Every finding on record at Woodcrest at Blakeford

Based on interview, record review, and facility document and policy review, the facility failed to submit an initial report of an allegation of staff-to-resident abuse to the state survey agency within two hours for 1 (Resident #31) of 1 resident reviewed for abuse. Specifically, CNA #18 failed to report an allegation of staff-to-resident abuse that occurred on 09/06/2024 until 09/13/2024. The findings include: A facility policy titled, Abuse, Neglect, Misappropriation Protocol, revised 04/2025, revealed, 1. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing. An admission Record revealed the facility admitted Resident #31 on 10/26/2023. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified severe dementia with agitation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was short-tempered and easily annoyed half or more of the days over the last two weeks. Resident #31's Care Plan included an undated focus area that indicated the resident was at risk for behavior problems. Interventions directed staff to intervene as necessary to ensure safety of resident and others (initiated 08/08/2024). A handwritten witness statement by Certified Nursing Assistant (CNA) #18, dated 09/13/2024, revealed when CNAs #17 and #18 went to assist Resident #31 with a shower, the resident stated they did not want a shower. The witness statement indicated CNA #17 told Resident #31 that the resident was getting a shower and began to pull the resident's clothes off. The witness statement revealed Resident #31 hit CNA #17. The witness statement revealed CNA #17 hit Resident #31 back, pointed their finger at the resident, and told the resident, You don't hit me. An undated facility investigative document titled Note for Meeting 9/13/'24 [2024] [sic] with [Name of police officer] revealed, Administrator explained that the team was notified this morning (9/13) of an allegation of abuse that had happened last Friday (9/6) between a staff member and the resident [Resident #31]. An email from the state reporting agency, dated 09/13/2024 at 10:42 AM, indicated the initial submission of an allegation of physical abuse. A facility incident report, dated 09/17/2024 at 12:53 PM, indicated a witness stated that she asked the alleged perpetrator to assist with transferring Resident #31 for a shower. The incident report indicated during the process, Resident #31 became combative and hit the alleged perpetrator. The incident report indicated the alleged perpetrator slapped Resident #31 back, pointed their finger at the resident, and stated, Don't hit me. The incident report concluded, The investigation was conducted and has been concluded as not substantiated by view of the findings. During an interview on 03/04/2024 at 9:30 AM, CNA #18 stated that she was in Resident #31's room to get the resident ready for a bath when the resident became aggressive. CNA #18 stated that she was being assisted with the transfer of Resident #31 by CNA #17. CNA #18 stated that during the transfer Resident #31 hit CNA #17, and CNA #17 hit the resident back and stated, You don't hit me. CNA #18 stated that she reported the incident to the Administrator (ADM) a couple of days later because she worked overnight and no one was around during the night to receive the report. CNA #18 stated there was a nurse present on the unit, but the nurse was friends with CNA #17, and CNA #18 did not feel like anything would be done. CNA #18 stated that Resident #31 was slapped with an open hand but was unsure as to what part of the resident's body was hit. CNA #18 stated that Resident #31 was not injured. CNA #18 stated that if abuse was identified it was supposed to be reported. CNA #18 stated that she did not remember when she should have reported the incident. During an interview on 03/04/2026 at 9:59 AM, the ADM stated that on 09/13/2024 CNA #18 reported that, while providing care, CNA #18 witnessed CNA #17 being hit by Resident #31 and then CNA #17 hitting the resident back on 09/06//2024. The ADM stated she had a conversation with CNA #18 about the timeliness of reporting, and she was not sure why CNA #18 did not report the incident immediately per the policy. During an interview on 03/05/2026 at 8:49 AM, the Director of Nursing (DON) stated that her expectation was for staff to report abuse to her or the abuse coordinator as soon as it was identified, and that was how staff were trained. During an interview on 03/05/2026 at 9:23 AM, the ADM stated the facility process was that allegations of abuse were to be reported immediately, and that pertained to all staff. The ADM stated staff were trained in abuse at the time of hire and with routine facility training. The ADM stated that CNA #18 should have reported the incident as soon as it was identified.

Based on facility policy review, record review, facility document review, and interview, the facility failed to activate a resident's physician orders for blood glucose monitoring and sliding scale insulin that were listed in the medication administration software queue, which caused staff to not monitor blood glucose levels or provide insulin according to the order. The deficiencies affected 1 (Resident # 78) of 2 residents reviewed for diabetes management. The facility implemented corrective actions to correct the identified deficient practice from [DATE] to [DATE], to include a change in electronic health record software, staff training, and ongoing audits; thus, past noncompliance was cited. The findings include: An undated facility policy titled, Insulin Administration indicated its Purpose was, To provide guidelines for the safe administration of insulin to residents with diabetes. The policy revealed Preparation included, 3. The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure it corresponds with the order on the medication sheet and the physician's order. The policy further indicated, Steps in the Procedure (Insulin Injections via Syringe) included, 2. Check blood glucose per physician order or facility protocol, 8. Check the order for the amount of insulin, and 12. Double check the order for the amount of insulin. The policy revealed, Documentation included, 1. The resident's blood glucose result, as ordered; and 2. The dose and concentration of the insulin injection. A Profile Face Sheet indicated the facility admitted Resident #78 on [DATE]. A 5-day Minimum Data Set (MDS) for a Medicare Part A stay, with an Assessment Reference Date (ARD) of [DATE], revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #78 had an active diagnosis of type 2 diabetes. Per the MDS, Resident #78 received insulin injections. Resident #78's care plan initiated included a category initiated of Diabetes. Interventions initiated [DATE] directed staff to check the resident's blood sugar levels via fingerstick per physician orders and to administer medications per physician orders. Resident #78's Interdisciplinary Notes dated [DATE] revealed that the facility admitted the resident for rehabilitation services and 24-hour skilled nursing care following a hospitalization due to a fall at home. According to the Interdisciplinary Notes, the resident had a medical history that included diagnoses of chronic kidney disease and type 2 diabetes mellitus. Resident #78's Physician's Orders, included an order, dated [DATE], to check the resident's blood sugar before meals and at bedtime, to be completed four times a day. The Physician Orders included an order, dated [DATE], for insulin aspart (a fast-acting insulin) 100 unit/milliliter (mL) (3 mL) insulin pen four times a day to be administered based on a sliding scale. The order had a stop date of [DATE]. The Physician Orders included an order, dated [DATE], for insulin aspart 100 unit/mL (3 mL) insulin pen four times a day to be administered based on a sliding scale. Resident #78's Interdisciplinary Notes included a note, dated [DATE] at 2:43 PM, that revealed that the resident's family member expressed concern that Resident #78's blood sugar levels had not been checked for the past couple of days, and they were concerned the resident was not on a short acting insulin. Resident #78's Medication Record for 01/2024 revealed that staff did not document the resident's blood sugar level or administration of insulin aspart on the following dates and times: - [DATE]- 5:00 PM, 8:00 PM - [DATE]- 7:00 AM, 11:00 AM, 5:00 PM, 8:00 PM - [DATE]- 7:00 AM, 11:00 AM, 5:00 PM, 8:00 PM A facility Medication Error Report, completed on [DATE], indicated that Nurse Practitioner (NP) #7 updated the resident's sliding scale insulin order on [DATE]; however, the update was not signed and remained in the unsigned order queue. The report indicated that as a result, the insulin aspart order was not active on the medication administration record (MAR), preventing nursing staff from seeing the updated order, and Resident #78 missed doses of insulin aspart, which occurred twice on [DATE], four times on [DATE], and four times on [DATE]. A typed statement from Physician #22, dated [DATE], indicated that Resident #78 had an extensive past medical history, including uncontrolled type 2 diabetes mellitus, chronic kidney disease (CKD) stage III, and hyperlipidemia. The statement indicated that Resident #78 received insulin based on a sliding scale on Friday, [DATE] but did not receive any insulin based on the sliding scale on [DATE] or [DATE]. The statement indicated that Resident #78's blood glucose reached a maximum level of 343 mg/dL on [DATE]. The statement indicated that on [DATE], Resident #78's glucose levels had improved, and the sliding scale insulin order was replaced and resumed on [DATE]. During an interview on [DATE] at 4:41 PM, NP #7 stated that she was unable to recall the events related to the resident's insulin due to the lapse of time. NP #7 stated that the Director of Nursing (DON) showed her a copy of the order indicating that she had discontinued it, and she acknowledged that it was an error. NP #7 stated that her intention was to edit the sliding scale order, not discontinue it; however, the electronic medical record software required a provider to unsign an order to bring it back for editing. NP #7 stated that in doing so, she failed to reactivate the insulin aspart order. During an interview on [DATE] at 11:19 AM, the DON stated that the nursing staff failed to identify that the insulin aspart order was missing and remained in the queue waiting to be reactivated after NP #7 erroneously unsigned the order for Resident #78. During an interview on [DATE] at 4:28 PM, the Administrator stated that her expectation was for staff to follow company policy. She further stated that for missing insulin doses where a plan of correction had been implemented, the expectation was for the DON or a designee to verify that all active orders were active and visible for the nurses. PAST NON-COMPLIANCE VERIFICATION A facility document titled, Deficient Practice of Medication Orders, dated [DATE], indicated that the electronic medical record software used by the facility had a feature in which all physician and nurse practitioner orders entered in the system were delayed from appearing on the nursing MAR until a nurse reviewed and signed the provider's order. The document indicated that the process could result in a delay in the orders becoming visible to nursing staff. Per the document, the issue had not occurred before the incident involving Resident #78. The facility implemented the following corrective actions: 1) What corrective actions will be accomplished for those residents found to have been affected by the deficient practice. [Resident #78] Expired [DATE] 0230 AM. Request [Physician #22] to review chart for possible cause of death d/t [due to] sliding scale insulin orders not being done over the weekend. [Resident #78's] scheduled Insulin was given as ordered. [The electronic medical record software used by the facility] has a feature that all MD/NP [medical doctor/nurse practitioner] orders entered into system are delayed until nurse reviews and signs the MD orders causing a delay in seeing orders on the nursing MAR. This review was completed on [DATE]. MD Review Attached. A delay occurred in nursing staff confirming orders starting on the evening of [DATE], [DATE] and [DATE]. Nurses working on Rehab [Rehabilitation] to home failed to sign unsigned orders. On [DATE] the DON called [the software company the facility used for their electronic medical records] to change this delay of orders appearing on the MAR but was unable to fix the system. Administrator discussed with Executive staff for approval of replacement of eHR [electronic health record] system. Approval of changing to a new system was approved by the Executive staff. Beginning on [DATE] a process was developed for unsigned orders to be checked daily M-F [Monday through Friday] each week to ensure that unsigned orders are signed that would allow orders to appear on the MAR. If orders are written on weekend the DON or designee on call would be called to sign any new orders. Implemented a Huddle at the beginning of each shift to ensure RNs [registered nurses], LPNs [licensed practical nurses], and CNAs [certified nursing assistants] are aware of any change in the care needs of their assigned resident. Copy of Huddle Sheet Attached. DON instructed staffing coordinator to coordinate with the Pharmacy Consulting to conduct Insulin in-service. Staffing Coordinator and Pharmacy Consultant will conduct an In-service on Insulin administration within a week. Staffing Coordinator began in-service on [DATE] and completed this in-service on [DATE]. Pharmacy Consultant conducted an additional in- person in-service on [DATE]. Any staff who fail to comply with the points of the in services will be further educated and/or progressively discipline will begin as indicated. On [DATE] the Health Care Consultant and DON reviewed [Resident #78's] medical record for identifying any standard of care Issues. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. Effective [DATE] the DON and designee reviewed all Resident's Physician orders and MARs for unsigned orders. Any orders not signed were signed Immediately and If necessary called MD/NP for follow-up. 3) What measure will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. The Administrator will recommend some Software program that other facilities use to the Executive Committee within 2 weeks that could eliminate the issues with unsigned order not printing on MAR timely. Monitoring sheets developed for the DON and/or designed to initial when orders have been checked and signed each day. Monitoring Sheet Attached. 4) How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e. [id est; that is], what quality assurance program will be put into place. At the QAPI [Quality Assurance and Performance Improvement] meetings the results of the monitoring by the DON and the designee will be reviewed, however any concerns identified will be addressed as discovered, including any needed education and/or progressive discipline. Beginning [DATE] DON will report monitoring outcomes of in-services on unsigned orders and change of software system at the quarterly QAPI Committee meetings. The survey team verified the above corrective actions had been implemented by the facility; thus, past noncompliance was cited.

Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure staff honored residents' rights related to self-determination, which affected 1 (Resident #31) of 1 resident reviewed for dignity concerns. The findings include: An undated facility policy titled, Resident Rights And Responsibilities, revealed, The resident has the right to, which included, Refuse treatment to the extent permitted by law and be informed of the medical consequences of such refusal, and Exercise his or her rights without being subjected to discrimination or reprisal. An admission Record revealed the facility admitted Resident #31 on 10/26/2023. According to the admission Record, the resident had a medical history that included a diagnosis of unspecified dementia, severe with agitation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/25/2024, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident was short-tempered, easily annoyed for half or more of the assessment's lookback period. The MDS indicated the resident was dependent on staff for showering/bathing and personal hygiene. Resident #31's care plan included a category titled, Behavior Problem, that indicated the resident had impaired behavior related to their dementia that was evidenced by being aggressive and resistant to care with staff. The care plan included a category titled, Resistive to Care, that revealed the resident resisted care related to a knowledge deficit, denial of illness, denial of risk factors, cognitive impairment, and mental/emotional illness. Interventions initiated on 08/08/2024 directed staff to discuss the resident's objections and fears, inform the resident about the risks of non-compliance, offer the resident as many choices as possible, and accept the resident's right to refuse and show respect for the resident's decisions. A facility document titled, Notes from Meeting on 09/13/'24 [2024] at 2:30pm with officer [officer's name], indicated that on 09/06/2023, an incident occurred between a staff member and Resident #31. Per the document, the Administrator stated that it had been reported that two staff members were providing care when the resident became agitated. A typed statement dated 09/13/2024 by Certified Nursing Assistant (CNA) #17, indicated that she had worked a shift lately when CNA #18 told her that Resident #31 refused their shower. The statement indicated that CNA #17 told CNA #18 that she would help because Resident #31 had to get their showers. The statement indicated that CNA #17 and CNA #18 helped the resident into a shower chair. A handwritten staff statement dated 09/13/2024 by CNA #18 indicated that it was Resident #31's shower day, that she entered the resident's room with CNA #17, and that CNA #18 told the resident that it was their shower day and they were going to help the resident get into the shower. The document indicated that Resident #31 said, No I don't want a shower. The statement indicated that CNA #17 told the resident that they were getting a shower and pulled the covers off the resident. The statement indicated that the aides placed the resident in a shower chair, CNA #17 left the room, and CNA #18 continued with providing the shower. During a telephone interview on 03/04/2026 at 9:17 AM, CNA #17 stated that the staff member who was assigned to Resident #31 told her that the resident refused their shower. She stated that she told the other staff member that it was the resident's day to get a shower and to go ahead and provide the shower. During an interview on 03/05/2026 at 8:49 AM, the Director of Nursing (DON) stated that if a resident refused provision of care, the staff were expected to come back later and try again. She stated that if the resident continued to refuse, staff were expected to leave the resident alone and notify the nurse of the refusal and see what the resident's preference was. She stated that it was expected that staff honor the residents' right to refuse provision of care/showers. During an interview on 03/05/2026 at 9:23 AM, the Administrator stated that staff were expected to acknowledge the residents' right to say no. She stated that staff were expected to come back to the resident another time and notify the nurse or social services staff of the refusal, or the resident's family if necessary.

Based on record review, interview, review of facility policy, and review of the American Heart Association Adult Basic Life Support Algorithm, the facility failed to have documented evidence that Emergency Medical Services (EMS or 911) was contacted or that an Automated External Defibrillator (AED) was utilized when cardiopulmonary resuscitation (CPR) was provided for 1 resident (Resident #78) of 2 residents reviewed for CPR, who had a physician's order for a full code (a medical directive indicating that if a person's heart stops or they stop breathing, healthcare providers will use all available life saving measures to revive them). The findings include: A facility policy titled, CPR - Do Not Resuscitate - DNR POST Form, revised 07/2025, revealed, Cardiopulmonary Resuscitation (CPR) shall be defined as the administering of any means or device to restore or support resuscitative functions in a resident, whether by mechanical devices, chest compressions, mouth-to-mouth resuscitation, cardiac massage, tracheal intubation, manual or mechanical ventilator or respirator, defibrillation, and/or the administration of drugs and/or chemical agents intended to restore cardiac and/or respiratory functions in a resident where cardiac or respiratory arrest has occurred or is believed to be imminent. The facility should direct staff to call 911 for resident emergencies except for residents who have a signed POST [Physician Orders for Scope of Treatment] form or other physician's order directing withholding of CPR, and residents who show American Heart Association [AHA] signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC). The 2020 American Heart Association Adult Basic Life Support Algorithm for Healthcare Providers revealed, Check for responsiveness. Shout for nearby help. Activate emergency response system via mobile device (if appropriate). Get an AED and emergency equipment (or send someone to do so). Per the algorithm, if No breathing or only gasping, pulse not felt staff should Start CPR. Perform cycles of 30 compressions and 2 breaths. Use AED as soon as it is available. A Profile Face Sheet indicated the facility admitted Resident #78 on [DATE]. According to the Profile Face Sheet, Resident #78 was full code. Resident #78's Interdisciplinary Notes dated [DATE] revealed that the facility admitted the resident for rehabilitation services and 24-hour skilled nursing care following a hospitalization due to a fall at home. According to the Interdisciplinary Notes, the resident had a medical history that included diagnoses of atrial fibrillation, history of multiple cardioversions, dysphagia, chronic kidney disease, mild cognitive impairment with memory loss, hypertension, urinary tract infection (UTI), influenza, and type 2 diabetes mellitus. A 5-day Minimum Data Set (MDS) for a Medicare Part A stay with an Assessment Reference Date (ARD) of [DATE], revealed Resident #78 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Resident #78's care plan dated [DATE] revealed Resuscitate: FULL CODE was in the top left corner on each page of the 12-page document. Resident #78's Physician's Orders for [DATE] revealed the resident had an order for a full code. Resident #78's Interdisciplinary Notes dated [DATE] at 5:15 AM revealed Registered Nurse (RN) #6 documented that she administered medication to the resident and checked the resident's vital signs at 8:20 PM (on [DATE]). Per the note, the resident was sitting in a wheelchair, watching television. The notes revealed a Certified Nursing Assistant (CNA) assisted the resident to the bathroom before going to bed at 10:00 PM and the CNA checked the resident again at 12:00 AM. The notes revealed at 2:00 AM on [DATE], the CNA found Resident #78 unresponsive and notified RN #6. The note revealed that RN #6 rushed to the room and assessed Resident #78. Per the note, the resident had no heart sounds, pulse, or respirations. The Interdisciplinary Notes revealed that staff initiated CPR, and fellow nursing staff assisted; however, the resident continued to have no pulses. According to the notes, despite staff' continued efforts, Resident #78 was pronounced deceased at 2:45 AM on [DATE]. There was no documented evidence that the facility contacted EMS/911 or used an AED during the resuscitation attempts. An electronic mail (e-mail) communication between the state agency and the fire department medical records department dated [DATE] at 2:40 PM revealed that in reference to Resident #78 on [DATE], the fire department responded, We do not have any reports under that name for that date. During an interview on [DATE] at 1:52 PM, CNA #4 reported that she was assigned to care for Resident #78 when the resident passed away. She stated when she saw the resident, the way the resident was lying was different and the resident's mouth was opened, and she called RN #6 to check the resident. Per CNA #4, RN #6 checked the resident's vital signs and could not detect a pulse. CNA #4 stated that RN #6 started CPR and asked RN #14 to call 911. CNA #4 stated RN #14 left to call 911, but she did not witness the RN making the call and could not remember whether EMS came to the facility because she resumed care of other residents. Telephone attempts to interview RN #6 on [DATE] at 3:03 PM and 6:01 PM were unsuccessful. Telephone attempts to interview RN #14 on [DATE] at 11:11 AM and 2:25 PM were unsuccessful. On [DATE] at 11:04 AM, Licensed Practical Nurse LPN 10 stated that if a resident who had no vital signs of life was a full code, the licensed nurse must initiate CPR, call 911, and get an AED. Per LPN #10, staff should continue CPR until EMS arrived. During an interview on [DATE] at 12:06 PM, the Director of Nursing (DON) stated that when a resident had an order for full code and was found not breathing, staff should initiate CPR, get the AED, call EMS, and continue CPR until EMS arrived. The DON stated that staff found Resident #78 unresponsive at 2:00 AM and RN #6 pronounced the resident deceased at 2:45 AM. The DON stated that at the time of the incident, the state was experiencing inclement weather. The DON stated staff verbally told her that they called EMS; however, she stated she had no evidence to verify that EMS was contacted. Per the DON, the facility contacted 911 dispatch, who told facility staff that they did not keep records from two years ago. A follow-up interview with the DON on [DATE] at 4:08 PM, revealed staff were educated on AED use as a part of CPR training and the facility had two AEDs. The DON stated she did not have a log for the AED for 2024 and did not know whether staff used an AED for Resident #78. Per the DON, the expectation was for staff to document the use of an AED and 911 notification. During an interview on [DATE] at 9:03 AM, the facility Health Care Consultant stated that per staff, on the morning of Resident #78's death, staff called EMS, but they did not show up due to bad weather. She stated the staff felt like the resident was clinically deceased prior to starting CPR. On [DATE] at 4:41 PM, Nurse Practitioner (NP) #7 indicated that when a resident was full code, the facility practice was to initiate CPR and contact 911, use the AED, and continue CPR until EMS arrived. During an interview on [DATE] at 11:54 AM, Medical Director (MD) #22 stated that a nurse should initiate CPR and contact EMS. He stated that if EMS could not make it due to a weather situation, they may be able to provide guidance by telephone. MD #22 further stated that if it was clear the resident was deceased and not responding to CPR, EMS did not need to come, and an RN was permitted to pronounce death in accordance with state practice standards. During an interview on [DATE] at 4:28 PM, the Administrator stated she expected staff to follow the facility's policy regarding CPR and to properly document in the resident's medical record all care and services that were provided to the resident.

Based on facility policy review, medical record review, and interview, the facility failed to perform Interdisciplinary Team (IDT) Care Plan meetings for 10 of 29 sampled residents (Resident #2, #3, #9, #12, #17, #21, #22, #28, #29, and #43) and the facility failed to revise the Care Plan for 1 of 29 sampled residents (Resident #2). The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with revision date 9/20/2021 revealed .the Interdisciplinary Team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .the IDT must review and update the care plan .when there has been a significant change in the resident's condition .when the desired outcome is not met .when the resident has been readmitted to the facility from a hospital stay .at least quarterly, in conjunction with the required quarterly Minimum Data Set [MDS] . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE] for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive abilities. Continued review of the MDS revealed Resident #2 had a weight loss of 5 percent (%) in the last month or loss of 10 % or more in last 6 months. Further review of the MDS revealed she did not receive antipsychotic drugs in the last 7 days. Review of the Care Plan for Resident #2 dated 3/21/2022, revealed a plan of care developed to address psychoactive drug use. Continued review revealed a plan of care developed to address nutrition but interventions were not updated when a significant weight loss was identified. Review of the medical record for Resident #2 revealed the last IDT Care Plan meeting was completed on 11/3/2021. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #3 revealed the last IDT Care Plan meeting was completed on 10/26/2021. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the medical record for Resident #9 revealed the last IDT Care Plan meeting was completed on 10/22/2021. Review of the medical record for Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #12 revealed the last IDT Care Plan meeting was completed on 4/12/2021. Review of the medical record for Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #17 revealed the last IDT Care Plan meeting completed on 10/26/2021. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #21 revealed the last IDT Care Plan meeting completed on 10/12/2021. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #22 revealed the last IDT Care Plan meeting completed on 10/15/2021. Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #28 revealed the last IDT Care Plan meeting completed on 10/21/2021. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #29 revealed the last IDT Care Plan meeting completed on 7/16/2021. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record for Resident #43 revealed the last IDT Care Plan meeting completed on 5/26/2021. During an interview on 3/23/2022 at 2:22 PM, the MDS Coordinator confirmed Resident #2 was not receiving psychoactive drugs and the care plan was incorrect. During an interview on 3/23/2022 at 2:39 PM, the Registered Dietician confirmed the Care Plan for Resident #2 did not reflect the updated interventions related to her significant weight loss. During an interview on 3/23/2022 at 5:05 PM, the Social Service Director confirmed that IDT Care Plan meetings should have been completed quarterly. She confirmed Resident #2, #3, #9, #12, #17, #21, #22, #28, #29, and #43 did not have quarterly IDT Care Plan meetings.

Based on facility documentation and interview the facility failed to have at least 8 hours of Registered Nurse (RN) coverage in the facility. The findings include: Review of the facility daily staffing revealed in November 2020 the facility had 5 days of no 8 hour RN coverage. December 2020 the facility had 3 days of no 8 hour RN coverage; January 2021 the facility had 1 day of no 8 hour RN coverage; February 2021 the facility had 3 days of no 8 hour RN coverage; March 2021 the facility had 1 day of no 8 hour RN coverage; May 2021 the facility had 1 day of no 8 hour RN coverage; June 2021 the facility had 1 day of no 8 hour RN coverage; July 2021 the facility had 3 days of no 8 hour RN coverage; August 2021 the facility had 2 days of no 8 hour RN coverage; December 2021 the facility had 1 day of no 8 hour RN coverage. During a telephone interview on 3/24/2022 at 10:24 AM, the Administrator confirmed there was no 8 hour RN coverage for the specific days in November and December 2020; January, February, March, April, May, June, July, August, and December 2021.

Based on facility policy review, medical record review, and interview, the facility failed to notify family of a change of condition for 1 of 29 sampled residents (Resident #2) related to a significant weight loss. The findings include: Review of the facility policy titled, Guidelines for Notifying Physicians/Family of Clinical Problems, with revision date of 2/2021 revealed, .all significant changes in resident status are assessed and documented in the medical record and family notified . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive abilities. Continued review of the MDS revealed weight loss with no physician prescribed weight-loss regimen. Review of the weights for Resident #2 revealed a weight of 125.8 pounds (lbs) on 9/5/2021 and 113.2 lbs on 3/20/2022 which revealed a 10 percent (%) weight loss. Review of the medical record revealed no notification to Resident #2's representative related to the significant weight loss. During an interview on 3/23/2022 at 3:32 PM the Registered Dietician confirmed the family had not been notified of the weight loss for Resident #2.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain privacy for 4 of 29 sampled residents (Resident #9, #11, #12, and #17) related to swallowing difficulties. Review of the facility's undated policy, titled, Notice of Privacy Practices, revealed, .Our Responsibilities .Maintain the privacy of your health information . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .ST (Speech Therapy) eval [evaluate] and treat as indicated .SLP (Speech Language Pathologist) to treat for dysphagia to increase swallow safety skills and symbolic language treatment to increase to communication/cognition for ADLs [Activities of Daily Living] safety, as indicated . Review of Resident #9's Care Plan dated 6/23/2021, revealed, .Nutritional Status .nutritional risk r/t [related to] Dysphagia .ST to evaluate as needed . Review of facility documentation titled, Safe Swallowing Strategies, dated 6/29, revealed, .Sit upright during meals .out of bed .eat slowly and take your time .take small bites and sips .stay upright for 20 minutes after meals .alternate between bites and sips .other:MECHANICAL SOFT/GROUND ADD SAUCES/GRAVY TO FOOD-FOOD MUST BE MOIST. PUREED SOUP .if you have questions, please call speech therapy .Pills 1-2 at a time with thin liquids as tolerated .assist with oral care .Avoid breakfast meats .Supervision with meals . Observation in Resident #9's room on 3/21/2022 at 11:30 AM, revealed a detailed safe swallowing instruction checklist with the resident's information displayed on her cabinet. During an interview on 3/21/2022 at 12:41 PM Speech Therapist #1 reviewed Resident #9's detailed safe swallowing instruction checklist and stated, In the past we have placed them [swallowing instruction checklist] on the cabinet in the resident's room; this is a way we communicate with family and caregivers who may care for them. I have worked in other facilities where we would place a paper over them to protect the patient's dignity, but here we just place them [swallowing instruction checklist] on the cabinet. During an interview on 3/22/2022 at 12:27 PM in Resident #9's room, Licensed Practical Nurse (LPN) #2 confirmed Resident #9 had a detailed safe swallowing instruction checklist displayed on her cabinet on 3/21/2022. He stated, It was up there yesterday, but we placed it in a folder today. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .ST eval and treat as indicated .SLP to treat for dysphagia to increase oropharyngeal swallow safety skills with the least restrictive diet . Review of facility documentation titled, Safe Swallowing Strategies, dated 1/27/2022, revealed, .Sit upright during meals .out of bed preferably .eat slowly and take your time .take small bites and sips .one sip of liquid at a time .stay upright for 20 minutes after meals .alternate between bites and sips .other: Regular-Meats must be chopped to a small bite size. Chop sides as needed .if you have questions, please call speech therapy .Assist with oral care 2-3 x's (times)/day . Observations in Resident #11's room on 3/22/2022 at 1:54 PM, 2:15 PM, 3:10 PM and 5:06 PM, revealed a detailed safe swallowing instruction checklist with the resident's information displayed on her cabinet. Observation and interview in Resident #11's room on 3/22/2022 at 5:08 PM, Licensed Practical Nurse (LPN) #1 confirmed a detailed safe swallowing checklist for Resident #11 was displayed on the cabinet in the resident's room. During an interview on 3/23/2022 at 5:25 PM, the Director of Nursing (DON) stated, my expectation would be for all resident information papers be covered if it's placed in the resident's room. During an interview on 3/23/2022 at 5:35 PM, Speech Therapist #2 confirmed any resident information should be protected and not exposed to view of visitors. She stated, If resident information is displayed in the resident's room it should be covered with another piece of paper to protect the resident's privacy. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident #12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility documentation titled, Swallow Strategies dated 3/2021 revealed .Mechanical Soft. Encourage naturally nectar thick liquids as Ensure, milk shakes, crush meds, as needed . Observation in Resident #12's room on 3/21/2022 at 11:38 AM revealed the Swallowing Strategies posted on the back wall next to Resident #12's bed. Obervations in Resident #12's room on 3/21/22 at 4:13 PM revealed the Swallowing Strategies posted on the back wall next to Resident #12's bed. Observation in Resident #12's room on 3/22/2022 at 10:15 AM revealed the Swallowing Strategies posted on the back wall next to Resident #12's bed. Observation and interview in Resident #12's room on 3/22/2022 at 10:29 AM the Speech Therapy Director confirmed another speech therapist had placed the swallowing strategies upon the walls of residents who had swallowing issues. The ST confirmed the information should not be visible to non caregivers and visitors while in the resident's room. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident #17's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . G-Tube 5 times a day; dysphagia . Review of the facility documentation titled, Safe Swallowing Strategies dated 5/18/2021 revealed .Liquids by teaspoon only 1/4 teaspoon .Give water by tsp [teaspoon] at end of feeding . Observation in Resident #17's room on 3/22/22 at 8:53 AM revealed the Swallowing Strategies posted on the back wall behind her bed. Observation and interview in Resident #17's room on 3/22/2022 at 10:35 AM, the Speech Therapy Director confirmed the information should not be visible to non caregivers and visitors while in the resident's room.

Based on facility policy review, observations, and interview, the facility failed to maintain dietary equipment in a sanitary manner in the dietary department during 1 of 3 observations. The findings include: Review of the facility's policy titled, Sanitation and Infection Prevention/Control, dated 1/2021, revealed, .detailing daily and weekly (as needed) cleaning for all areas and equipment in the department . Observation in the dietary department on 3/21/2022 at 10:35 AM, revealed the pan under the stove burners had a moderate amount of black burned particles on the surface. During an interview on 3/21/2022 at 10:36 AM, the Certified Dietary Manager (CDM) confirmed the pan under the stove burners had a moderate amount of black burned particles on the surface and she stated she did not know when it had been cleaned.

Based on facility documentation, medical record review, observation and interview the facility failed to serve a therapeutic diet during the lunch meal for 1 of 29 sampled residents (Resident #12) observed. The findings include: Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Dysphagia, Oropharyngeal Phase. Review of Resident #12's Physician Orders dated 8/24/2021, revealed .MS [mechanical soft] Ground, NAS [No added salt] . Review of the Annual Minimum Data Set (MDS) dated [DATE], revealed Resident #12 required a mechanical altered diet. Review of the lunch meal ticket dated 3/22/2022, revealed .MS [mechanical soft] Deluxe Hamburger . Observation in Resident #12's room at 12:07 PM, revealed Resident #12 had a lunch tray with hamburger and steamed broccoli. Continued observation revealed the Certified Nurse Assistant (CNA) #3 looked at the meal ticket and identified the meal which was delivered was not a mechanical soft diet. During an interview on 3/22/2022 at 12:11 PM, CNA #3 confirmed Resident #12's lunch tray did not match the meal ticket. During an interview with Certified Dietary Manager (CDM) and Registered Dietician (RD) on 3/22/2022 at 1:15 PM, confirmed they had served Resident #12 a ground beef patti. The CDM and RD confirmed the hamburger was not a mechanical soft diet.

Based on facility policy review, medical record review, observation, and interview, the facility failed to store medications and biologicals appropriately for 4 of 29 sampled residents (Resident #10, Resident #33, Resident #47, and Resident #304) reviewed receiving medications and biologicals. The findings include: Review of the facility's policy titled, Storage of Medications, revised April 2007 revealed, .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Compartments .containing drugs and biologicals shall be locked when not in use .items shall not be left unattended if opened or otherwise potentially available to others . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had no pressure ulcers and received no wound care. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly MDS assessment dated [DATE] revealed Resident #47 had no wounds or wound care. Continued review revealed the resident rarely/never understood and the resident scored 3 on the cognitive skills for daily decision making indicating the resident was severely cognitively impaired. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #304 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[brand named] 6% [[MEDICATION(S)] [MEDICATION(S)]]-Instill two drops in each eye three times daily as needed .Dry Eye Syndrome .3/21/2021 . Observation in Resident #10's room on 3/21/2022 at 11:33 AM, revealed a non-adherent wound gauze dressing (fine mesh, absorbent gauze impregnated with white petroleum) and a bottle of wound cleanser were stored in an unlocked cabinet. Observation in Resident #33's room on 3/22/2022 at 9:15 AM, revealed one bottle of Stoma Powder (powder to absorb moisture around the stoma) was on the nightstand. Observation and interview in Resident #33's room on 3/22/2022 at 9:16 AM, Licensed Practical Nurse (LPN) #1 confirmed a bottle of stoma powder was on the resident's nightstand and not stored correctly. Observation in Resident #304's room on 3/21/2022 at 10:50 AM, revealed a bottle of [named] lubricant eye drops (provides soothing comfort, add moisture and leaves eyes refreshed) on the resident's overbed table. Observation in Resident #47's room on 3/21/2022 at 11:19 AM, revealed a bottle of wound cleanser, and a bottle of fingernail polish remover were stored in an unlocked cabinet. During an interview on 3/21/2022 at 11:02 AM in Resident #304's room, LPN #3 confirmed a bottle of eye drops were on the resident's overbed table. LPN #3 stated, she should not have these in here. During an interview on 3/21/2022 at 11:37 AM in Resident #10's room, the Wound Care Nurse confirmed the resident had wound care supplies stored in an unlocked cabinet in her room. During an interview on 3/21/2022 at 11:38 AM in Resident #47's room, the Wound Care Nurse confirmed Resident #47 had wound care supplies and fingernail polish remover stored in her room in an unlocked cabinet. He stated, nail polish remover should definitely not be in there.

Based on facility policy review, medical record review, and interview, the facility failed to implement a care plan for 1 of 29 sampled residents (Resident #29) reviewed for care plans. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 9/2021, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's care plan dated 2/8/2022 revealed no care plan for [CONDITION(S)]. During an interview on 3/23/2022 at 10:36 AM, Miminum Data Set (MDS) nurse confirmed Resident #29 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of the facility policy, review of the manufacturer's recommendation, observation, interview and review of the Dishware/Warewashing Machine Temperature Log, the facility failed to operate the dish machine wash cycle within the recommended minimum 160 degrees Fahrenheit (F) in 1 of 6 observations. The findings include: Review of the undated facility policy, Dish-Machine Temperatures, revealed .Temps (temperatures) are taken daily and documented if they aren't to standard-Chef or Dietary Director must be informed immediately. Wash Tank Temp must be 160 degrees F. Final Rinse Temp must be 180 degrees F .If findings aren't to standard, Maintenance and Ecolab (chemical supplier, monitored dish machine operation) will be informed to correct any problems . Review of the dish machine manufacturer's recommendation revealed the minimum wash temperature was 160 degrees F. Observation on 4/15/19 at 7:38 AM in the dietary department dishroom revealed the dish machine was in operation. Further observation revealed various pots, pans, utensils, and sheet pans were processed through the dish machine. Further observation of 3 consecutive wash cycles revealed the wash temperatures were 154, 154, and 152 degrees F. Further observation revealed the dietary staff member, working the clean side of the dish machine, removed the cleaned items from the dish machine and stored the items on racks in order to dry. Interview with Dietary Staff #1 on 4/15/19 at 7:38 AM, working the dirty side of the dish machine, in the dietary dishroom revealed the dietary staff member had .already taken and recorded the wash and rinse temperatures of the dish machine on the dish machine log (Dishware/Warewashing Machine Temperature Log) . Review of the Dishware/Warewashing Machine Temperature Log for (MONTH) 2019 revealed the wash temperatures in 22 of the 93 opportunities were less than 160 degrees F. Review of the (MONTH) 2019 log revealed no documentation of the 2/28/19 lunch and dinner dish machine wash and rinse temperatures, leaving 82 opportunities. Further review of the (MONTH) 2019 log revealed the wash temperatures in 82 of the 82 opportunities were less than 160 degrees F. Review of the (MONTH) 2019 log revealed the wash temperatures in 90 of the 93 opportunities were less than 160 degrees F. Review of the log for 4/1/19 to 4/15/19 breakfast revealed the wash temperatures in 43 of 43 opportunities were less than 160 degrees F. Interview with the Certified Dietary Manager on 4/15/19 at 10:00 AM in the conference room confirmed the dish machine wash temperature did not meet the minimum temperature of 160 degrees F per the manufacturer's recommendation.

Based on review of facility policy, medical record review, observation, and interview, the facility failed to store medication in a locked and safe manner for 1 resident (Resident #273) of 23 sampled residents. Findings include: Review of the facility policy Storage of Medications revised 9/03, revealed .Medications are stored in the containers in which they are received .Compartments containing medications are locked when not in use .Medications are stored in an orderly manner in cabinets, drawers or carts . Medical record review revealed Resident #273 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 4/2/18 at 2:51 PM in Resident #273's room revealed nasal spray (Afrin 0.5 %) and eye drops (Refresh eye drops) were in a clear plastic cup on top of the bedside table and were left unattended. Interview with Licensed Practical Nurse (LPN) #6 on 4/2/18 at 3:33 PM confirmed the nasal spray and eye drops were left on the bedside table unattended. Interview with the Director of Nursing (DON) on 4/4/18 at the L Hall lounge area at 2:23 PM confirmed the facility failed to store medication in a locked and safe manner for Resident #273.

Based on facility policy, medical record review and interview, the facility failed to ensure 1 resident of 12 sampled residents (Resident #19) was free of a significant medication error. Findings include: Review of facility policy Medication Administration revised 9/2017, revealed .Medications must be administered in accordance with the orders, including any required time frame . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Physician order [REDACTED].#19 was to receive [MEDICATION NAME] (laxative) 17 grams every other day for [DIAGNOSES REDACTED]. Medical record review of the Medication Administration Records for 7/1/17 - 4/3/18 revealed Resident #19 received the [MEDICATION NAME] every day. Interview with the Director of Nursing (DON) on 4/3/18 at 3:44 PM at the main nurse station revealed Resident #19 had been stable and had not experienced any adverse effects from the significant medication error. Continued interview with the DON confirmed the facility failed to follow the physician order [REDACTED].

Based on medical record review and interview the facility failed to transmit resident assessments within the required timeframe for 6 of 23 sampled residents (Resident #2, Resident #3, Resident #4, Resident #6, Resident #7 and Resident #11). Findings include: Medical record review revealed Resident #2 was admitted to the facility 10/4/17 and discharged [DATE]. Continued review revealed a discharged Minimum Data Set (MDS) completed and transmitted 11/7/17. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE]. Continued review revealed a discharged MDS completed 10/31/17 was transmitted 11/21/17. Medical record review revealed Resident #4 was admitted to the facility on [DATE]. Continued review of the MDS revealed the following: A Quarterly MDS completed 3/10/17 was transmitted 5/24/17. A Quarterly MDS completed 6/2/17 was transmitted 7/10/17. A Quarterly MDS completed 9/1/17 was transmitted 11/22/17. A Quarterly MDS completed 11/30/17 was transmitted 12/5/17. An Annual MDS completed 3/5/18 had not been transmitted as of 4/4/18. Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Continued review of the MDS revealed the following: A Quarterly MDS completed 9/11/17 was transmitted 12/15/17. A Quarterly MDS completed 12/11/17 was transmitted 12/29/17. A Quarterly MDS completed 3/12/18 had not been transmitted as of 4/4/18. Medical record review revealed Resident #7 was admitted to the facility on [DATE]. Continued review revealed a Quarterly MDS completed 3/16/18 had not been transmitted as of 4/4/18. Medical record review revealed Resident #11 admitted to the facility on [DATE]. Continued review of the MDS revealed the following: A Quarterly MDS completed 3/8/17 was transmitted 4/14/17. A Quarterly MDS completed 6/7/17 was transmitted 8/1/17. A Quarterly MDS completed 9/6/17 was transmitted 12/15/17. An Annual MDS completed 12/13/17 was transmitted 1/19/18. A Quarterly MDS completed 3/7/18 had not been transmitted as of 4/4/18. Interview with the Director of Nursing on 4/4/18 at 10:23 AM in the dining room revealed she expected the resident assessment to be transmitted as required within the timeframe. Interview with the MDS Coordinator on 4/4/18 at 9:45 AM in her office revealed she was responsible for transmission of all resident MDS. The MDS Coordinator confirmed the MDS for Resident #2, Resident #3, Resident #4, Resident #6, Resident #7 and Resident #11 were not transmitted within the required timeframe.

Based on medical record review and interview the facility failed to complete resident assessments within the required timeframe for 6 of 23 sampled residents (Resident #2, Resident #3, Resident #4, Resident #6, Resident #7 and Resident #11). Findings include: Medical record review revealed Resident #2 was admitted to the facility on [DATE] and discharged on [DATE]. Continued review revealed the Discharge Minimum Data Set (MDS) was completed 11/7/17. Medical record review revealed Resident #3 was admitted to the facility on [DATE] and discharged on [DATE]. Continued review revealed the Discharge MDS was completed 11/21/17. Medical record review revealed Resident #4 was admitted to the facility on [DATE]. Continued review of the MDS revealed the following: A Quarterly MDS due 2/10/17 was completed 3/10/17. A Quarterly MDS due 5/12/17 was completed 6/2/17. A Quarterly MDS due 8/11/17 was completed 9/1/17. A Quarterly MDS due 11/10/17 was completed 11/30/17. An Annual MDS due 2/11/18 was completed 3/5/18. Medical record review revealed Resident #6 was admitted to the facility on [DATE]. Continued review of the MDS revealed the following: A Quarterly MDS due 8/21/17 was completed 9/11/17. A Quarterly MDS due 11/20/17 was completed 12/11/17. A Quarterly MDS due 2/19/18 was completed 3/12/18. Medical record review revealed Resident #7 admitted to the facility on [DATE]. Continued review of the MDS revealed the following: A Quarterly MDS due on 11/24/17 was completed 12/15/17. A Quarterly MDS due 2/23/18 was completed 3/16/18. Medical record review revealed Resident #11 was admitted to the facility on [DATE]. Continued review of the MDS revealed the following: A Quarterly MDS due 2/15/17 and was completed 3/8/17. A Quarterly MDS due 5/17/17 was completed 6/7/17. A Quarterly MDS due 8/16/17 was completed 9/6/17. An Annual MDS due 11/15/17 was completed 12/13/17. A Quarterly MDS due 2/14/18 was completed 3/7/18. Interview with the Director of Nursing on 4/4/18 at 10:23 AM in the dining room revealed she expected the resident assessments to be completed as required within the timeframe. Interview with the MDS Coordinator on 4/4/18 at 9:45 AM in her office revealed she was responsible for completion of all resident MDS. The MDS Coordinator confirmed the MDS for Resident #2, Resident #3, Resident #4, Resident #6, Resident #7 and Resident #11 were not completed within the required timeframe.

Based on observation and interview, the facility dietary department failed to maintain food storage equipment and food preparation equipment in a sanitary manner. The findings included: Observation on 12/19/16 at 12:20 PM, and on 12/20/16 at 9:00 AM, with the Dietary Manager present who confirmed the findings in interview, revealed the following: Walk-in refrigerator floor perimeter had a heavy black accumulation of debris, and food debris was under the storage racks lining the perimeter walls. Walk-in refrigerator had 2 strips of galvanized steel over the joints of the floor running the width of the refrigerator. There was an accumulation of brown colored fluid along the length of both sides of both strips. Grill had a heavy black accumulation of debris under the grill grate, on the interior side walls, and on the back splash. Griddle interior side walls and the back splash had a heavy accumulation of blackened debris. Griddle food waste slot had an accumulation of dried food debris. Six burner range top had a heavy accumulation of blackened debris around the six burner grates, on the backsplash, and on the interior side wall. Additional observation on 12/20/16 beginning at 9:00 AM, with the Dietary Manager present who confirmed the findings in interview, revealed the following: The foil lined spill pan for the range top had dried food debris and an accumulation of blackened debris under the foil liner. 23 of 23 full size sheet pans stored on a rack in the dishroom had an accumulation of debris on the exterior perimeter and on the interior corners. 12 of 12 full size sheet pans stored on a rack in the food production area and bakery area had an accumulation of debris on the exterior perimeter and on the interior corners. 3 of 3 muffin tins stored on a rack in the food production area and bakery area had a heavy black accumulation of debris on the exterior.

Based on observation and interview, the facility dietary department failed to maintain cold food at or less than 41 degrees Fahrenheit (F) on the resident mid-day meal trayline. The findings included: Observation on 12/19/16 beginning at 11:55 AM in the Woodcrest kitchen, with the Dietary Manager present, revealed the resident mid-day meal trayline was in progress. Further observation revealed the dietary staff obtaining temperatures and the carrot cake with cream cheese frosting was 48.9 degrees F, and the chocolate fudge pie was 42.6 degrees F when removed from the reach-in refrigerator. Six individual milk cartons were stored on top of ice in a container placed on top of the tray delivery cart. One carton was 42.9 degrees F and the second carton was 46.2 degrees F. The Dietary Manager instructed the staff to place the desserts on ice. Observation on 12/19/16 at 12:27 PM in the Woodcrest kitchen revealed no dessert on ice and a delivery cart coming out of the kitchen with 12 trays containing 6 carrot cake or fudge pie desserts. The Dietary Manager obtained the temperatures of the carrot cake with cream cheese frosting at 48.6 degrees F and the chocolate fudge pie was 42.3 degrees F. Interview with the Dietary Manager on 12/19/16 at 12:27 PM, in the Woodcrest kitchen,confirmed the 2 cartons of milk placed on top of the ice, the carrot cake and chocolate fudge pie temperatures were inappropriate on the trayline during the 11:55 AM observation. Further interview at 12:29 PM at the delivery cart by the Woodcrest kitchen confirmed the desserts had not been placed on ice and the staff .used what they had had on hand . Further interview confirmed the cake and pie temperatures on the trays exceeded 41 degrees and were inappropriate.

Based on observation and interview, the facility dietary department failed to maintain 1 of 3 convection ovens in a safe manner. The findings included: Observation on 12/19/16 at 12:20 PM, and on 12/20/16 at 9:00 AM with the Dietary Manager present on both observations, revealed the lower convection oven, of the 2 stacked convection ovens by the paper storeroom, had missing screws in the left door handle and the handle was loose. Interview with the Dietary Manager on 12/20/16 at 9:00 AM by the stacked convection oven confirmed the lower oven was used for food production and the handle was loose due to missing screws.

Based on medical record review and interviews, it was determined the facility failed to ensure the pharmacy delivered the correct medication as ordered by the physician for 1 of 5 (Resident #5) sampled residents. The delivery and administration of Decadron instead of Medrol lead to skin conditions worsening and causing actual harm to Resident #5. The findings included: Medical record review of Resident #5 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's medical record revealed a hospitalized from [DATE] to 10/3/08 during which time treatment was provided for a variety of conditions including an acute respiratory condition with infection and rheumatoid arthritis and a history of the use of Medrol prior to and during hospitalization for treatment of [REDACTED]. Review of the hospital discharge summary dated 10/3/08 revealed [DIAGNOSES REDACTED]. Resident #5's admission medication orders on 10/3/08 included Medrol 8 milligrams (mg) in the AM and 4 mg in the PM. The drug regimen continued to include an order for [REDACTED]. Review of assessment documentation of Resident #5 dated 11/3/08 by the nurse practitioner in the interdisciplinary team notes revealed a cough for 3 days which "is deep and productive" along with a sore throat. A chest x-ray was obtained due to Resident #5's history of pneumonia. Resident #5 was subsequently transferred to the hospital for further evaluation on 11/4/08. At the time of transfer on 11/4/08, medical record documentation revealed Resident #5 had a current order for and was receiving Medrol 8 mg in the AM and 4 mg at bedtime. Review of Resident #5's hospital admission History and Physical evaluation dated 11/4/08 revealed treatment for [REDACTED]. The evaluation report noted a review of systems in which the skin was described as warm and intact except for sacral wounds with bandages in place and the extremities were noted to have no clubbing, cyanosis or edema. Documentation of a pulmonology consultation dated 11/4/08 revealed aside from the current respiratory problem, Resident #5 "is on chronic steroids and has maintained an overall excellent status." The report revealed ongoing [DIAGNOSES REDACTED]. Documentation of exam of extremities revealed Resident #5 "has well healed skin without near the degree of tears" previously present. Review of hospital documentation revealed the Resident #5's hospital drug regimen included Medrol 4 mg in the AM and 4 mg at bedtime. Resident #5 was transferred back to the facility on [DATE] with discharge [DIAGNOSES REDACTED]. Resident #5's medication discharge orders included Medrol 4 mg in the AM and 4 mg in the PM. Review of Resident #5's hospital return orders included Medrol 4 mg in the AM and 4 mg at bedtime. The orders were written on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, review of the facility pharmacy services delivery sheet dated 11/5/08 revealed the medication Dexamethasone (Decadron) was delivered instead of Medrol which had been ordered. The nursing staff began administering Decadron instead of Medrol. During an interview in the private dining room on 2/13/09 at 1:00 PM, the current Director of Nursing (DON) confirmed Decadron had been administered instead of the ordered Medrol. Review of the initial recapitulation (recap) orders for 12/1/08 through 12/31/08 revealed the medication "Decadron 4 MG. tablet Dexamethasone 4 MG. tablet take 2 tablets once daily and 1 at bedtime." These recap orders were noted to have been signed by Resident #5's physician and noted on the MAR indicated [REDACTED]. A review of the verbal/phone order forms revealed an order dated 12/8/08 signed by the nurse practitioner to decrease Medrol to 4 mg in the morning and evening. However, the medication order was transcribed as Decadron 4 mg in the am and pm and noted on the MAR indicated [REDACTED]. Review of nurse's notes dated 12/30/08 revealed Resident #5's temperature was elevated and there was increased pain. Arrangements were made and the resident was transferred to the hospital per order of physician. Further documentation revealed admission to hospital was needed related to high risk of development of sepsis related to multiple wounds, long term steroid use, complex medical history, and increase of pain. Review of the discharge summary and hospital course from 12/30/08 to 1/5/09 for Resident #5 by the attending Hospitalist included the following: Recent extensive hospitalization for pneumonia, empyema and respiratory failure. Transitioned to skilled nursing facility. (10/3/08) Had aggressively advanced diet to recuperate significant protein losses. Had decubitus ulcers on coccyx and left thorax which had not significantly improved despite aggressive daily care. Developed a fever and was transferred to hospital. (12/30/08) Had "profound-appearing necrotic nodules over the lower extremities as well as mottling of the feet." "Found to have significant third spacing edema, skin atrophy and necrotic ulcers from steroid toxicity." Had skin tear to lower left leg resulting in a large flap which was sutured. Was placed on broad spectrum antibiotics. Endured significant pain with any type of movement. The right shoulder was "frozen." Would not be able to undergo significant rehabilitation due to fragility of skin and poor functional status. Respiratory status was worsening with limited therapy options. The focus became comfort, high oxygen and pain medication and Lasix for noncardiogenic pulmonary edema. Resident declined with death on 1/5/09. Final [DIAGNOSES REDACTED]. During an interview in the facility's private dinning room on 2/19/09 at 2:15 PM, the current DON stated she had been told of the medication error (Decadron administered instead of Medrol as described above) on 1/2/09 when at the hospital to visit Resident #5. The DON saw Resident #5's Rheumatology specialist who was with a family member of Resident #5. The Doctor at that time questioned when the Decadron was substituted for the Medrol. The DON revealed she was not aware of the substitution and agreed to check into the issue and follow-up with the Doctor. The DON revealed that on 1/5/09, she began to review documentation to try and piece together what happened. During review of the Resident #5's medical record, the DON saw where Medrol had been ordered originally on 10/3/08 and was on the MAR for 10/08 and 11/08 but Decadron was on the MAR for December 2008. The DON made a call to the pharmacy which confirmed the delivery of Decadron and not Medrol on 11/5/08 and subsequently. The DON revealed that the medication had been signed in by an agency nurse on 11/5/08 that no longer works at the facility. The DON revealed not knowing how/why the error was not caught. A investigation was initiated into the incident. A telephone interview was conducted on 2/18/09 at 12:50 PM, with Resident #5's Rheumatology Specialist who was documented as following the case in hospital reports during the 8/9/08, 11/4/08 and 12/30/08 admissions. During this interview the Rheumatologist revealed Resident #5's primary medication for the RA was Remacade and a low dose of Medrol 4 and 8 mg per day and that the resident had done "pretty well" on these medications. The Rheumatologist revealed having found out about the error (as previously described above) from a "lab paper" of Resident #5 that had been sent to him with a list of medications attached which indicated Resident #5 was receiving Decadron as opposed to Medrol. The Rheumatology specialist revealed that at some point Decadron was substituted for Medrol and that the 4 mg dose of Decadron was approximately 5 times stronger than Medrol. The Rheumatology specialist stated, "(Resident #5) already had thinning of the skin" and was "very ill." An increased dose can "cause thinning of the skin and skin tears. Increased steroids is hard on the skin. It is hard to say how much was due to the substitution." Resident #5 "never had large areas of skin sheering off as she did in the hospital." The "increased dose (of steroids) led to worsening of the skin. Increased steroids suppress the immune system increasing the risk for infection." Review of Glucocorticoid Systemic Equivalencies table provided by the Department of Pharmacy Services supported the information related to potency provided by the Rheumatology physician as described above. The review revealed the anti-inflammatory potency of Decadron is approximately 5 times more than Medrol. During a telephone interview on 3/3/09 at 2:30 PM, an interview was conducted with the attending Hospitalist (hospital physician) for Resident #5 from 12/30/08 through 1/5/09. The Hospitalist revealed the following information. The Hospitalist attended Resident #5 from admission on 12/30/08 to 1/5/09 and the resident had prolonged illnesses. The resident had a prolonged stay in the hospital prior to nursing home admission. The Hospitalist stated, "It was a miracle the resident (#5) survived and made it out to the nursing home." The resident did have a "steroid induced skin necrosis." One was "fearful to touch" the resident "in the hospital due to fragility of skin." The Hospitalist once observed the resident being moved during which the resident sustained [REDACTED]. When skin was torn to the lower leg, the resident had no pain perception. Hospice care was decided upon by resident/family. Resident #5 had a significant decubitus ulcer. The steroid induced skin necrosis impeded healing of skin and clearance of infection. There is "a high degree of certainty, it (Decadron) lead to worsening of the skin condition through out the body and may have prevented healing of decubitus ulcers in the nursing home. Decadron is a stronger drug than Medrol. It did cause harm. There was a gap in knowledge at the pharmacy, an egregious error. I don't know why pharmacy felt it was an adequate substitution. Both medicines are common. Decadron had a more delayed effect. One would not notice changes right away as in a quicker acting medication." A telephone interview was conducted with the facility's attending Physician of Resident #5 on 3/30/09 at 4:45 PM. Resident #5's attending Physician was asked about the administration of Decadron instead of Medrol. The attending Physician stated, "That was a surprise to all." The facility had "no idea it (medications) had been switched out." The attending Physician confirmed he had signed the recap orders as written which included Decadron instead of Medrol. The attending Physician stated he signs "a million orders at the end of the month. It all goes by so fast." He revealed he did not mean to sign for Decadron and did not notice the change on the recap orders. He wanted the resident to continue treatment with Medrol. "I trust the nurses to have it right." A telephone interview was conducted with Resident #5's NP on 3/31/09 at 11:00 AM. The NP was asked about the administration of Decadron instead of the Medrol. The NP revealed she did not know the resident had been receiving Decadron. She thought the resident was receiving Medrol. She prescribed from the hospital discharge orders of 11/5/08. She did not notice the change to Decadron on the December 2008 Recap form or look at the MAR. The NP stated, "I was just going by the discharge order and working in the chart." The NP revealed in her opinion the Decadron "caused skin thinning. It is a much more potent drug." The NP revealed that this explains how the resident got septic causing increased pain in the wound. It caused suppression of the immune system. Refer to F333 and F386

Based on medical record review and interviews, it was determined the facility failed to ensure the physician consistently reviewed the total program of care for appropriateness which led to 1 of 5 (Resident #5) sampled residents receiving the administration of [MEDICATION NAME] medication instead of [MEDICATION NAME] which lead to worsening skin conditions causing harm to Resident #5. The findings included: Medical record review of Resident #5 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #5 revealed a hospitalization from [DATE] to [DATE] during which time treatment was provided for a variety of conditions including an acute respiratory condition with infection and [MEDICAL CONDITION] Arthritis (RA) and a history of the use of [MEDICATION NAME] prior to and during hospitalization for treatment of [REDACTED]. Review of Resident #5's admission medication orders dated [DATE] included an order for [REDACTED]. Review of [DATE] physician orders [REDACTED]. Review of Resident #5's initial skin assessment documented on the wound/skin healing record dated [DATE] revealed 2 pressure ulcer wounds. Review of multiple Non-pressure Skin Condition Reports revealed 13 additional wounds. These wounds were documented as wounds #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, and #15 which were described as full thickness injury (1); soft tissue injury (5); skin tear (2); laceration (1); blister (1). All of the wounds described above were provided treatment and all wounds were noted healed at various points between [DATE] and [DATE] except wounds #1, #2, #3 and #8. These wounds had some decrease in size with treatment as noted on the skin assessment reports. Review of recapitulation (recap) physician orders [REDACTED]. Review of progress notes of Resident #5 dated [DATE] by the nurse practitioner revealed the Resident #5 developed a cough and sore throat for three days and was transferred to the hospital for further evaluation. At the time of transfer on [DATE], medical record documentation revealed Resident #5 had a current order for and was receiving [MEDICATION NAME] 8 mg in the AM and 4 mg at bedtime. Review of Resident #5's hospital admission History and Physical evaluation dated [DATE] revealed treatment for [REDACTED]. The evaluation report noted a review of systems in which the skin was described as warm and intact except for sacral wounds with bandages in place and the extremities were noted to have no clubbing, cyanosis or [MEDICAL CONDITION]. Documentation of a pulmonology consultation dated [DATE] revealed aside from the current respiratory problem, Resident #5 "is on chronic steroids and has maintained an overall excellent status." The report revealed ongoing [DIAGNOSES REDACTED]. Documentation of exam of extremities revealed Resident #5 "has well healed skin without near the degree of tears" previously present. Review of hospital documentation revealed Resident #5's hospital drug regimen included [MEDICATION NAME] 4 mg in the AM and 4 mg at bedtime. Resident #5 was transferred back to the facility on [DATE] with discharge [DIAGNOSES REDACTED]. Review of Resident #5's hospital return orders for [DATE] through [DATE] documented on the recap physician order [REDACTED]. The physician visit dated [DATE] included an assessment of a skin tear and bruising of Resident #5. Resident #5's medical record revealed the orders for [DATE] through [DATE] were written on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. #2 PO (by mouth) with food" and "[MEDICATION NAME] 4 MG. #1 PO q (every) hs hour of sleep)" and were documented as being administered [DATE] through [DATE]. However, review of the facility pharmacy services delivery sheet dated [DATE] revealed the medication [MEDICATION NAME] ([MEDICATION NAME]) was delivered instead of [MEDICATION NAME] which had been ordered. The nursing staff began administering [MEDICATION NAME] instead of [MEDICATION NAME]. Review of the initial recap orders for [DATE] through [DATE] revealed the medication "[MEDICATION NAME] 4 MG. tablet [MEDICATION NAME] 4 MG. tablet take 2 tablets once daily and 1 at bedtime." A review of the MAR for [DATE] revealed the [MEDICATION NAME] was administered as ordered through [DATE]. Review of verbal/phone order forms revealed an order to decrease [MEDICATION NAME] to 4 mg by mouth in the AM and PM signed by the Nurse Practitioner. However, review of the revised order on the MAR for [DATE] through [DATE] beginning [DATE] displayed the medication [MEDICATION NAME] 4 mg PO q am and pm. The AM dose of [MEDICATION NAME] was documented as being administered from [DATE] through [DATE]. Review of the initial recap orders for ,[DATE] revealed the attending physician's signature dated [DATE]. Review of the physician progress notes [REDACTED].#5's medical program. There was no documentation of awareness of the use of [MEDICATION NAME] as documented on the recap order form for ,[DATE] instead of [MEDICATION NAME] as documented for ,[DATE] and ,[DATE]. Review of skin assessment report documentation of Resident #5 after returning to the nursing home on [DATE] revealed wound #1-pressure ulcer-on coccyx was measured 2.2 by (x) 15 x 1.0 with 0.9 undermining with scant serous exudate; wound #2 pressure ulcer on [MEDICATION NAME] spine was measured 0.7 x 0.3 x 0.0. Non-pressure ulcer wounds #3, #8 and #9 were still present. Treatment was on going for these wounds. Review of the non-pressure skin condition report of Resident #5 revealed 8 new wounds which developed after Resident #5 returned to the facility on [DATE] with treatment provided. These wounds included left upper extremity skin tear on [DATE] measuring 3.5 x 0.2 with steri strips applied and noted closed on [DATE]; left elbow skin tear on [DATE] measuring 1.0 x 0.2 and noted closed on [DATE]; right cheek skin tear measuring 1.0 x 0.1 with steri strips applied and noted closed on [DATE]; left knee skin tear on [DATE] measuring 1.1 x 5.0 with on going treatment; right ankle skin tear on [DATE] measuring 0.1 x 1.2 CM. with treatment ongoing; left posterior arm skin tear on 12 13 08 measuring 1.0 x 0.8 with treatment ongoing; right lateral knee skin tear on [DATE] measuring 5.0 x 5.2 with treatment ongoing. Review of interdisciplinary team (IDT) documentation and NP documentation in [DATE] revealed changes in skin condition and an overall decline in condition. Documentation of the decline included the development of and worsening of [MEDICAL CONDITION] to the lower extremities, a development of infection to the coccyx wound and to a large skin tear from a fall on [DATE], an increase in pain including pain in bilateral calfs with discoloration and a continuing skin fragility with easy tearing on touch or movement. Review of nurse's notes dated [DATE] revealed Resident #5's temperature was elevated and there was increased pain. Arrangements were made and Resident #5 was transferred to the hospital per order of physician. Further documentation revealed admission to the hospital was needed related to high risk of development [MEDICAL CONDITION] related to multiple wounds, long term steroid use, complex medical history, and increase of pain. Review of the discharge summary and hospital course from [DATE] to [DATE] for Resident #5 by the attending hospitality included the following: Recent extensive hospitalization for pneumonia, empyema and [MEDICAL CONDITION]. Transitioned to skilled nursing facility. ([DATE]) Had aggressively advanced diet to recuperate significant protein losses. Had decubitus ulcers on coccyx and left thorax which had not significantly improved despite aggressive daily care. Developed a fever and was transferred to hospital. ([DATE]) Had "profound-appearing necrotic nodules over the lower extremities as well as mottling of the feet." "Found to have significant third spacing [MEDICAL CONDITION], skin atrophy and necrotic ulcers from steroid toxicity." Had skin tear to lower left leg resulting in a large flap which was sutured. Was placed on broad spectrum antibiotics. Endured significant pain with any type of movement. The right shoulder was "frozen." Would not be able to undergo significant rehabilitation due to fragility of skin and poor functional status. Respiratory status was worsening with limited therapy options. The focus became comfort, high oxygen and pain medication and [MEDICATION NAME] for noncardiogenic [MEDICAL CONDITIONS]. Resident declined with death on [DATE]. Final [DIAGNOSES REDACTED]. During an interview in the facility's private dinning room on [DATE] at 2:15 PM, the current DON stated she had been told of the medication error ([MEDICATION NAME] administered instead of [MEDICATION NAME] as described above) on [DATE] when at the hospital to visit Resident #5. The DON saw Resident #5's Rheumatology specialist who was with a family member of Resident #5. The Doctor at that time questioned when the [MEDICATION NAME] was substituted for the [MEDICATION NAME]. The DON revealed she was not aware of the substitution and agreed to check into the issue and follow-up with the Doctor. The DON revealed that on [DATE], she began to review documentation to try and piece together what happened. During review of the Resident #5's medical record, the DON saw where [MEDICATION NAME] had been ordered originally on [DATE] and was on the MAR for ,[DATE] and ,[DATE] but [MEDICATION NAME] was on the MAR for [DATE]. The DON made a call to the pharmacy which confirmed the delivery of [MEDICATION NAME] and not [MEDICATION NAME] on [DATE] and subsequently. The DON revealed that the medication had been signed in by an agency nurse on [DATE] that no longer works at the facility. The DON revealed not knowing how/why the error was not caught. A investigation was initiated into the incident. A telephone interview was conducted on [DATE] at 12:50 PM, with Resident #5's Rheumatology Specialist who was documented as following the case in hospital reports during the [DATE], [DATE] and [DATE] admissions. During this interview the Rheumatologist revealed Resident #5's primary medication for the RA was Remacade and a low dose of [MEDICATION NAME] 4 and 8 mg per day and that the resident had done "pretty well" on these medications. The Rheumatologist revealed having found out about the error (as previously described above) from a "lab paper" of Resident #5 that had been sent to him with a list of medications attached which indicated Resident #5 was receiving [MEDICATION NAME] as opposed to [MEDICATION NAME]. The Rheumatology specialist revealed that at some point [MEDICATION NAME] was substituted for [MEDICATION NAME] and that the 4 mg dose of [MEDICATION NAME] was approximately 5 times stronger than [MEDICATION NAME]. The Rheumatology specialist stated, "(Resident #5) already had thinning of the skin" and was "very ill." An increased dose can "cause thinning of the skin and skin tears. Increased steroids is hard on the skin. It is hard to say how much was due to the substitution." Resident #5 "never had large areas of skin sheering off as she did in the hospital." The "increased dose (of steroids) led to worsening of the skin. Increased steroids suppress the immune system increasing the risk for infection." Review of Glucocorticoid Systemic Equivalencies table provided by the Department of Pharmacy Services supported the information related to potency provided by the Rheumatology physician as described above. The review revealed the anti-[MEDICAL CONDITION] potency of [MEDICATION NAME] is approximately 5 times more than [MEDICATION NAME]. During a telephone interview on [DATE] at 2:30 PM, an interview was conducted with the attending Hospitalist (hospital physician) for Resident #5 from [DATE] through [DATE]. The Hospitalist revealed the following information. The Hospitalist attended Resident #5 from admission on [DATE] to [DATE] and the resident had prolonged illnesses. The resident had a prolonged stay in the hospital prior to nursing home admission. The Hospitalist stated, "It was a miracle the resident (#5) survived and made it out to the nursing home." The resident did have a "steroid induced skin necrosis." One was "fearful to touch" the resident "in the hospital due to fragility of skin." The Hospitalist once observed the resident being moved during which the resident sustained [REDACTED]. When skin was torn to the lower leg, the resident had no pain perception. Hospice care was decided upon by resident/family. Resident #5 had a significant decubitus ulcer. The steroid induced skin necrosis impeded healing of skin and clearance of infection. There is "a high degree of certainty, it ([MEDICATION NAME]) lead to worsening of the skin condition through out the body and may have prevented healing of decubitus ulcers in the nursing home. [MEDICATION NAME] is a stronger drug than [MEDICATION NAME]. It did cause harm. There was a gap in knowledge at the pharmacy, an egregious error. I don't know why pharmacy felt it was an adequate substitution. Both medicines are common. [MEDICATION NAME] had a more delayed effect. One would not notice changes right away as in a quicker acting medication." A telephone interview was conducted with the facility's attending Physician of Resident #5 on [DATE] at 4:45 PM. Resident #5's attending Physician was asked about the administration of [MEDICATION NAME] instead of [MEDICATION NAME]. The attending Physician stated, "That was a surprise to all." The facility had "no idea it (medications) had been switched out." The attending Physician confirmed he had signed the recap orders as written which included [MEDICATION NAME] instead of [MEDICATION NAME]. The attending Physician stated he signs "a million orders at the end of the month. It all goes by so fast." He revealed he did not mean to sign for [MEDICATION NAME] and did not notice the change on the recap orders. He wanted the resident to continue treatment with [MEDICATION NAME]. "I trust the nurses to have it right." A telephone interview was conducted with Resident #5's NP on [DATE] at 11:00 AM. The NP was asked about the administration of [MEDICATION NAME] instead of the [MEDICATION NAME]. The NP revealed she did not know the resident had been receiving [MEDICATION NAME]. She thought the resident was receiving [MEDICATION NAME]. She prescribed from the hospital discharge orders of [DATE]. She did not notice the change to [MEDICATION NAME] on the [DATE] Recap form or look at the MAR. The NP stated, "I was just going by the discharge order and working in the chart." The NP revealed in her opinion the [MEDICATION NAME] "caused skin thinning. It is a much more potent drug." The NP revealed that this explains how the resident got septic causing increased pain in the wound. It caused suppression of the immune system. The attending physician failed to consistently reviewed the total program of care for appropriateness which led to Resident #5 receiving [MEDICATION NAME] medication instead of [MEDICATION NAME] which caused actual harm when Resident #5's skin conditions worsened.

Based on medical record review and interviews, it was determined the facility failed to ensure the medication ([MEDICATION NAME]) provided by the pharmacy and administered to 1 of 5 (Resident #5) sampled residents was the correct medication ([MEDICATION NAME]) as ordered by the physician. The failure of the facility to administer the appropriate medication resulted in a significant medication error causing harm to Resident #5. The findings included: Medical record review of Resident #5 revealed an admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medical record of Resident #5 revealed a hospitalization from [DATE] to [DATE] during which time treatment was provided for a variety of conditions including an acute respiratory condition with infection and [MEDICAL CONDITION] arthritis and a history [MEDICATION NAME] use prior to and during hospitalization for the treatment of [REDACTED]. Review of Resident #5's hospital discharge summary dated [DATE] revealed [DIAGNOSES REDACTED]. Resident #5's admission medication orders on [DATE] included [MEDICATION NAME] 8 milligrams (mg) in the AM and 4 mg in the PM. The drug regimen continued to include an order for [REDACTED]. Review of Resident #5's initial skin assessment documented on the wound/skin healing record dated [DATE] revealed 2 pressure ulcer wounds. Wound #1 noted on the coccyx area was described as 4.5 by (x) 2.5 x 1.0 centimeters (cm) (unstageable) with scant serous exudate with whitest green slough at wound bed and 1.3 cm undermining. Wound #2 on the lower [MEDICATION NAME] spine was described as 1.5 x 1.0 x 0.0 cm. (unstageable) with scant serous drainage with white tan slough at wound bed. A review of multiple Non-pressure Skin Condition Reports for Resident #5 revealed 13 additional wounds. Wound #3 on the right posterior upper back was described as thoracotomy extubation site measuring 1.0 x 1.0 with 0.5 of depth and "undermining 1.5 cm." Wound #8 on the posterior left calf/distal aspect was described as a soft tissue injury measuring 3.0 x 0.8 x 0.0 cm. Wound #9 on the posterior left knee was described as a red, fluid filled, soft, fragile hematoma measuring 8.0 x 8.0. Additional review of Resident #5's Non-Pressure Skin Condition reports revealed wounds #4, #5, #6, #7, #9, #10, #11, #12, #13, #14, and #15 which were described as full thickness injury (1); soft tissue injury (5); skin tear (2); laceration (1); blister (1). All of the wounds described above were provided treatment and all wounds were noted healed at various points between [DATE] and [DATE] except wounds #1, #2, #3 and #8. These wounds had decreased in size with treatment as noted on the skin assessment reports. Review of assessment documentation of Resident #5 dated [DATE] by the nurse practitioner in the interdisciplinary team notes revealed a cough for 3 days which "is deep and productive" along with a sore throat. A chest x-ray was obtained due to Resident #5's history of pneumonia. Resident #5 was subsequently transferred to the hospital for further evaluation on [DATE]. At the time of transfer on [DATE], medical record documentation revealed Resident #5 had a current order for and was receiving [MEDICATION NAME] 8 mg in the AM and 4 mg at bedtime. Review of Resident #5's hospital admission History and Physical evaluation dated [DATE] revealed treatment for [REDACTED]. The evaluation report noted a review of systems in which the skin was described as warm and intact except for sacral wounds with bandages in place and the extremities were noted to have no clubbing, cyanosis or [MEDICAL CONDITION]. Documentation of a pulmonology consultation dated [DATE] revealed aside from the current respiratory problem, Resident #5 "is on chronic steroids and has maintained an overall excellent status." The report revealed ongoing [DIAGNOSES REDACTED]. Documentation of exam of extremities revealed Resident #5 "has well healed skin without near the degree of tears" previously present. Review of hospital documentation revealed the Resident #5's hospital drug regimen included [MEDICATION NAME] 4 mg in the AM and 4 mg at bedtime. Resident #5 was transferred back to the facility on [DATE] with discharge [DIAGNOSES REDACTED]. Resident #5's medication discharge orders included [MEDICATION NAME] 4 mg in the AM and 4 mg in the PM. Review of Resident #5's hospital return orders included [MEDICATION NAME] 4 mg in the AM and 4 mg at bedtime. The orders were written on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, review of the facility pharmacy services delivery sheet dated [DATE] revealed the medication [MEDICATION NAME] ([MEDICATION NAME]) was delivered instead of [MEDICATION NAME] which had been ordered. The nursing staff began administering [MEDICATION NAME] instead of [MEDICATION NAME]. During an interview in the private dining room on [DATE] at 1:00 PM, the current Director of Nursing (DON) confirmed [MEDICATION NAME] had been administered instead of the ordered [MEDICATION NAME]. Review of the initial recapitulation (recap) orders for [DATE] through [DATE] revealed the medication "[MEDICATION NAME] 4 MG. tablet [MEDICATION NAME] 4 MG. tablet take 2 tablets once daily and 1 at bedtime." These recap orders were noted to have been signed by Resident #5's physician and noted on the MAR indicated [REDACTED]. A review of the verbal/phone order forms revealed an order dated [DATE] signed by the nurse practitioner to decrease [MEDICATION NAME] to 4 mg in the morning and evening. However, the medication order was transcribed as [MEDICATION NAME] 4 mg in the am and pm and noted on the MAR indicated [REDACTED]. Review of skin assessment report documentation of Resident #5 after return to nursing home on [DATE] revealed pressure ulcer wound #1 on coccyx was measured 2.2 x 1.5 x 1.0 with 0.9 undermining with scant serous exudate; pressure ulcer wound on [MEDICATION NAME] spine was measured 0.7 x 0.3 x 0.0; wound #3 on right posterior upper back measured 1.0 x 0.5 x 0.3 with scant serous exudates; wound #8 on left posterior calf measured 2.8 x 0.8 x 0.0. Coccyx wound #1 on [DATE] measured 1.8 x 1.0 x 1.0. [MEDICATION NAME] wound #2 on [DATE] measured 0.7 x 0.3 x 0.0 and noted pink and closed. Wound #3 on right posterior upper back measured 0.2 x 0.5 x 0.2 with scant serous exudates. Wound #8 on left posterior calf was measured 1.0 x 0.3 x 0.0 with scant serous exudates. Hematoma wound #9 was noted healed on [DATE]. Review of the non-pressure skin condition report for Resident #5 revealed 8 new wounds which developed after Resident #5's return to the facility on [DATE] with treatment provided. These wounds included left upper extremity skin tear on [DATE] measuring 3.5 x 0.2 with steri strips applied and noted closed on [DATE]; left elbow skin tear on [DATE] measuring 1.0 x 0.2 and noted closed on [DATE]; right cheek skin tear measuring 1.0 x 0.1 with steri strips applied and noted closed on [DATE]; left knee skin tear on [DATE] measuring 1.1 x 5.0 with on going treatment; right ankle skin tear on [DATE] measuring 0.1 x 1.2 CM. with treatment ongoing; left posterior arm skin tear on 12 13 08 measuring 1.0 x 0.8 with treatment ongoing; right lateral knee skin tear on [DATE] measuring 5.0 x 5.2 with treatment ongoing. Review of interdisciplinary team (IDT) documentation and nurse practitioner (NP) documentation in [DATE] revealed changes in skin condition as follows: a. [DATE] by IDT - Resident is having some significant swelling in bilateral lower extremities. b. [DATE] by NP - Left lower extremity worse will add "[MEDICATION NAME] 20 MG. BID (two times a day) X (times) 3 days." and decrease [MEDICATION NAME] to 4 MG in the morning and evening. c. [DATE] by NP - Wound on coccyx looks worse with plan to obtain blood work and culture of coccyx wound. Culture report dated [DATE] revealed infection with few [MEDICAL CONDITION] Susceptible Staphylococcus Aureus (MSSA), few Streptococcus-Viridans group and rare Pseudomonas Aeruginosa (PSA). d. [DATE] by NP - Resident complained of painful calfs and noted very painful calfs bilaterally to gentle palpation with violaceous discoloration. Noted may indicate poor venous circulation verses skin thinning from years of steroid use. Plan to obtain bilateral Doppler test. e. [DATE] by NP - Doppler test showed bilateral popliteal thrombi-non-occlusive. f. [DATE] by IDT - Bilateral Doppler test done with [MEDICATION NAME] discontinued and Pavex and Aspirin initiated. g. [DATE] by NP - Notes fall from wheelchair during transport in van on way to son's house for visit sustaining skin tear below right knee, contusion to right face, excoriation to right posterior calf and right shoulder with treatment described. h. [DATE] - No improvement (of wounds) noted this week due to declining condition. Noted large amount of serous drainage of both lower extremities with 3 to (-) 4 plus [MEDICAL CONDITION] noted. i. [DATE] - Swab of right knee for culture-Report revealed infection including [MEDICAL CONDITION] (MRSA). Review of nurse's notes dated [DATE] revealed Resident #5's temperature was elevated and there was increased pain. Arrangements were made and the resident was transferred to the hospital per order of physician. Further documentation revealed admission to hospital was needed related to high risk of development [MEDICAL CONDITION] related to multiple wounds, long term steroid use, complex medical history, and increase of pain. Review of the discharge summary and hospital course from [DATE] to [DATE] for Resident #5 by the attending Hospitalist included the following: Recent extensive hospitalization for pneumonia, empyema and [MEDICAL CONDITION]. Transitioned to skilled nursing facility. ([DATE]) Had aggressively advanced diet to recuperate significant protein losses. Had decubitus ulcers on coccyx and left thorax which had not significantly improved despite aggressive daily care. Developed a fever and was transferred to hospital. ([DATE]) Had "profound-appearing necrotic nodules over the lower extremities as well as mottling of the feet." "Found to have significant third spacing [MEDICAL CONDITION], skin atrophy and necrotic ulcers from steroid toxicity." Had skin tear to lower left leg resulting in a large flap which was sutured. Was placed on broad spectrum antibiotics. Endured significant pain with any type of movement. The right shoulder was "frozen." Would not be able to undergo significant rehabilitation due to fragility of skin and poor functional status. Respiratory status was worsening with limited therapy options. The focus became comfort, high oxygen and pain medication and [MEDICATION NAME] for noncardiogenic [MEDICAL CONDITIONS]. Resident declined with death on [DATE]. Final [DIAGNOSES REDACTED]. During an interview in the facility's private dinning room on [DATE] at 2:15 PM, the current DON stated she had been told of the medication error ([MEDICATION NAME] administered instead of [MEDICATION NAME] as described above) on [DATE] when at the hospital to visit Resident #5. The DON saw Resident #5's Rheumatology specialist who was with a family member of Resident #5. The Doctor at that time questioned when the [MEDICATION NAME] was substituted for the [MEDICATION NAME]. The DON revealed she was not aware of the substitution and agreed to check into the issue and follow-up with the Doctor. The DON revealed that on [DATE], she began to review documentation to try and piece together what happened. During review of the Resident #5's medical record, the DON saw where [MEDICATION NAME] had been ordered originally on [DATE] and was on the MAR for ,[DATE] and ,[DATE] but [MEDICATION NAME] was on the MAR for [DATE]. The DON made a call to the pharmacy which confirmed the delivery of [MEDICATION NAME] and not [MEDICATION NAME] on [DATE] and subsequently. The DON revealed that the medication had been signed in by an agency nurse on [DATE] that no longer works at the facility. The DON revealed not knowing how/why the error was not caught. A investigation was initiated into the incident. A telephone interview was conducted on [DATE] at 12:50 PM, with Resident #5's Rheumatology Specialist who was documented as following the case in hospital reports during the [DATE], [DATE] and [DATE] admissions. During this interview the Rheumatologist revealed Resident #5's primary medication for the RA was Remacade and a low dose of [MEDICATION NAME] 4 and 8 mg per day and that the resident had done "pretty well" on these medications. The Rheumatologist revealed having found out about the error (as previously described above) from a "lab paper" of Resident #5 that had been sent to him with a list of medications attached which indicated Resident #5 was receiving [MEDICATION NAME] as opposed to [MEDICATION NAME]. The Rheumatology specialist revealed that at some point [MEDICATION NAME] was substituted for [MEDICATION NAME] and that the 4 mg dose of [MEDICATION NAME] was approximately 5 times stronger than [MEDICATION NAME]. The Rheumatology specialist stated, "(Resident #5) already had thinning of the skin" and was "very ill." An increased dose can "cause thinning of the skin and skin tears. Increased steroids is hard on the skin. It is hard to say how much was due to the substitution." Resident #5 "never had large areas of skin sheering off as she did in the hospital." The "increased dose (of steroids) led to worsening of the skin. Increased steroids suppress the immune system increasing the risk for infection." Review of Glucocorticoid Systemic Equivalencies table provided by the Department of Pharmacy Services supported the information related to potency provided by the Rheumatology physician as described above. The review revealed the anti-[MEDICAL CONDITION] potency of [MEDICATION NAME] is approximately 5 times more than [MEDICATION NAME]. During a telephone interview on [DATE] at 2:30 PM, an interview was conducted with the attending Hospitalist (hospital physician) for Resident #5 from [DATE] through [DATE]. The Hospitalist revealed the following information. The Hospitalist attended Resident #5 from admission on [DATE] to [DATE] and the resident had prolonged illnesses. The resident had a prolonged stay in the hospital prior to nursing home admission. The Hospitalist stated, "It was a miracle the resident (#5) survived and made it out to the nursing home." The resident did have a "steroid induced skin necrosis." One was "fearful to touch" the resident "in the hospital due to fragility of skin." The Hospitalist once observed the resident being moved during which the resident sustained [REDACTED]. When skin was torn to the lower leg, the resident had no pain perception. Hospice care was decided upon by resident/family. Resident #5 had a significant decubitus ulcer. The steroid induced skin necrosis impeded healing of skin and clearance of infection. There is "a high degree of certainty, it ([MEDICATION NAME]) lead to worsening of the skin condition through out the body and may have prevented healing of decubitus ulcers in the nursing home. [MEDICATION NAME] is a stronger drug than [MEDICATION NAME]. It did cause harm. There was a gap in knowledge at the pharmacy, an egregious error. I don't know why pharmacy felt it was an adequate substitution. Both medicines are common. [MEDICATION NAME] had a more delayed effect. One would not notice changes right away as in a quicker acting medication." A telephone interview was conducted with the facility's attending Physician of Resident #5 on [DATE] at 4:45 PM. Resident #5's attending Physician was asked about the administration of [MEDICATION NAME] instead of [MEDICATION NAME]. The attending Physician stated, "That was a surprise to all." The facility had "no idea it (medications) had been switched out." The attending Physician confirmed he had signed the recap orders as written which included [MEDICATION NAME] instead of [MEDICATION NAME]. The attending Physician stated he signs "a million orders at the end of the month. It all goes by so fast." He revealed he did not mean to sign for [MEDICATION NAME] and did not notice the change on the recap orders. He wanted the resident to continue treatment with [MEDICATION NAME]. "I trust the nurses to have it right." A telephone interview was conducted with Resident #5's NP on [DATE] at 11:00 AM. The NP was asked about the administration of [MEDICATION NAME] instead of the [MEDICATION NAME]. The NP revealed she did not know the resident had been receiving [MEDICATION NAME]. She thought the resident was receiving [MEDICATION NAME]. She prescribed from the hospital discharge orders of [DATE]. She did not notice the change to [MEDICATION NAME] on the [DATE] Recap form or look at the MAR. The NP stated, "I was just going by the discharge order and working in the chart." The NP revealed in her opinion the [MEDICATION NAME] "caused skin thinning. It is a much more potent drug." The NP revealed that this explains how the resident got septic causing increased pain in the wound. It caused suppression of the immune system. The significant medication error of the administration of [MEDICATION NAME] instead of [MEDICATION NAME] caused actual harm to Resident #5.