication could not be administered as ordered by the provider due to it not being available. When the nurse notified the pharmacy of the medication not being available to administer the pharmacy stated the medication required lab work to be completed and faxed to the pharmacy prior to dispensing the medication. On 10/22/24 the provider was notified, and an order was obtained to draw stat lab work on 10/22/24. The results of the labs were received on 10/23/24 in the morning and the provider failed to place a physician order to fax the results to the pharmacy so the medication could be dispensed. On 10/25/24 at 1:26 pm the nurse notified the pharmacy the medication was not available to administer. Upon notifying the pharmacy the pharmacy stated they had not received the lab results to dispense the medication. The provider was notified and stated the lab work had been completed and needed to be faxed to the pharmacy. The lab results were faxed to the pharmacy and received by the pharmacy at 1:42PM. The pharmacy dispensed the medication at 1:59pm. The facility received Resident #11's medication on 10/26/24 at 2:00 am. On 10/26/24 Resident #11's medication of Clozapine was administered at 8:00am to the resident as ordered by the provider. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: An audit of all current residents was completed by the Director of Nursing on 10/23/24 to determine if any other residents required lab work previous to medication distribution from pharmacy. No other residents required lab work prior to medication distribution indicating that there were no other residents affected by the deficient practice of significant medication errors. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated on 11/8/24 of the new process by the Director of Nursing. When the order appears on the Medication Administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Education was provided by the Director of Nursing to licensed staff and licensed agency staff on 11/12/24 to 11/13/24 that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: On 11/4/24 the Quality Assurance team (Administrator, Director of Nursing, Assistant Director of Nursing, nurse practitioner, Medical Director, social services director, admissions director and therapy director) met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; the results were received and faxed to pharmacy when applicable; and the medication is administered as ordered by the provider to prevent a significant medication error; and when the order appears on the Medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent a significant medication error on Monday through Friday with ordered lab work through the weekend reviewed Monday for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee monthly for three months for review and, if warranted, further action. Alleged date of immediate jeopardy removal date and compliance date: 11/14/2024 The corrective action plan was validated on 11/26/24. Interviews were conducted with a sample of nurses to verify education was conducted for nurses regarding processing lab results and pharmacy notification of lab results. Documentation of in-service records were reviewed. The initial audit was verified as well as the ongoing monitoring audits to identify residents that required labs for medication administration were verified to be completed. In an interview with the Director of Nursing on 11/26/24 at 12:00 pm, she stated that nurses, had been educated on the process for physician orders for medications that required lab monitoring and the completion of labs, to include to fax results to the pharmacy where indicated. The providers were also educated on the new process. Resident #11's medical record revealed the resident had received all prescribed doses of Clozapine from 11/14/24 through present. He had an order for labs and a separate order to fax lab results related to the medication, clozapine to the pharmacy every 28 days. The facility's immediate jeopardy removal date and compliance date of 11/14/24 was validated.

Based on record review, observations, and interviews with resident, staff and the Physician, the facility failed to protect the residents' right to be free from resident to resident abuse for 3 of 5 residents reviewed for abuse (Resident #222, Resident #61, and Resident #41). On 10/19/23 Resident #2, a male resident, entered Resident #222's room (a female resident) and punched her in her legs multiple times with a closed fist as she was sitting on her bed. On 6/22/24 Resident #2 punched Resident #61 (a female resident) in the face multiple times with a closed fist at the nurse's station due to the belief that she was cheating on him. Resident #222 and Resident #61 were vulnerable and were unable to protect themselves. The physical abuse had a high likelihood of resulting in serious physical and psychosocial harm. A reasonable person expects to be protected from physical abuse in their home and would suffer trauma such as feelings of fear, anxiety, and intimidation. Additionally, the facility failed to protect Resident #41 from verbal abuse perpetrated by Resident #6 when he verbally threatened Resident #41 stating he was going to kill her and everyone else in the facility. Immediate jeopardy began on 10/19/23 when Resident #2 punched Resident #222 multiple times in the legs with a closed fist. Immediate jeopardy was removed on 10/11/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Example #2 for Resident #41 was cited at scope and severity D. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included non-traumatic intracranial hemorrhage (stroke) and hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), schizophrenia and dementia. Review of the care plan for Resident #2 initiated on 4/7/23, identified problems of: Behaviors including swinging at staff, yelling, history of throwing himself on the floor for attention, kicking and hitting at staff, wandering in and out of other resident's rooms, resident to resident altercation and pushing equipment forcefully. The goal was the resident would have no negative outcomes related to behaviors through the next review. Interventions included administer medications as ordered and observe for side effects and effectiveness. Anticipate and meet the resident's needs, explain all procedures to the resident before starting and allow the resident time to adjust to changes. If reasonable, discuss the behavior with the resident and explain/reinforce why the behavior is inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner, divert attention and remove from the situation and take to an alternate location as needed. Monitor behavior episodes and attempt to determine underlying causes considering location, time of day, persons involved and situations. Document behavior and potential causes. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #2 was severely cognitively impaired and required supervision or touching assistance with wheelchair mobility. He was coded as having no hallucinations or delusions and receiving antipsychotic, antianxiety and antidepressant medications. He was coded as having had other behavioral symptoms not directed toward others. The active physician's orders for Resident #2 on 10/19/23 included the following psychotropic medications: - Fluoxetine (antidepressant medication) 10 milligrams (mg) once daily - Olanzapine (antipsychotic medication) 7.5 mg once daily - Ativan (antianxiety medication) 0.5 mg twice daily - Trazodone (antidepressant used for sleep) 75 mg once daily - Depakote (mood stabilizer) 375 mg twice daily - Buspirone (antianxiety medication) 5 mg twice daily. Review of a progress note written by Nurse #2 on 10/19/23 at 2:14 AM stated Resident #2 was going in and out of other residents' rooms. He was cursing at Nurse #2 and became combative when she tried to remove him. Review of a progress note written by Nurse #2 on 10/19/23 at 4:50 AM stated Resident #2 was in the employee break room, removing items from the refrigerator and throwing them on the floor. The note further stated Resident #2 was verbally abusive and physically combative. Nurse #2 indicated they were unable to redirect him. a. Resident #222 was admitted to the facility on [DATE] with diagnoses that included reduced mobility and moderate intellectual disabilities. The admission MDS dated [DATE] revealed Resident #222 was severely cognitively impaired with no behaviors. It further revealed she had no impairment of upper or lower extremities and needed substantial assistance with activities of daily living. A review of Resident #222's comprehensive care plan revealed no care plan for behaviors. A nurse's note written by Nurse #1 on 10/19/23 at 8:23 PM stated she was notified by the Physical Therapist (PT) that Resident #2 hit Resident #222 with a closed fist. The note further stated Resident #2 was fighting and kicking the PT and Nurse Aide (NA) #2 while they removed him from the room. Resident #2 was holding onto the handrails in the hall trying to get back into the room, attempted to hit NA #2 and Nurse #1 in the face with a closed fist. DON #2 attempted to calm Resident #2 but was unsuccessful. Nurse #1 notified Nurse Practitioner #1 and received a one-time order for antipsychotic medication which they gave with no effect. Emergency Medical Services (EMS) and the Sheriff were notified. They arrived at the facility and transported Resident #2 to the hospital. A review of Resident #2's record revealed an order dated 10/19/23 for 2.5 milliliters (ml) of Haldol (antipsychotic medication) injection solution 5 mg/1 ml to be given intramuscularly (injected into a muscle) one time only for behaviors. An interview with the PT who witnessed the resident abuse on 10/19/23 was interviewed on 10/11/24 at 9:40 AM. He stated he heard yelling coming from the room of Resident #222 and went to investigate. When the PT entered the room, he observed Resident #222 sitting on the edge of her bed. Resident #2 had come into her room in his wheelchair and was punching her on the legs repeatedly with a closed fist. Resident #222 was not physically responding. The PT immediately removed Resident #2 from Resident #222's room. The PT further stated Resident #2 held onto furniture and the handrail outside the room when he removed him from the situation. When the PT got Resident #2 into the hall he yelled to Nurse #1 and NA #3 to help. He told them what he had witnessed and immediately went and reported the incident to the Therapy Department Manager. The PT revealed Resident #222 looked surprised but not upset or crying. The PT revealed he was familiar with Resident #2 and he was not surprised he struck another resident as he often hit staff. He further revealed that Resident #2 was unpredictable in his actions and often struck without notice. NA #2 was not available for interview. Nurse #1 was not available for interview. A nurse's note written by DON #2 on 10/19/23 at 8:21 PM revealed she was called to the hallway outside of Resident #222's room at approximately 6:50 PM to help with Resident #2 who was striking and kicking staff and attempting to get back into the room of Resident #222. The note further revealed she brought him in his wheelchair to the nurse's station to attempt to redirect him but was unsuccessful. Resident #222 was taken to the hospital by EMS at approximately 7:10 PM due to his behaviors and being a danger to himself and others. An interview was conducted with DON #2 on 10/9/24 at 3:24 PM. She stated she was called to the hallway outside the room of Resident #222 at approximately 6:50 PM on 10/19/23 because Nurse #1 and NA #3 needed help with Resident #2 who was fighting with staff. When she arrived, Resident #2 was holding onto the handrails in the hall while the PT, Nurse #1 and NA #3 were attempting to have him let go. Resident #2 did let go of the handrail, but then tried to punch DON #2, NA #3 and the PT. DON #2 was able to take him to the nurse's station where she attempted to calm him without success. DON #2 further stated Nurse #1 called Nurse Practitioner (NP) #1 and received a one-time order for a psychotropic medication (Haldol injection) to help calm him without effect. Nurse #1 then called EMS who sent the Sheriff and an ambulance. Resident #2 was then taken to the hospital. He returned to the facility the same evening. DON #2 revealed she assessed Resident #222 approximately 30 minutes after the incident and she was free of physical injury such as bruising or scratches. She further revealed Resident #222 did not recall the incident at that time. DON #2 indicated Resident #222 was not able to defend herself due to her cognitive status. She also indicated staff were afraid of Resident #2 as he was strong enough to push medication, treatment and food carts into them, sometimes backing them into a corner. He also hit, kicked and screamed at staff without warning. NA #3 was not available for interview. Police report dated 10/19/23 indicated that when he responded to the call Resident #2 was at the nurse's station with staff and was calm. It further indicated that Resident #2 was transported to the hospital by EMS. An emergency room note dated 10/19/23 stated Resident #2 was brought to the hospital by ambulance after a combative episode at the facility. He was not combative with hospital staff. The note further stated Resident #2 was given Trazodone and Ativan to help him sleep and basic blood and urine tests were performed to rule out dehydration and infection. The tests were unremarkable. Resident #2 was transported back to the facility the same day with no new orders. A Nurse's note written by Nurse #2 on 10/19/23 revealed Resident #2 returned to facility at 11:35 PM accompanied by two ambulance attendants. He was alert, awake and calm when returned to the facility. Physician's orders dated 10/20/23 indicated Resident #2's olanzapine was changed from 7.5 mg once daily to 5 mg twice daily and clonazepam (antianxiety medication) 0.25 mg three times a day was initiated. A psychiatric note completed by Nurse Practitioner (FNP) #2 on 10/30/23 revealed: Recent medication changes have had mild improvements in his behaviors and DON feels this is the best combination he has been on so far, but there are still concerns about how his behaviors are affecting the safety of himself, other residents and staff. He has impulsivity with rage and loves to terrorize. He reportedly went after a pregnant staff member. He was noted to push medication carts with his wheelchair until staff were backed into a corner or until he hit them with the cart. Staff felt he has no problem hitting or punching people. This has created issues providing care to him as staff were scared of him when he became agitated. The facility has had to involve law enforcement due to his behaviors. He was sneaking into the staff breakroom and will get into whatever is in there and he has been stealing food off other residents' trays. Facility noises appeared to overstimulate him and his behaviors got notably worse at shift change around 4 pm. The note further stated Resident #2 was not a danger to himself or others at that time. Interventions included changes to his psychotropic medication regime and a referral to psychotherapy. NP #2 was unavailable for interview. A telephone interview with the Physician on 10/14/24 at 10:25 AM revealed he did not recall the 10/19/23 incident, and he did not see mention of it in his progress note. The Physician stated Resident #2 was capable of striking other residents in October of 2023 but did not feel he was capable recently due to a decline in function. He further stated the resident has had psychiatric services involved throughout his stay at the facility. b. Resident #61 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (alteration in brain function), decreased renal function and the need for dialysis. A review of the Admission MDS dated [DATE] revealed Resident #61 was severely cognitively impaired with no behaviors. She was able to walk less than 10 feet with a walker and substantial assistance. Resident #61's comprehensive care plan revealed she was not care planned for behaviors. A nurse's note completed by Nurse #3 on 6/22/24 at 6:52 PM stated Resident #61 was punched in the face twice by Resident #2 at the nurse's station. Resident #61 was pulled to safety by staff. Resident #2 was still trying to hit the staff. NP #3 was called and ordered a one time dose of a psychotropic medication that was given with no effectiveness. EMS was called and the ambulance and Sheriff arrived. Resident #2 attempted to hit and kick the Sheriff and ambulance crew. He was taken to the hospital for evaluation. Skin check sheet for Resident #61 dated 6/22/24 was completed by Nurse #3 and it revealed there were no injuries to Resident #61. A review of Resident #2's record revealed an order dated 6/22/24 for 2.5 ml of Haldol injection solution 5 mg/1 ml to be given intramuscularly one time only for behaviors. In a telephone interview with Nurse #3 on 10/9/24 at 9:07 AM she stated on 6/22/24 she witnessed Resident #2 wheel his wheelchair to the nurse's station where Resident #61 was sitting in her wheelchair, yelled at her that she had been cheating on him (they were not a couple) and punched her in the nose twice. Resident #2 was removed from the area by an NA and she (Nurse #3) attended to Resident #61. She stated Resident #61 was upset but not crying. Resident #61 had no physical injuries at that time. She further stated Resident #61 was not able to protect herself from an attack due to age and debility. Nurse #3 revealed Resident #2 was unpredictable and volatile at baseline. She stated he would lash out at staff, trying to punch or kick them, go into other residents' rooms, get into the staff break room and throw stuff around and push medication and food carts into staff. Nurse #3 further revealed that many staff were afraid of being, or have been, hurt by him. A nurse's note written by DON #3 on 6/22/24 at 8:56 PM revealed he assessed Resident #61 for bruising or swelling of the nasal area and the area was clear of obvious injury. The police report for 6/22/24 was requested and law enforcement indicated there was no police report. The hospital emergency room visit note dated 6/22/24 revealed Resident #2 was calm and did not recall assaulting Resident #61, staff or the Sheriff. It further stated he appeared to have cognitive deficits and could not hold a full conversation but could answer yes/no questions. Basic labs were run and were reported as unremarkable. No changes or recommendations were made. Resident #2 returned to the facility on [DATE]. An interview with Resident #61 was conducted on 10/7/24 at 3:00 PM. She did not recall being punched by Resident # 2 on 6/22/24. In a telephone interview with DON #3 on 10/10/24 at 11:16 AM he stated he was not in the building at the time of the 6/22/24 incident but came in and filed a report with the State Agency, Adult Protective Services (APS) and local police. He further stated staff reported Resident #2 came up to Resident #61 at the nurse's station and punched her in the nose twice. DON #3 revealed Resident #2 was unpredictable in his actions such as screaming, kicking out or attempting to strike staff. DON #3 had not known Resident #2 to strike out at other residents, but he had only worked there for less than two weeks at the time of the incident. Resident #2 was observed on 10/7/24 at 9:10 AM lying quietly in his bed. A second observation was conducted on 10/10/24 at 10:15 AM. Resident #2 was sitting up in his wheelchair in his room screaming. When spoken to, he stopped screaming, smiled and waved. Resident #2 continued screaming afterward. An interview with the Physician on 10/14/24 at 10:25 AM revealed he did not recall the incident on 6/22/24 as he was out of the country at the time. The Physician stated Resident #2 was capable of striking other residents in June of 2024 but did not feel he was capable at this time due to a decline in function. He further stated the resident has had Psychiatric services involved throughout his stay at the facility. Administrator #1 was notified of Immediate Jeopardy on 10/10/24 at 9:25 AM. The facility implemented the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 10/19/23 Resident #2 was in Resident #222's room when a staff member heard residents talking. The staff member went into Resident #222's room and observed Resident #222 hitting Resident #2 with a closed fist. Staff immediately removed Resident #222 from the resident's room. Residents were assessed for injuries by the staff nurse on 10/19/23. No injuries were noted. Resident #2 and Resident #222 were unable to recall the events of the incident. Resident #2's physician was notified on 10/19/23. All attempts to calm Resident #2 were unsuccessful. Resident #2 was sent to the hospital emergency department on 10/19/23 for further evaluation. On 10/20/23 Social Services offered emotional support to Resident #222 and documented no signs of distress, discomfort or pain noted. Upon Resident #2 returning to the facility resident was placed on increased supervision and assessed by psychiatric nurse practitioner on 10/30/23. On 6/22/24 Resident #2 was observed punching Resident #61 in the nose with a closed fist twice while both were in their wheelchairs at nurses' station. Staff immediately separated the residents. Resident #2 was sent to emergency room for further evaluation. Resident #61 was assessed with no injuries noted. Resident #2 continues to reside at the facility under psychiatric care and services. Resident #2 continues to receive medications as ordered and has not had any further altercations. He has shown a decrease in overall aggressive behaviors. Resident #222 no longer resides in the facility. Resident #61 continues to reside in the facility without further concerns. All Staff were interviewed by the Scheduler and Administrative Assistant on 10/10/24. All residents that were able to participate in an interview were interviewed by the Social Services and Admissions Director on 10/10/24. The questions that they were asked were the following: Do you know about abuse? Do you know who to report abuse to? Do you feel safe in the facility? Do you have any concerns about abuse (physical, verbal, emotional, sexual, financial)? Any further allegations made will be investigated towards resolution by the Administrator and /or Director of Nurses. All residents were assessed by nurses via skin sweeps for suspicious injuries on 10/10/24. No suspicious injuries (those injuries that would be evident without a reasonable or rational explanation for the injury) were noted at those times. All residents were assessed by the Director of Nursing, Assistant Director of Nursing and Unit Manager for behaviors including verbal abuse, physical aggression to ensure appropriate care plans were in place to prevent resident to resident altercation. 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. Education - All staff including nurses, certified nursing assistants, agency/contract staff, all ancillary staff, and all newly hired employees will be educated on the Abuse Prevention Policy. The policy describes the right for residents to be free from abuse, neglect, exploitation or mistreatment. Staff will receive education on managing residents who have aggressive behaviors. Staff will be educated on verbal and nonverbal signs of aggression such as increased agitation, yelling out and clenching of fists. Staff will be educated on techniques to de-escalate residents displaying increased agitation such as removing the residents from the trigger and providing a quiet place for de-escalation. Staff will be trained to use the behavioral monitoring forms to document any aggressive behavior, including what happened before, during, and after the incident. All education will be completed by the DON/ADON designee by 10/10/2024. This education will include 1:1, and group training sessions. The Administrator/designee will be the person who will ensure all licensed nurses, certified nursing assistants, agency/contract staff, all ancillary staff, and all newly hired employees will be educated. No staff will work after 10/10/2024 until education has been received. Alleged date of Immediate jeopardy removal: 10/11/24. Onsite validation of the immediate jeopardy removal plan was completed on 10/11/2024. Interviews confirmed that all staff working on 10/11/24 were educated on the Abuse Prevention Policy. Staff were also educated on managing residents who have aggressive behaviors, verbal and nonverbal signs of aggression such as increased agitation, yelling out and clenching of fists, as well as techniques to de-escalate residents displaying increased agitation such as removing the residents from the trigger and providing a quiet place for de-escalation. Nurses were trained to use behavioral monitoring forms to document any aggressive behavior, including what happened before, during, and after the incident. Nurse aides indicated they would notify the Nurse of any aggressive behaviors, abuse, or incidents involving residents. All other staff indicated they would report to the Nurse, Director of Nursing or Administrator. Verification was completed that all staff scheduled to work 10/11/24 were reeducated prior to returning to duty. The immediate jeopardy removal date of 10/11/24 was validated. 37468 2. Resident #41 was admitted to the facility on [DATE]. Review of Resident #41's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She had no behaviors documented and required supervision with locomotion on and off unit. Review of Resident #6's Minimum Data Set assessment dated [DATE] revealed he was assessed as cognitively intact. He had no behaviors documented. Resident #6's active care plan as of 11/28/23 revealed there was no care plan for behaviors. An investigational summary completed by Previous Director of Nursing #1 dated 12/5/23 revealed on 11/29/23 Resident #41 reported that Resident #6 was outside in the smoking area with her. Resident #6 rolled up to Resident #41 in the wheelchair, stood up getting in her face, and stated he would kill her and other people. She stated she felt threatened and was afraid of him at that moment. She reported this to a staff member who brought her directly to the Previous Director of Nursing #1. Facility staff interviewed both residents and Resident #6 was not able to recall specific details. Resident #41 was able to recite what happened and that Resident #41 immediately removed herself from the situation and told staff about the incident. During an interview on 10/7/24 at 1:57 PM Resident #6 stated he did not remember the incident. During an interview on 10/10/24 at 11:01 AM Resident #41 stated she remembered the incident with Resident #6 a long time ago. She stated she was in the smoking area and as far as she could remember it was just herself and Resident #6 out there. She stated Resident #6 rolled up to her while she was in her wheelchair, stood up in front of her, and yelled at her, I will kill you and everyone here! She stated Resident #6 had never done this to her before or since. She stated at that moment, it made her afraid and she turned around, entered the dining room, and was met by the Activities Director. She told the Activities Director what Resident #6 had said to her and the Activities Director ensured her safety and removed her from the situation. She stated she did not remember much else about the incident, it did not affect her daily life at the facility, and she was not traumatized by the incident. She concluded she was being followed by psychiatric services and the facility set up a psychiatric evaluation following the incident as well as getting her statement. During an interview on 10/10/24 at 11:25 AM the Activities Director stated on 11/29/23 she was in the dining room preparing an activity for the residents. From the dining room she could view the smoking area through the dining room windows. Resident #6 and Resident #41 were in the smoking area at that time. She stated Resident #6 rolled over to Resident #41 and was making gestures in her face. She did not recall him standing up but he was up very close and personal in a threatening manner. The Activities Director went to the door as Resident #41 turned to the door and motioned to the Activities Director to let her come inside. Once inside, Resident #41 told the Activities Director that Resident #6 had threatened to kill her and called her some vulgar names. The Activities Director immediately took the resident to administration at that time and let Resident #41 recount what happened as another staff member took Resident #6 to his room. During an interview on 10/10/24 at 11:41 AM Administrator #1 stated she started working at the facility on 7/29/24. She stated she was not at the facility during the time of the incident. She stated since she became the Administrator, Resident #41 had not indicated to her any concerns of being fearful of Resident #6. She concluded residents should not be verbally threatened to be killed in the facility.

Based on record review and staff interviews the facility failed to transcribe an order for [REDACTED].# 59) resulting in a critical [MEDICATION NAME] level and hospitalization . Findings included: Resident # 59 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of laboratory results, dated 12/31/13, indicated a [MEDICATION NAME] level of 19.4 (acceptable range is 10.0-20.0). The results were reported to the physician who then ordered a repeat [MEDICATION NAME] level in one month. On 1/31/14, a [MEDICATION NAME] level of 38.9 was reported to the facility. The results were flagged as "Alert". On the laboratory result slip was handwritten (check mark) 200 mg (milligrams) q (symbol for every) hs (bedtime). The nurse had also written to recheck the level in 1 week. Under "see below", were the words, "Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity". The nurse reported the elevated [MEDICATION NAME] level and on 1/31/14 at 6:30 AM a physician's telephone order was written to (symbol for decrease) [MEDICATION NAME] 200 mg via G tube (gastrostomy tube) (symbol for every) hs (hour of sleep). The physician had initialed the laboratory form, but there was no date of review. Review of the Medication Administration Record (MAR) for January 2014, indicated Resident # 59 had received [MEDICATION NAME] 200 mg at 9:00 AM and 300 mg at bedtime. After receiving the 1/31/14 order, the nurse discontinued the 300 mg bedtime dose of [MEDICATION NAME] and rewrote the bedtime dose to reflect the 200 mg ordered by the physician. Laboratory results received by the facility, on 02/08/14, indicated Resident # 59's [MEDICATION NAME] level was 48.6. The results were flagged as "Critical". The laboratory report also documented the results were confirmed. Under "see below", were the words, "Patient drug level exceeds published reference range. Evaluate clinically for signs of potential toxicity". Hand written at the bottom of the laboratory reporting form was instructions to repeat the [MEDICATION NAME] level on 02/09/14 and to hold all doses of [MEDICATION NAME] on 02/08/14 until the physician was notified of the [MEDICATION NAME] level on 02/09/14. A physician's telephone order with the same information was written and timed at 10:00 AM. Review of the MAR for February 2014 indicated Resident # 59 had received [MEDICATION NAME] 200 mg every morning at 9:00 AM and had also received [MEDICATION NAME] 300 mg every night at 8:00 PM. Further review of the February 2014 MAR revealed the 1/31/14 order for the decrease in the bedtime dose of [MEDICATION NAME] to 200 mg had not been transcribed onto the February 2014 MAR. At 8:00 PM on 02/08/14, a physician's telephone order was written to send Resident # 59 to the emergency department for evaluation and treatment. A SBAR (a written assessment that is used prior to calling the physician) with a date of 02/08/14 and a time of 8:15 PM, indicated the Resident # 59 presented with shortness of breath, lethargic and non-responsive. Under SITUATION, the nurse documented a decrease in oxygen, change in level of consciousness and breath sounds. She documented the symptoms started on 02/08/14. Vital signs were listed as a blood pressure of 161/107 (the top number or systolic has a high normal of 140 and the bottom number or diastolic should not exceed 90), pulse of 125 (normal standard is 72), respiratory rate of 32 (normal range is 16-20), and a temperature of 100.8 (normal is usually defined as 98.6 degrees Fahrenheit). Under FUNCTIONAL STATUS, the nurse documented Resident # 59 ws not responding to any stimuli. The HOSPITAL DISCHARGE SUMMARY, dated 02/14/14, indicated the admitting and final [DIAGNOSES REDACTED]. An interview was held with the Staff Development Coordinator (SDC) on 8/28/14 at 3:40 PM. The SDC described the process for end of the month reconciliation. She stated after one nurse checks the orders against the physician's orders [REDACTED]. Any changes that occurs after the second check should be written on the current and the new MAR by the nurse that received the order. The 11-7 shift, prior to the start of the new month, also checked for any new orders and transcribed those, as needed, to the new MAR. The SDC stated that any nurse that received an order or checked the MAR (such as the 11-7 nurse checks) after MARS were completed was not expected to sign the MAR indicating another check had been completed. The SDC added that laboratory results identified as criticals and alerts were called to the physician immediately. New orders were customarily written on the laboratory result sheet as received from the physician, but added new orders also had to be written on a physician's telephone order sheet. The nurse added If a critical labs were received, the nurse on the hall was expected to call the physician immediately and carry through any orders received. The SDC stated if a nurse received an alert or critical [MEDICATION NAME] level, that nurse would need to assess the resident to see if the resident was arousable. The SDC stated It would be reasonable to expect the nurse would compare the previous month's MAR with the new MAR on the first day of the new month. She stated she could not say that was the current practice. The SDC stated the nurse that wrote and transcribed the 1/31/14 order did not work for the facility any longer. The Director of Nursing (DON) was interviewed on 8/28/14 at 4:42 PM. She stated the expectation would have been to assess and document the findings after the [MEDICATION NAME] alert was received. She also stated she considered the [MEDICATION NAME] transcription error a significant medication error. On 8/29/14 at 11:57 AM, the Corporate Nurse Consultant stated an action plan for transcription of orders, especially end of month reconcilliation had been identified in April 2014. She stated at that time, only 1 check of orders was completed by staff. Medication variances were completed and given to the physician. A new process, that included checking pink slips (copies of physician's orders [REDACTED]. Audits were completed, but she stated she was unable to locate the audit results.