GRACE CARE CENTER OF HENRIETTA

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, for 1 of 7 (Resident #1) residents reviewed for resident rights. <BR/>The facility failed to provide Resident #1 hospice care per resident's request. <BR/>This failure placed residents at risk of their rights to make choices about their life being disregarded.<BR/>Findings include:<BR/>Record Review of Resident #1 admission Record dated 02/22/25 revealed Resident #1 was an [AGE] year-old female with an original admission date of 01/16/25 with the latest return date of 02/06/25. Resident had a diagnosis of multiple myeloma in remission (bone cancer) and Poly osteoarthritis (a form of arthritis that affects multiple joints simultaneously. This condition is characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). The resident was her own responsible party. <BR/>Record review of Resident #1's admission MDS, dated [DATE] revealed Resident #1 had a BIMS score of 13 (cognitively intact). Her pain assessment was negative for the 5-day look back period. <BR/>Record review of Resident #1's Care Plan on 02/16/25 revealed a care plan for pain related to multiple myeloma, osteoarthritis, and skin blisters.<BR/>Record review of Resident #1 electronic record revealed the Resident #1 requested hospice services on 02/16/25 due to uncontrolled pain. The facility physician wrote an order for hospice services on 02/16/25 and an order for Tylenol 3 every 4 hours as needed for pain. A progress note dated 02/16/25, by LVN A revealed Corporate is to be notified before any ancillary services are permitted into the facility. DON to send email to proper corporate person. <BR/>Record review of Resident #1's pain levels revealed on 02/16/25, Resident #1 started experiencing pain at a pain level of 8 and constantly stayed at a high level since that time with intermittent reduction related to pain medication administration. <BR/>Record review of Resident #1's Medication Administration Record for February 2025, revealed she was prescribed: Acetaminophen-Codeine Oral Tablet 300-30mg at bedtime for Poly osteoarthritis and Multiple Myeloma in relapse with an order date of 02/16/25 and Acetaminophen-Codeine Oral Tablet 300-30mg every 4 hours as needed for pain with an order date of 02/16/25. <BR/>In an interview during the entrance conference on 03/07/25 at 9:30 am, LVN A stated Resident #1 has requested hospice services on 02/16/25 but the CEO had not approved the services. She said Resident #1 was in pain, the Facility Physician has ordered pain medication, but it only helped some. <BR/>In an interview and observation with Resident #1 on 02/23/25 at 12:30 pm, the resident was sitting up in her recliner very still and stiff and did not move any part of her body throughout the conversation. She expressed that she was in a lot of pain , especially in her right shoulder. She rated her pain at an 8 on a scale of 1-10 and said her pain never gets below a 6. <BR/>She said she received pain medications, but they only help a little and just takes the edge off. She said she would like hospice services to help with pain. She said she requested hospice services but did not know the status of hospice care. <BR/>In an interview with the DON on 02/24/25 at 10:50 am, she said the CEO had to approve hospice services before they could proceed with getting the resident hospice care. She said she emailed the owner of the facility on 02/17/25 requesting hospice services for Resident #1. The DON provided documentation of the email. Stated the Owner never responded to the e-mail. <BR/>In a record review of an e-mail dated 02/17/25 at 11:05 am from the Director of Nursing to the CEO, the DON requested Patient Care Coordination as Resident #1 has expressed interest in initiating care with hospice. Can we please being the process to set this up?<BR/>In an interview on 02/25/25 at 9:30 am with Resident #1 's POA, she said Resident #1 expressed to her on 02/16/25 that she wanted hospice services due to pain. She said she talked to Resident #1 daily on the phone and Resident #1 had expressed to her that she had been a lot of pain daily. She said she was told by the facility that corporate had to approve hospice care before hospice services could be obtained and are waiting on that to happen. She said she was upset due to the long time it was taking to get Resident #1 on hospice services to help with her pain. <BR/>In an interview with the DON on 02/25/25 at 10:00 am, she said she went ahead and contacted hospice services for Resident #1 without the permission of the CEO due to the resident being in pain. <BR/>In an interview with the facility physician on 02/25/25 at 12:00 pm, she said the facility contacted her on 02/16/24 that Resident #1 was requesting hospice services per patient request and that she was in pain. She said she wrote an order for hospice services on 02/16/24 and an order to increase her pain medication. She said it was her expectation the order would be carried out the same or next day as it was a critical situation and you do not know what the resident is going through. She said she was informed by the facility the CEO had to approve hospice services before they could be started. She said this was the first time this had happened, and the facility did not give an explanation as to why. <BR/>In an interview on 02/25/25 at 3:15 pm, The DON stated the CEO just contacted her and would not approve hospice services for Resident #1 until the hospice company contacted him personally . She said she gave the information to the hospice company. <BR/>In an interview with the CEO on 02/25/25 at 4:20 pm, he stated hospice contracts had to be reviewed on a case-by-case basis. He said Resident #1 could have hospice care, but a contract had to be signed first, he said he contacted the Human Resource Director this morning to sign a contract for hospice services. When the CEO was informed it had been 8-days since Resident #1 requested hospice services at this time due to the resident being in pain, he said he felt like it was an adequate response time by the facility for the resident to be placed on hospice services . <BR/>In an interview with the CEO on 02/25/25 at 4:55 pm, he said Resident #1 had been placed on hospice services. <BR/>In an interview on 02/26/25 at 1:00 pm, the Social Worker she said an acceptable time for a resident to be placed on hospice services would be 24 to 48 hours.<BR/>Record review of the facility policy Resident Rights, dated a revised December 2016, revealed the following [in part]:<BR/>Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>e. self-determination<BR/>f. communication with and access to people and services, both inside and outside the facility<BR/>h. be supportive by the facility in exercising his or her rights<BR/>s. choose an attending physician and participate in the decision-making regarding his or her care.<BR/>In a record review of the facility policy Hospice Program, dated Quarter 2, 2020, revealed the following [in part]:<BR/>Policy statement: Hospice services are available to residents at the end of life.<BR/>Policy Interpretation and Implementation:<BR/>8. When a resident has been diagnosed as terminally ill, the Director of Nursing/designee will contact the hospice agency and request that a visit /interview with the resident/family be conducted to determine the resident's wishes relative to participation in the hospice program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 4 (Resident # 1, Resident #2, Resident #9, Resident #11) of 14 residents reviewed for Quality of Care. <BR/>The facility failed to ensure Residents #2, #9, and #11 made it to their scheduled doctor appointments for follow up and other scheduled appointments. <BR/>The facility failed to provide needed care and services in accordance with Resident #1's preferences to attain hospice services. <BR/>This failure could affect the ability for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being. <BR/>Findings included:<BR/>Observation on [DATE] at 1:15 pm revealed the facility Van appeared dusty inside. The registration tags expired 11/24. <BR/>In an interview on [DATE] at 10:00 am the Human Resource Director stated the van registration was not completed and had expired in December. The Human Resource Director stated it had not been renewed due to the petty cash account was not accessible. She stated no residents went out to the hospital. <BR/>In an interview on [DATE] at 10:16 am the vehicle insurance company stated the policy was cancelled and would not provide the date it was cancelled. <BR/>Record review of electronic file for Resident #9 revealed he was a [AGE] year-old male with admission date of [DATE]. Resident #9 had diagnoses of acute on chronic diastolic (congestive) heart failure (weakening of heart when heart can't pump blood to give normal supply), type 2 diabetes mellitus with diabetic chronic kidney disease (adult onset diabetes and kidneys damaged due to high blood sugar levels), atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of plaque inside arteries causing heart disease), benign prostatic hyperplasia with lower urinary tract symptoms (non-cancerous enlargement of prostate gland), chronic kidney disease, stage 3 unspecified (mild to moderate kidney damage and may struggle to filter waste), pressure ulcer of right ankle, unstageable (wound where base is covered by slough making it impossible to determine true depth). The Resident was his own responsible party. <BR/>In an interview on [DATE] at 10:50 am the DON stated she saw the documentation a few weeks ago that the insurance policy for the van was canceled. She stated Resident #9 had missed some doctors' appointments due to the van situation. <BR/>In an interview on [DATE] at 11:00 am LVN E stated Resident #9 had an appointment on [DATE] with the nephrologist that had not been rescheduled as of this date, and an appointment with the cardiologist on [DATE] that had been rescheduled for [DATE] that were missed due to not having the facility van insurance. <BR/>In an interview on [DATE] at 12:25pm CNA H stated she stopped driving residents in the van in January due to the van not having insurance. <BR/>In an interview on [DATE] at 12:50 pm the DON stated there was no log of van usage because it has not been used due to no van insurance. <BR/>In an interview on [DATE] at 9:00 am the vehicle insurance company stated the insurance policy was not reinstated.<BR/>Record review of electronic file for Resident #2 revealed she was a [AGE] year-old female with an original admission date of [DATE] with the latest return date of [DATE]. Resident #2 had diagnoses of Alzheimer's disease (disease that destroys memory and other important mental functions), type 2 diabetes mellitus with diabetic chronic kidney disease (kidneys damaged due to high blood sugar levels), anemia (low iron), diverticulosis of both small and large intestine without perforation or abscess without bleeding (small bulging pouches that can form in lining of digestive tract), urinary tract infection (bladder infection). The resident was her own responsible party. <BR/>In an interview on [DATE] at 9:00 am LVN A stated Resident #2 was having light vaginal bleeding and physician A wanted to see her and we could not send her due to the van not having insurance. LVN A said physician A said she would come to the facility.<BR/>In an interview on [DATE] at 11:03 am the DON stated Resident #2 was having light vaginal bleeding on [DATE]; They contacted physician A and wanted her to be brought to her office but told Physician A they were not able to transport the resident due to no insurance on the van. Physician A said she would come up to the facility to see the resident but never did. The resident was transferred to the ER on [DATE] via hospital ambulance. <BR/>Record review of hospital record for Resident #2 reflected No new orders. Still Has UTI. All bleeding was negative. Transvaginal ultrasound was negative. All labs good. X-rays completed with no findings. <BR/>Record review of electronic file for Resident #11 revealed she was a [AGE] year-old female with an admission date of [DATE]. Resident #11 had diagnoses of type 1 diabetes mellitus with diabetic chronic kidney disease (juvenile diabetes and kidneys damaged due to high blood sugar levels), chronic kidney disease (kidney failure), type 1 diabetes mellitus with diabetic neuropathy (nerve damage caused by persistent high blood sugars), essential (primary) hypertension (high blood pressure), neuromuscular scoliosis, lumbar region (sideways curvature of spine), hyperlipidemia (high fat in blood), legal blindness, deficiency of other specified b group vitamins (B vitamin levels lower than normal), magnesium deficiency (levels lower than normal), vitamin d deficiency (levels lower than normal), hypokalemia (high potassium), elevation of levels of liver transaminase levels (liver damage), other seizures (uncontrolled jerking, loss of consciousness, other symptoms caused by abnormal electrical brain activity). The Resident was her own responsible party. <BR/>In an interview on [DATE] at 11:00 am LVN E stated Resident #11 had an appointment scheduled for [DATE] with physician B that was missed due to not having the facility van insurance. <BR/>In an interview on [DATE] at 8:24 am Physician B stated Resident #11 had an appointment with him yesterday, but the facility called and cancelled, stated they didn't have enough staff. <BR/>In an interview on [DATE] at 12:00 pm Physician A stated she was not aware residents missed doctor appointments due to no insurance on the van. Physician A stated she was not informed by the facility about Resident #9's missed cardiology and kidney appointments and said those appointments were considered critical to attend. Physician A stated the facility called and Resident #2 reported bleeding from her vaginal area; Physician A said she asked them to bring her to her office, but they stated they could not due to no insurance on the van. <BR/>Record review of an appointment book revealed Resident #11 missed an appointment on [DATE] with the Primary care doctor; Resident #9 missed an appointment on [DATE] with the cardiologist and it was rescheduled for [DATE]. Resident #9 missed an appointment on [DATE] with the kidney doctor. <BR/>Record review of progress notes dated [DATE] by LVN E revealed Resident #11 Rescheduled residents appt today due to unable to transfer in company van. Rescheduled for [DATE] at 9:30am. <BR/>Record review of Transportation, Social Services policy dated [DATE] revealed Our facility shall help arrange transportation for residents as needed.<BR/>Record review of Resident #1's admission Record dated [DATE] revealed Resident #1 was an [AGE] year-old female with an original admission date of [DATE] with the latest return date of [DATE]. Resident #1 had diagnoses of multiple myeloma in remission (bone cancer) and Poly osteoarthritis (a form of arthritis that affects multiple joints simultaneously. This condition is characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). The resident was her own responsible party. <BR/>Record review of Resident #1's admission MDS, dated [DATE] revealed Resident #1 had a BIMS score of 12 (moderate cognitive impairment). <BR/>Record review of Resident #1's care plan, dated as revised on [DATE] revealed the following [in part]:Focus: [Resident #1] has pain related to multiple myeloma, osteoarthritis, and skin blisters.<BR/>Goal: The resident will not have an interruption in normal activities due to pain through the review period. Interventions: *Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. * Resident will not have an interruption in normal activities due to pain. *Comfort will be maintained. *Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain.<BR/>Record review of Resident #1's Physician Orders revealed the following:<BR/>A. May have hospice of resident choosing, evaluate for service, start date of [DATE].<BR/>B. Tylenol with Codeine #3 tablet 300-30mg at bedtime for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of [DATE].<BR/>C. Tylenol with Codeine #3 tablet 300-30mg every 4 hours as needed for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of [DATE].<BR/>Record review of Resident #1's electronic record revealed Resident #1 requested hospice services on [DATE] due to uncontrolled pain. The facility physician wrote an order for hospice services on [DATE] and an order for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours as needed for pain. A progress note dated [DATE], by LVN A revealed Corporate is to be notified before any ancillary services are permitted into the facility. DON to send email to proper corporate person. <BR/>In an interview on [DATE] at 10:50 a.m., the DON said she was aware Resident #1 was expressing pain that was not resolved with current treatment. The facility Physician increased her pain medication and referred resident to Hospice on [DATE]; however, Hospice could not be obtained because it required the CEO's approval. The DON provided e-mail communication with the CEO requesting hospice services.<BR/>In a record review of an e-mail dated [DATE] at 11:05 a.m., from the Director of Nursing to the CEO, the DON requested Patient Care Coordination as Resident #1 has expressed interest in initiating care with hospice. Can we please begin the process to set this up?<BR/>In a record review of a progress note dated [DATE] at 9:06 a.m. revealed, Resident #1 asked the LVN When is the hospice person coming to see me. <BR/>In an interview on [DATE] at 9:30 a.m., Resident #1's POA said Resident #1 expressed to her on [DATE] that she wanted hospice services due to pain. She said she was told by the facility that corporate had to approve hospice care and they were waiting on that. She said she was upset and did not know why it was taking so long for Resident #1 to be placed on hospice services.<BR/>In an interview on [DATE] at 10:00 a.m., the DON reported she went ahead and contacted hospice services on this date for Resident #1 without the permission of the CEO. <BR/>In an interview on [DATE] at 12:00 p.m., facility Physician A said the facility contacted her on [DATE] as Resident #1 was requesting hospice services because her pain was not resolving with current regiment. She said on [DATE] she ordered for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours and referred her to hospice for more effective pain management. She said it was her expectation the order would be carried out the same day ordered if possible as it was a critical situation and you do not know what the resident is going through. She said she was informed by the facility the CEO had to approve hospice services for a resident before they would be evaluated for services. She said this was the first time that [a resident was not provided hospice directly after Physician put in order]had happened.<BR/>In an interview on [DATE] at 4:20 p.m., the CEO stated hospice contracts have to be on a case-by-case basis and a contract had to be signed first. He said he contacted the Human Resource Director this morning to get a contract signed. When informed it had been 8-days since Resident #1 requested hospice services and the resident had been experiencing uncontrolled pain, he said he felt like it was an adequate response time by the facility for the resident to be placed on hospice services. <BR/>In a follow-up interview on [DATE] at 4:55 pm, the CEO reported Resident #1 was now on hospice services. <BR/>Record review of Resident Rights policy dated [DATE] revealed f. communication with and access to people and services, both inside and outside the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #1) residents reviewed for pain.<BR/>The facility failed to manage Resident #1's pain at an acceptable level per her preference until hospice services could be obtained. It took the facility 8-days to arrange hospice services. <BR/>This deficient practice could place residents at risk of increased pain, discomfort, being unable to perform daily activities, psychological effects, and a diminished quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's admission Record dated 02/22/25 revealed Resident #1 was an [AGE] year-old female with an original admission date of 01/16/25 with the latest return date of 02/06/25. Resident #1 had diagnoses of multiple myeloma in remission (bone cancer) and Poly osteoarthritis (a form of arthritis that affects multiple joints simultaneously. This condition is characterized by the degeneration of cartilage and the underlying bone within a joint, leading to pain, stiffness, and impaired movement). The resident was her own responsible party. <BR/>Record review of Resident #1's admission MDS, dated [DATE] revealed Resident #1 had a BIMS score of 12 (moderate cognitive impairment). MDS was negative for pain. <BR/>Record review of Resident #1's Pain assessment dated [DATE] revealed the resident expressed pain in the last 5 days, pain was frequent, hard to sleep at night. It stated Resident #1 was ordered Tylenol #3 for 7 days on previous admission but was admitted to the hospital before regimen was completed. Medication was not reordered when Resident #1 was readmitted . Revealed resident is repositioned and is somewhat effective. <BR/>Record review of Resident #1's care plan, dated as revised on 02/16/25 revealed the following [in part]:<BR/>Focus: [Resident #1] has pain related to multiple myeloma, osteoarthritis, and skin blisters.<BR/>Goal: The resident will not have an interruption in normal activities due to pain through the review period.<BR/>Interventions: *Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. * Resident will not have an interruption in normal activities due to pain. *Comfort will be maintained. *Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain.<BR/>Record review of Resident #1's Physician Orders revealed the following:<BR/>A. Monitor for pain every shift, use 1-10 scale for alert residents and use pain aide for confused residents, document which pain scale used to assess residents pain rating, start date of 01/30/25.<BR/>B. May have hospice of resident choosing, evaluate for service, start date of 02/16/25.<BR/>C. Tylenol with Codeine #3 tablet 300-30mg at bedtime for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of 02/16/25.<BR/>D. Tylenol with Codeine #3 tablet 300-30mg every 4 hours as needed for Poly osteoarthritis and Multiple Myeloma in Relapse with a start date of 02/16/25.<BR/>Record review of Resident #1's electronic record revealed Resident #1 requested hospice services on 02/16/25 due to uncontrolled pain. The facility physician wrote an order for hospice services on 02/16/25 and an order for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours as needed for pain. A progress note dated 02/16/25, by LVN A revealed Corporate is to be notified before any ancillary services are permitted into the facility. DON to send email to proper corporate person. <BR/>In a record review of an e-mail dated 02/17/25 at 11:05 a.m., from the Director of Nursing to the CEO, the DON requested Patient Care Coordination as Resident #1 has expressed interest in initiating care with hospice. Can we please begin the process to set this up?<BR/>In an observation and interview with Resident #1 on 02/23/25 at 12:30 p.m., the resident was sitting up in her recliner very still and stiff and didn't move her body throughout the conversation. She expressed that she was in pain. She said that she received pain medications, but they only help a little. She said her pain was currently at a level 6. She said her pain never got below a 6 with medication, just took the edge off. She said that she would like hospice services to help with pain. She said she requested hospice services but did not know the status of hospice care. <BR/>Record review of the MAR revealed the resident had received pain medication on 2/23/25 at 12:00 pm. With a follow up pain score of 2- effective at 2:20pm. <BR/>Record review of Resident #1's progress notes and MAR reflected they failed to have documentation of the physician order to monitor pain every shift as ordered on 01/30/25. <BR/>Record review of Resident #1's MAR for February 2025 revealed the resident did not receive her schedule Tylenol #3 at bedtime on 02/15/25 and 02/21/25. No adverse effect noted. <BR/>In an interview on 02/24/25 at 10:50 a.m., the DON said she was aware Resident #1 was expressing pain that was not resolved with current treatment. The facility Physician increased her pain medication and referred resident to Hospice on 02/16/25; however, Hospice could not be obtained because it required the CEO's approval. The DON provided e-mail communication with the CEO requesting hospice services.<BR/>In a record review of a progress note dated 02/24/25 at 9:06 a.m., Resident #1 asked the LVN When is the hospice person coming to see me. <BR/>In an interview on 02/25/25 at 9:30 a.m., Resident #1's POA said Resident #1 expressed to her on 02/16/25 that she wanted hospice services due to pain. She said that she talks to Resident #1 daily on the phone and Resident #1 has expressed to her that she was in a lot of pain. She said she was told by the facility that corporate had to approve hospice care and they were waiting on that. She said she was upset and did not know why it was taking so long for Resident #1 to be placed on hospice services.<BR/>In an interview on 02/25/25 at 10:00 a.m., the DON reported she went ahead and contacted hospice services on this date for Resident #1 without the permission of the CEO. <BR/>In an interview on 02/25/25 at 12:00 p.m., the facility Physician A said the facility contacted her on 02/16/25 as Resident #1 was requesting hospice services because her pain was not resolving with current regiment. She said on 02/16/2 she ordered for Tylenol #3 at bedtime and Tylenol #3 PRN every 4 hours and referred her to hospice for more effective pain management. She said it was her expectation the order would be carried out the same day ordered if possible as it was a critical situation and you do not know what the resident is going through. She said she was informed by the facility the CEO had to approve hospice services for a resident before they would be evaluated for services. She said this was the first time that had happened.<BR/>Record review of Resident #1's electronic record revealed: <BR/>2/16/25 at 2:45pm, pain score of 7. PRN pain medication given, and it was effective.<BR/>2/17/25 at 4:03am, pain score of 5. PRN pain medication given, and it was effective.<BR/>2/19/25 at 8:14am, pain score of 7. PRN pain medication provided, and it was effective. <BR/>2/20/25 at 12:35am, pain score of 4. PRN pain medication provided and was effective.<BR/>2/20/25 at 3:19pm, pain score of 7. PRN pain medication provided, and it was effective.<BR/>2/21/25 at 8:47am, pain score of 7. PRN pain medication given, and it was effective. <BR/>2/23/25 at 11:49pm, pain score of 7. PRN pain medication provided, and it was effective. <BR/>2/24/25 at 9:02am, pain score of 8. PRN pain medication provided, and it was effective. <BR/>2/24/25 at 1:03pm, pain score of 7. PRN pain medication provided, and it was effective.<BR/>2/25/25 at 5:01am, pain score of 8. PRN pain medication provided, and it was effective. <BR/>In an interview on 02/25/25 at 4:20 p.m., the CEO stated hospice contracts have to be on a case-by-case basis and a contract had to be signed first. He said he contacted the Human Resource Director this morning to get a contract signed. When informed it had been 8-days since Resident #1 requested hospice services and the resident had been experiencing uncontrolled pain, he said he felt like it was an adequate response time by the facility for the resident to be placed on hospice services. <BR/>In a follow-up interview on 02/25/25 at 4:55 pm, the CEO reported Resident #1 was now on hospice services. <BR/>In an interview on 02/27/25 at 9:50 am, Physician A said the facility did not contact her regarding Resident #1's breakthrough pain she was experiencing. She said it was her expectation the facility should have contacted her. She said she would have prescribed something different until she was placed under hospice care. <BR/>In an interview on 2/28/25 at 12:30 pm, the DON said she was not aware that Resident #1 did not receive her scheduled Tylenol #3 at bedtime on 02/15/25 and 2/21/25. <BR/>In a follow up interview on 4/7/25 at 12:38pm, Physician A stated that if pain improved, she considers that effective but if not then it is not effective. Physician A said it depends on the patient. Physician A ordered hospice services for Resident #1 due to patient preference and terminal prognosis. Physician A stated Resident #1's pain is being managed now and she believes it took a minute [last break through pain noted on 2/28/25] when Hospice took over to prevent breakthrough pain. Physician A stated Hospice can provide care and comfort and that is their purpose. <BR/>In an interview on 4/7/25 at 4:30pm with LVN D, she stated that Resident #1 had never told her the medications were not effective and Resident #1 could tell her if it was effective or not effective and she went by what Resident #1 told her. <BR/>In an interview on 4/7/25 at 4:49pm with LVN D, she stated that she considers pain medication effective if residents tell her it is effective or if she goes back and they are asleep. She stated Resident #1 never told her it wasn't effective. <BR/>A record review of the facility policy Pain assessment and Management, not dated, revealed the following [in part]:<BR/>Purpose: The purpose of this procedure is to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain.<BR/>Monitoring and Modifying Approaches:<BR/>1. Reevaluate the resident's pain and consequences of pain at least each shift or significant changes in levels of chronic pain and at least weekly in stable chronic pain.<BR/>2. Monitor the following factors to determine if the resident's pain is being adequately controlled:<BR/>a. The resident's response to interventions and level of comfort over time.<BR/>4. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. <BR/>Documentation:<BR/>1. Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. <BR/>Reporting: Report the following information to the physician or practitioner:<BR/>1. Significant changes in the level of the resident's pain.<BR/>3. Prolonged, unrelieved pain despite care plan interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs, that meet the needs of each resident for 4 of 10 residents ( Resident #'s 2, 9 ,12, 15, and 16) reviewed for pharmacy services. <BR/>The facility failed to follow pharmaceutical procedures to accurately and timely complete documentation of controlled drug administration for 3 residents (Resident #'s 9, 12, and 15). LVN D signed out for narcotic medications at the start of the shift, not after she administered the medications over the course of the shift.<BR/>The facility failed to ensure Resident #2 did not have medications left at the bedside.<BR/>The facility failed to ensure that Resident 16's medication was the same dosage.<BR/>This failure could place residents at risk of medication overdose, medication under-dose, ineffective therapeutic outcomes and residents receiving the wrong medications.<BR/>Findings included:<BR/>Resident ID #2<BR/>Record review of Resident #2's MDS, dated [DATE], revealed Resident ID #2 was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia without behavioral disturbances, diabetes, coronary artery disease and anemia. His BIMS score was 14, which indicated the resident was cognitively intact.<BR/>Observation on 1/10/2022 at 11:15 AM revealed a tube of Cream labeled Clotrim-Betameth 1-0.5% Cream ( an antifungal and steroid combination cream) on the resident's bedside table. <BR/>Observation on 1/11/2022 at 9:30 AM revealed a tube of Cream labeled Clotrim-Betameth 1-0.5% Cream ( an antifungal and steroid combination cream) on the resident's bedside table. <BR/>Record review of Resident #2's active physician orders dated 01/10/2022, at 11:15 2021 AM included the following prescription medication Clotrim-Betameth 1-0.5% Cream 2 times daily, scheduled AM and PM to rash on perineal area. <BR/>In an interview with Resident ID # 2 on 1/11/22 at 11:20 AM he stated he did not know how the medication got on his bedside table. He denied having applied the medication himself . <BR/>In an interview with LVN D 01/11/2022 at 1:10 PM she revealed she did not recall leaving the medication at Resident' #2's bedside.<BR/>Resident ID # 9 <BR/>Record review of Resident # 9's Quarterly MDS dated [DATE], revealed Resident ID # 9 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, age related cognitive decline, anxiety disorder, repeated falls and altered mental status. <BR/>Record review of Resident #9's active physician orders as of 01/10/22, included the following controlled drugs lorazepam 0.5 mg 1 by mouth 2 times daily.<BR/>Observation of Resident ID # 9's med pass on at 11:30 AM revealed Resident ID # 9 received lorazepam 0.5 mg 1 tablet by mouth at 11:30 AM and this was documented on the MAR at that time. LVN D did not sign the narcotic count sheet when she prepared and administered this medication.<BR/>Interview with LVN D at 11:30 AM revealed that she did not sign the narcotic count sheet for this medication because she had signed for all of her narcotics for her shift when she arrived at the facility to begin her shift at 6:00 AM. LVN D stated she is aware the correct pharmacy procedure is to sign the narcotic count sheet when she pulls the medication to be administered. She stated by signing hours before the medication was pulled would cause a discrepancy in the narcotic count she stated she knew this was not the correct way to document a narcotic and stated she did it because she was in a hurry. She revealed she often did this if she thought it was going to be a busy day and there were people that had called in for her shift. She stated not signing for narcotics at the time of administration could lead to the resident receiving the wrong dose of medication or drug diversion. <BR/>Record review of Resident ID # 9's narcotic count sheet for Lorazepam 0.5 mg on 1/10/2022 revealed the documented count of the Lorazepam 0.5 mg was 32 . <BR/> Observation of the medication card on 1/10/22 @ 11:30 AM that contained the Lorazepam revealed a total count of 33 tablets before the drug was administered <BR/> Resident ID # 12<BR/>Record review of Resident # 12's quarterly MDS dated [DATE], revealed Resident ID #4 was admitted to the facility on [DATE] with the following diagnoses: dementia, urinary tract infection, anxiety disorder and depression.<BR/>Record review of Resident #12's active physician orders dated 01/10/2022, included the following controlled drug Norco 10/325 mg 1 by mouth every 6 hours.<BR/>Observation of LVN D conducting Resident # 12's med pass on at 11:30 AM revealed Resident ID # 12 was administered Norco 10/325 mg 1 tablet by mouth and LVN D documented on the MAR at the time of administration. <BR/>Observation and interview with LVN D on 1/10/22 at 11:30 AM revealed she did not sign the narcotic count sheet at the time the Norco was administered.<BR/>Record review of Resident #12's narcotic count sheet for Norco 10/325 mg revealed the documented count for the Norco 10/325 mg was 102 . <BR/>Observation of the medication card containing the Norco on 1/10/22 at 11:30 AM tablets revealed a total count of 103 tablets before administration . <BR/>Resident ID #15<BR/>Record review of Resident # 15's Annual MDS dated [DATE], revealed Resident ID #15 was admitted to the facility on [DATE] with the following diagnoses: Weight loss, depression and protein calorie malnutrition. H <BR/>Record review of Resident #15's active physician orders dated 01/10/2022, included the following controlled drug Tramadol 50 mgs 2 tablets by mouth 2 times a day. <BR/>Observation of LVN D conducting Resident # 15's med pass on 01/10/2022 at 11:30 AM revealed Resident ID #15 received Tramadol 50 mg 2 tablets which was documented on the MAR at the time of administration. <BR/>Interview with LVN [NAME] at 11:30 AM on 1/10/22 revealed that she had signed for the narcotic at the beginning of her shift. <BR/>Record review of Resident #15's narcotic count sheet for revealed the documented count of the Tramadol was 62 . <BR/> Observation of the medication card containing the Tramadol at 11:30 AM on 1/10/22 tablets revealed a total count of 64 tablets before administration . <BR/>An interview with the DON on 6/22/2020 at 3:00 PM revealed that she expected nurses to sign for controlled medication immediately when administering them, she stated she did not know that LVN D had not signed for her controlled drugs when administering them. <BR/>Resident #16<BR/>An observation on 01/11/2022 7:45 AM of med cart #1 revealed Resident ID # 16 had a medications that was the incorrect dosage. Resident ID # 16 had a light orange oval tablet in a blister pack labeled : Spironolactone 50 mg 1 tablet by mouth every evening. (A medication to treat high blood pressure and edema). <BR/>Review of the Medication administration Record gave the following instructions: Spironolactone 25 mg give one tablet in the morning <BR/>Review of Resident ID # 16's face sheet dated 01/11/2021, revealed resident ID # 16 was a [AGE] year-old- male admitted to the facility on [DATE]. <BR/>Review of Resident ID # 16's physician orders dated 01/11/22 included the following orders: Spironolactone 25 mg give one tablet by mouth in the morning for congestive heart failure, ( start date 07/26/2021).<BR/>In an interview on 10/08/21 at 2:00 PM LVN E stated she would notify her ADON and hold the medications until the order was clarified by the physician after comparing the label on the medication card to the physicians order. She stated the dosage on the blister pack did not match the dosage listed on the medication administration record She stated that it was each nurse's responsibility to see that medications were the correct dosag , <BR/>In an interview on 01 /11/2022 at 9:10 AM the ADON revealed it was each nurse's responsibility that medications be properly labeled with the correct medication and dosage according to the physicians orders. She stated the pharmacy consultant also checked the carts for cleanliness , proper storage and labeling of medications at each monthly visit. <BR/>Interview with the DON on 01/11/22 at 9:30 AM stated the med should not have been given without the proper dosage on the packaging. She stated she did not know how this occurred. <BR/>In a review of the facility's Policy and Procedure, provided by the DON, dated 9/2018 ,titled Controlled Substances, documented [in part]:<BR/>Accurate inventory of all controlled medications at all times. <BR/> The nurse administering the medication will record the following information immediately : date and time drug is administered on the MAR and accountability record (control drug individual count sheet), amount of drug administered ( accountability record) , remaining balance of drug (accountability record), and signature of nurse administering drug ( accountability record) . Initials of the nurse administering the dose, completed after the medication has been administered. (MAR)<BR/>Review of the facilities policy titled Medication Administration dated revised February 2020, revealed in part:<BR/>11. Verify the pharmacy prescription label on the drug and the manufacturers identification system match the MAR. If there is a discrepancy check the order and notify the pharmacy ; do not give the medication until clarified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication regimen, in that:<BR/>Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, a narcotic medication, and a diuretic medication on 2/29/2024 at approximately 10:20 AM. Resident #1 became unresponsive on 2/29/2024 at 11:15 AM and was transported by ambulance to the local hospital emergency room. Resident #1 was admitted to the hospital on [DATE] with a diagnosis of hypotension (abnormally low blood pressure) due to drugs.<BR/>An Immediate Jeopardy was identified on 03/07/2024. The Immediate Jeopardy Template was provided to the Administrator on 03/07/2024 at 5:15 PM. While the Immediate Jeopardy was removed on 03/08/2024 at 6:55 PM, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. <BR/>This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death.<BR/>The findings included:<BR/>Review of Resident #1's admission Record, dated 3/01/2024, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident had an Out of Hospital DNR Code Status. The resident's diagnoses included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), pneumonia, urinary tract infection, congestive heart failure (the heart's main pumping chamber - left ventricle - becomes stiff and unable to fill properly), hypertension (high blood pressure), dementia (impaired brain function and thought processes), and hypothyroidism (thyroid disorder). <BR/>Review of Resident #1's comprehensive care plan, dated 2/28/2024 revealed it addressed hypertension related to congestive heart failure. The care plan approaches included to give anti-hypertensive medications at ordered and monitor for side effects such as orthostatic hypotension and increased heart rate.<BR/>Review of Resident #1's Medication Administration Record, dated February 2024, revealed LVN A documented a blood pressure of 121/75 on the morning of 2/29/2024. The record documented Resident #1's medication orders included:<BR/>Cozaar 50 mg daily (anti-hypertensive medication)<BR/>Metoprolol succinate 12.5 mg daily (anti-hypertensive medication)<BR/>Furosemide 10 mg daily (diuretic medication)<BR/>Tramadol 50 mg daily at bedtime for pain (opioid pain relief medication).<BR/>Review of the Medication Incident Report, dated 2/29/2024 revealed the DON documented Resident #1 was given the wrong medication by LVN A, who immediately reported she had given Resident #1 another resident's medications by mistake. The resident's physician was called at 10:33 AM and informed Resident #1 received anti-hypertensives and a narcotic. Orders were received to monitor the resident's BP and monitor her closely. At approximately 11:15 AM, LVN A reported Resident #1 was unconscious and non-verbal. The DON found Resident #1 unconscious in the dining area and gave her a sternal rub and called her name in a loud voice. The DON listened to her heart and lung sounds and none were noted. Resident #1 was placed on a mat on the floor, oxygen was applied, and 911 was called. The DON continued sternal rubs and called the resident's name. EMS arrived just as Resident #1 stated she was awake and could hear the DON. The DON assisted EMS with putting Resident #1 onto the gurney. The physician was called at 11:24 AM and was notified Resident #1 was transported to the local hospital. The family was notified by LVN A and LVN B. The DON documented the resident had been alert and oriented that morning.<BR/>Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:33 AM revealed LVN A documented the resident's family and physician were contacted about the wrong medication being given.<BR/>Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:48 AM revealed LVN A documented the resident's physician was called at 10:33 AM and he stated to monitor the resident's BP and monitor the resident closely. The LVN documented she went to check the resident's BP at 11:15 AM in the dining room and found the resident unresponsive. The LVN got the DON. The resident was laid on the floor and oxygen was applied. The DON did sternal rubs and 911 was called. The resident left with EMS. The physician and family were notified.<BR/>Review of Resident #1's hospital medical record, dated 2/29/2024, revealed the following [in part]:<BR/>History of Present Illness<BR/>Patient was given another resident's medications that included:<BR/>Amlodipine 10 mg (blood pressure lowering - calcium channel blocker)<BR/>Carvedilol 25 mg (blood pressure lowering - alpha-beta blocker)<BR/>Isosorbide mononitrate ER (extended release) 60 mg (nitrate - blood vessel widening, preventative for chest pain)<BR/>Norco 7.5 mg (Hydrocodone - opioid for pain relief)<BR/>Spironolactone 25 mg (diuretic - fluid reduction)<BR/>She then went unresponsive with no pulse and no breaths. By the time EMS arrives she was breathing on her own and had a pulse. She was found to be hypotensive and brought in. <BR/>Clinical Impression<BR/>Hypotension due to drugs.<BR/>Chronic anemia associated with chronic disease.<BR/>Triage: 2/29/24 at 11:20 AM - BP 59/24.<BR/>In an interview on 3/01//2024 at 2:18 PM, the DON stated LVN A had made a medication error the prior day on 2/29/2024. She stated LVN A got distracted when someone was talking to her and she grabbed the wrong medication cup and gave Resident #1 the medications for another resident. She stated the medications included a blood pressure pill and Norco. The DON stated LVN A immediately told her at 10:30 AM. She stated LVN A realized what she had done when she did it. The DON stated she called Resident #1's physician at 10:33 AM, and he asked what BP medication Resident #1 had been given, which was Isosorbide 60 mg. The physician stated that was a high amount of blood pressure medication for her and to monitor her BP. The DON stated at 11:15 AM, Resident #1 was unresponsive, had no heartbeat or pulse, and oxygen was applied. The DON stated she did a sternum rub and someone called 911. The DON stated she called the physician at 11:24 AM and notified him Resident #1 was awake, alert, and on her way to the ER. The DON stated she had LVN A call and notify the resident's family. The DON stated the ADON accompanied LVN A on her next medication pass. The DON stated she completed an incident report for the med error. The DON stated LVN A was a new nurse and was hired within the last year. <BR/>In an interview on 3/01/2024 at 3:40 PM, the ADON stated she had made random observations of LVN A during the past few months and there was never anything observed that gave her reason for alarm or concern. The ADON stated she did not know when the medications were being given yesterday morning or if LVN A was passing medications from the medication cart or from the medication room. The ADON stated LVN A told her what happened. LVN A was asked if she had passed any more medications since the incident and she said no. The ADON stated she went through LVN A's next medication pass with her about noon on 2/29/2024. She stated LVN A passed medications from the medication room (carried the medication cup from the medication room rather than pushing the medication cart) due to not having a full medication pass at that time. The ADON stated she observed LVN A through the whole process from start to finish. She stated she observed LVN A review the resident's medication order, open the medication cart and find the correct medication, verify the labeled medication card with the order, pop the medication from the bubble pack card into the medication cup, and take it to the resident and verify, and administered the medication. LVN A initialed the resident's electronic MAR after the medication was administered. The ADON stated the incident with Resident #1 was the only medication error that has been made since she started employment in the facility during November 2023. The ADON stated LVN A was the youngest and newest nurse, and the other licensed nurses have had more experience. The ADON stated she thought LVN A was competent and she made a mistake when she got busy. She stated LVN A needed to slow down and think about what she was doing. The ADON stated the standard of practice was to pop medications from the cards for one resident at a time. <BR/>In an interview on 3/01/2024 at 4:43 PM, LVN A stated when she arrived at work on the morning 2/29/2024, the computer for the medication cart had not been charged and she had it plugged it into the outlet in the medication room. She stated she had taken a resident's vital signs and blood pressure and had placed his medications in a cup on top of the medication cart in the medication room. She stated she gathered her equipment to take Resident #1's vital signs (BP cuff, thermometer, oxygen pulse oximeter) and carried the medication cup and equipment to Resident #1 who was in the sunroom. LVN A stated she had it in her head to give Resident #1 the medications and she gave them to her and then took her vital signs. She stated it was about 10:20 AM. She stated she then went back to the medication room to enter the medications were given on the MAR when she realized what she had done. LVN A stated she immediately reported her error to the DON. Resident #1 was assessed and was later found to be unresponsive. The DON called the doctor. LVN A stated she called the family and said Resident #1 had been given the wrong medications and was on the way to the hospital. She stated the BP medication given was Isosorbide. LVN stated she felt awful about it and became tearful. She stated she would focus on the process of start to finish for one resident at a time. LVN A demonstrated how she reviewed a medication order in the electronic MAR, unlocked the medication cart and to find the medication and compared the card to the order in the computer, signed out the medication in the narcotic book if applicable, popped the medication from the card into a medication cup, replaced the medication card in the cart and locked it, gave the medication to the resident, and then returned and documented Y in the electronic MAR. LVN A stated she learned from this error and would focus and think about what she was doing.<BR/>Observation and interview on 3/04/2024 at 1:45 PM with Resident #1 in the hospital revealed she was laying on her back in bed with the head of the bed elevated. She was using supplemental oxygen via nasal cannula. Resident #1 was awake, alert, and oriented. Resident #1 stated her doctor had been to the hospital to see her. Resident #1 stated she was feeling some better. She stated she had gone to the nursing facility after being in the hospital with pneumonia. Resident #1 stated she found out what had happened to her at the nursing home and stated she did not receive good care there. Resident #1 stated she planned to go to a different nursing home where her family members had both been and she had visited them. She stated she was familiar with the place. Resident #1 stated she could not walk very well anymore and hoped to receive therapy there. Resident #1 stated she took Tramadol and it helped with her hip and leg pain. She stated she had a wheelchair and a power chair and hoped to be able to use it again. <BR/>In an interview on 3/05/2024 at 1:24 PM, the DON stated the ADON had observed LVN A give the entire lunch medication pass on Hall 2 and Hall 3 on 2/29/2024. She stated she did verbal counseling with LVN A on Thursday, 2/29/2024. The DON stated on Saturday, 3/02/2024 she came to the facility and did an in-service training on the medication administration policy and procedure with LVN A and gave her a suspension notice pending investigation. The DON stated the Administrator determined LVN A may need more training and needed to be taken off the schedule. The DON stated she came to the facility on Saturday and suspended LVN A's employment per the Administrator's directive. She stated the Administrator spoke with her corporate boss on 3/04/24 and he gave instruction for LVN A to have additional instruction for the medication pass with the medication pass checklist to be completed for 3 days - Thursday, Friday and Saturday. The DON stated LVN A was scheduled to return to work on Thursday 3/07/24 and the ADON would go with her during the medication pass with a checklist. The DON stated this was the first medication error LVN A had made since she started employment during November 2023.<BR/>In a telephone interview on 3/06/2024 at 12:51 PM, Resident #1's physician stated he was aware of the incident and had been called immediately by a nurse at the facility. The physician stated he had been at the facility the morning of Thursday 2/29/24 before the incident. He stated Resident #1 was fine and was going to therapy. The physician stated Resident #1 became syncopal after being given the other resident's blood pressure medications. He stated she was responsive when the ambulance crew arrived to transport her to the ER. The physician stated the safety concern for Resident #1 was her blood pressure going too low and making her pass out. He stated the other medications did not have huge concerns (pain and diuretic medications). He stated the BP medications were the main concern.<BR/>Review of the facility's policy and procedure for Medication Administration, dated 1/2013 revealed the following [in part]:<BR/>Purpose:<BR/>To administer the following according to the principles of medication administration, including the right medication, to the right resident/patient at the right time, and in the right dose and route.<BR/>Equipment:<BR/>Medication as ordered<BR/>Administration supplies as indicated<BR/>Procedure:<BR/>1. Verify physician's orders for medications to be administered.<BR/>2. Review any special precautions and perform needed evaluations prior to administering medication to the resident/patient.<BR/>Review resident/patient allergies.<BR/>Review pertinent lab results, as indicated .<BR/>Perform needed evaluations prior to administering specific medications (e.g., pulse, blood pressure, blood glucose).<BR/>3. Identify resident/patient via wristband or picture ID.<BR/>4. Explain the procedure to the resident/patient. Include the type of medication ordered, the reason, frequency, and route .<BR/>10. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time .<BR/>13. Verify the following, again, by comparing medication to MAR prior to administering:<BR/>Correct resident/patient<BR/>Correct medication<BR/>Expiration date<BR/>Dose and dosage form<BR/>Route<BR/>Time .<BR/>This was determined to be an Immediate Jeopardy on 3/07/2024. The Administrator was provided the Immediate Jeopardy Template on 3/07/2024 at 5:15 PM and a Plan of Removal was requested. <BR/>The following Plan of Removal submitted by the facility and accepted on 3/08/2024 at 4:37 PM:<BR/>1. Resident #1 was immediately assessed by the Licensed Nurse (LN) on 02/29/24 and the physician was notified of the medication error with a new order to monitor the resident's blood pressure closely. The order was noted by the LN. When the LN went to monitor Resident #1 after receiving the order, the resident was found unresponsive. The LN called EMS which responded quickly, and the resident was discharged to the ER for observation on 02/29/24.<BR/>2. The 24-hour report was reviewed on 3/7/24 by the Assistant Director of Nursing (ADON) for the past 72 hours to ensure there were no further medication errors and/or changes in any resident's condition. Any concerns will be addressed by a LN if identified. The results of the report covering the past 72 hours found no additional medication errors or changes in residents' condition. No further physician notification of actions by the licensed nurse was necessary.<BR/>3. When the Director of Nursing (DON) interviewed the LN on 02/29/24 who made medication error, it was determined that the LN dispensed the medication for a resident other than resident #1. She then realized that she needed to take resident #1's blood pressure, and subsequently also gave the other resident's medication to resident #1. The education provided to this LN by the DON included avoiding distractions and completing the medication pass one resident at a time once starting the medication administration process.<BR/>Beginning 3/6/24, LNs and Certified Medication Aides (CMAs) will have a medication pass observation completed by a Registered Nurse (RN) prior to the beginning of their next shift and receive education as needed for any concerns identified by the RN conducting the observation. The RN will observe a minimum of 50% of the LNs or CMAs medication pass for that scheduled time to validate competency. The RN will stop the LN or CMA if they identify a problem and provide immediate reeducation in real time on the issue identified. The medication administration observations will be documented on the facility's Medication Administration/Technique Observation tool which follows the facility's Medication Management policy. <BR/>On 3/8/24, the LNs and CMAs went through additional medication administration education that was provided by the ADON. This education included avoiding distractions to the medication pass and once starting to dispense medication for a resident, not to stop and perform any other non-emergent tasks. It also included following the facilities procedure on Medication Administration from the facilities Nursing Procedure Manual. The LNs and CMAs understanding of the education will be demonstrated through RN observed medication administration observations previously described.<BR/>All newly hired LNs and CMAs will go through medication pass validations by a LN with the tools mentioned above during their orientation.<BR/>4. The DON, ADON or designee will complete med pass observations weekly for 12 weeks to ensure licensed nurse and medications aides continue to administer medications per physician's orders and to the right resident. The Medical Director was notified of this survey outcome on 3/8/24 and will be involved in the facility QAPI process surrounding this plan. A report of the medication administration audits will be submitted to the QAPI committee for review and recommendations as needed. The facility held an initial QAPI meeting on 3/8/24 to review the outcome of the medication administration observations to this point. Starting the week of March 11, 2024, a QAPI meeting will be conducted weekly for 4 weeks then monthly. The DON is responsible for monitoring and additional actions to this plan if needed.<BR/>Date of Compliance: 03/08/24<BR/>Monitoring and verification of the facility's Plan of Removal began on 3/08/2024 at 4:40 PM as follows:<BR/>Observation on 3/06/2024 at 11:46 AM revealed the DON was observing LVN C passing medications and was using a medication administration competency checklist. <BR/>In an interview on 3/06/2024 at 11:52 AM, the DON stated she did medication administration competency checklist for LVN C. She stated the MDS Coordinator had observed LVN D and did the medication competency on her. The DON stated they were the only 2 LVNs at the facility. She stated 6 more LVNs would be evaluated for medication administration competency. The DON stated LVN A would have 3 days of evaluation using the medication checklists. She stated tomorrow and Friday (3/07/24 and 3/08/24) the ADON would observe LVN A and complete the medication administration checklist and on Saturday, 3/09/24 the weekend RN would observe LVN A and complete the medication administration checklist.<BR/>In an interview on 3/07/2024 at 2:32 PM, the MDS Coordinator stated she had evaluated LVN D and completed the medication checklist with her yesterday on 3/06/2024.<BR/>During an observation and interview on 3/07/2024 at 4:03 PM, MA E was observed during the preparation of medication to administer to a resident. She stated she would not take the medication cart down the hallway, due to only having medication for 1 resident. MA E reviewed the resident's medication orders in the electronic medication administration record, unlocked the medication cart and located the medication card, popped the medication into a medication cup, returned the medication card to the cart, and locked the medication cart. She proceeded to walk down the hallway to the resident's room carrying the medication cup and a glass with water, and stated she identified the resident by her picture on the medication administration record and by her room number. MA E identified herself to the resident, explained the pills she had brought for the resident, tapped the pills from the medication cup into the resident's mouth, and offered her the glass of water. MA E left the resident's room and walked back to the medication cart, pulled up the resident's medication administration record, initialed the medication had been given, and closed the electronic medication administration record.<BR/>During an observation and interview on 3/07/2024 at 4:40 PM, LVN B was observed during the preparation of medication to administer to a resident who was seated at a table in the dining room. The LVN pushed the medication cart from the medication room and positioned the cart against the wall to the right of the entrance to the dining room. LVN B stated she took the medication cart into the halls when she had the main medication pass, but sometimes just carried the medication cup and a glass of water to the resident if it was only one resident. LVN B reviewed the medication order in the resident's electronic medication administration record. The resident's picture was in the upper left-hand corner of the medication administration record. LVN B unlocked the medication cart, found the medication card and compared it to the order on the medication administration record. She popped one tablet from the medication card into a medication cup, returned the medication card into the medication cart, and locked the cart. LVN B hit the screen saver on the computer, took the medication cup and a glass of water to the resident and watched her swallow the medication. She returned to the medication cart and entered the medication administered on electronic medication administration record and closed the record.<BR/>In an interview on 3/08/2024 at 11:02 AM the ADON stated she was accompanying LVN A during the medication passes for the day.<BR/>Review of the fax cover sheet dated 3/08/2024 at 1:41 PM revealed the Administrator had sent the Medical Director a notification letter regarding the medication error, a copy of the IJ Template and the facility's draft Plan of Removal.<BR/>Review of the in-service training record dated 3/08/2024 at 2:00 PM revealed a training was provided to the licensed nurses regarding the topic of medication management and the facility's policy and procedure for medication error preventing and reporting. The attendance sheet was signed by a medication aide, 5 LVNs, and the weekend RN.<BR/>In an interview on 3/08/2024 at 5:37 PM, LVN B stated the ADON had watched her pass medications yesterday on 3/07/2024. LVN B stated the nurses had in-service training that day at 2:00 PM and the topics covered were medication errors, the types of medication errors - giving the wrong medication or transcription errors in orders, using the 5 Rights of Medication administration, and avoiding distractions when preparing medications for administration.<BR/>Observation on 3/08/2024 at 5:48 PM revealed the ADON was accompanying LVN A on the medication pass in Hall 2. The medication cart was in the hallway.<BR/>Review of the QAPI Meeting Sign-in Sheet, dated 3/08/2024 at 3:00 PM, revealed the committee discussed the IJ Plan of Removal for medication error.<BR/>During an interview and record review on 3/08/2024 at 4:26 PM, the ADON provided a copy of the 72 Hour Summary report dated 3/04/24 - 3/07/24. She stated the 24-hour report was printed from the program used for the residents' electronic health records and included new orders, progress notes, weights and vital signs. She stated there was not a way to filter all the information that was included in the report. The ADON stated the MDS Coordinator reviewed the 24-hour report in the morning, Monday through Friday, and she sent an email to the Administrator, DON, ADON, and therapy staff with any concerns or anything that needed follow-up. Review of the copy of the 72 Hour Summary report revealed it consisted of 32 pages and the first page had been signed as reviewed by the ADON on 3/07/24 at 1900 (7 PM). The 72 Hour Summary report had 10 hand-written documented notations for vital signs and weight changes that had been rechecked.<BR/>[This interview and record review were conducted prior to the acceptance of the final draft of the Plan of Removal.]<BR/>The Administrator was informed the Immediate Jeopardy was removed on 3/08/24 at 6:55 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow menus for one of one facility. <BR/>The facility failed to follow their menus prepared in advance daily for 11 meals dated 2/10/25 -3/13/25. <BR/>This failure could affect the residents by the menus failing to meet the residents' choices and dietary needs. <BR/>Findings included:<BR/>Interview on 2/22/25 at 11:15am with [NAME] B stated the facility got a truck in yesterday but the food supplies remain low. Stated the facility was out of coffee, milk, bread, sweeter. Stated the facility had to substitute meals due to not having the food on the menu. Stated they try to make it as close as possible to the menus to make sure the residents are receiving the correct nutritional value. At times the facility had no bread or milk. [NAME] B stated she purchased food for the residents out of her own pocket without reimbursement, mostly condiments, ketchup, and mustard. <BR/>Observation on 2/22/25 at 11:15am of food supply closet showed food supplies low. The facility had can goods most of them dated yesterday. Dishwasher had chemicals. Had 7 days of nonperishables. <BR/>Interview on 2/22/25 at 9:00am with LVN A stated residents did not have milk, coffee, hot chocolate. LVN and night staff bought it yesterday. There was no sugar free sweetener. LVN A stated the dietary manager was buying food. <BR/>Interview on 2/23/25 at 10:50am with DON & Human Resource Director stated the vendor does not deliver milk due to non-payment. <BR/>Observation on 2/23/25 at 12:23pm no menu posted in dining room. Residents stated food is good. Observed pork chops, mixed vegetables, mashed potatoes, roll. <BR/>Record review of the residents revealed no significant weight loss. <BR/>Interview on 2/24/25 at 10:45am with Dietary Manager stated the residents had $6 a day for meals. Dietary manager stated she ordered food two times a week for $480. Stated that is not enough food to be able to follow the menus. Stated they had to substitute meals. Dietary manager stated today, the meal required hamburger meat and they didn't have enough money for that, so had chicken instead. Stated the Nutritionist approved the substitutions. Stated the facility used Magic Cups instead of the shakes that were ordered for the residents and the Dietician approved the change. Stated she had purchased food out of her own pocket without reimbursement from the facility. Coffee, milk, sweet & low, tea bags, whatever is needed.<BR/>Interview on 3/9/25 at 12:55pm with dietary manager stated she had to substitute chicken for roast. Roast is too expensive to buy. <BR/>Interview on 3/10/25 at 9:15am with LVN E stated they never know what was being served. Stated a <BR/>resident will ask sometimes, and they had to go and ask dietary. Stated they serve a lot of chicken and <BR/>fish. Sometimes the activity director will provide snacks. Stated HR went and bought coffee yesterday <BR/>for the residents. <BR/>Observation on 3/10/25 at 9:20am showed food pantry appears low. <BR/>Interview dated 3/10/25 at 10:45am with dietary manager provided substitution list. Stated she had to <BR/>switch around the menus to what she was able to purchase. Stated she is placed an order today, but <BR/>did not have enough money to purchase the menu and will have to substitute 2 meals. Stated with <BR/>what she ordered today she was $12 over. Don't know if they will approve it or not. Dietary manager<BR/> stated she switched day around to make them work. Stated her budget had not increased, or no one <BR/>had told her. Stated she provided peanut butter and jelly, or meat sandwiches, or vanilla wafers as snacks.<BR/>Record review of substitution log, 3/10/25 at 11:38 am.<BR/>Substituted meals on:<BR/>2/10/25 - Meal Chicken breast, rice, California veggies (substituted with chili w/beans, salad, carrots, relish plate).<BR/>2/19/25 - Meal Cheeseburger on bun, French fries (substituted with vegetable lasagna, California veggies, rolls). <BR/>2/22/25 - Meal BBQ chicken, potato salad, green beans, honeybun cake (substituted with chicken/turkey, carrots, mashed potato, fruit). <BR/>2/21/25 - Meal vegetable soup, roast beef sandwich (substituted with tomato soup and turkey sandwich). <BR/>2/23/25 - meal spinach, peach cobbler (substituted with 4 way mix veg, sliced peaches).<BR/>2/24/25 - Meal fiesta beef bean casserole, Spanish rice, corn relish, pears (substituted with ham with pineapple, baked beans coleslaw, rolls, frosted strawberry cake).<BR/>2/25/25 - meal ham, baked beans, [NAME] slaw, pineapples with mandarin oranges (substituted with BBQ chicken, scalloped potatoes, green beans, rolls, Jello).<BR/>2/26/25 - green beans, frosted angel food cake (substituted with carrots, frosted yellow cake).<BR/>2/27/25 meal sweet & sour meatballs, rice, chocolate &eacute;clair (substituted with Italian sausage pizza, cherry Jello). <BR/>2/28/25 meal tomato soup, grilled cheese (substituted with chuckwagon steak, mashed potatoes, carrots).<BR/>3/9/25 Lunch Meal pot roast over $200, chocolate cream pie (substituted breaded chicken, pineapples) Dinner meal garlic pepper pork, strawberry shortcake (substituted with Salisbury steaks, frosted cinnamon cake).<BR/>3/10/25 Lunch meal brussels sprouts, raspberry peaches (substituted with broccoli mixed vegetables, raspberry applesauce) Dinner meal Ham & Cheese sandwiches with lettuce & tomato, crackers, navy bean soup, fruit cup (substituted with BBQ pork sliders, French fries, tomato & zucchini, mandarin oranges).<BR/>Interview dated 3/10/25 at 11:54am with Dietician stated changed meals due to trucks not coming in. Coming at end of March. Stated change in ownership. She was at facility a few weeks ago and had concern about budget of food. Cannot do anything about upper management and budget. She stated she knew about cuts in food budget from upper management, don't have enough money to order the sufficient amount of food. She stated she was not aware of all substitutions, should be no more than 2 a week and she will reach out to facility about substitutions and to approve them. Going to have to simplify the resident's menus for breakfast due to the high price of eggs. <BR/>Investigator requested dietary policy and it was not provided.

Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of one facility reviewed.<BR/>The facility failed to have sufficient resources to satisfy (pay) debts timely and when they come due. The phone and internet were disconnected, service repair bills/vendors were not paid, and the facility van did not have insurance or current registration tags. The facility failed to provide enough money to purchase the food necessary to follow the menus and to purchase printer supplies. <BR/>An Immediate Jeopardy was identified on 03/14/25 at 3:52 pm. The IJ template was provided to the facility on 3/14/25 at 3:52pm. While the Immediate Jeopardy was removed on 03/19/25 at 4:36 pm, the facility remained out of compliance at scope of widespread and a severity level of no actual harm with potential for more than minimal harm because the facility needs to take action to ensure there is a plan for vendors to be paid timely, so services are not rescinded, and the residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident.<BR/>These failures could place residents at risk of not receiving essential care and services that the facility is responsible for providing.<BR/>Findings included:<BR/>During an interview on 02/22/25 at 9:30 am, the DON said the facility had not had an Administrator since December 20, 2024. She said: the facility had not been paying vendors. The phones/fax were not working. The staff had to utilize their own cell phones to conduct facility business. The facility is not able to send or receive faxes. A staff member bought a pre-paid cell phone, so the residents were able to call their family and vice versa. The staff went and bought milk, coffee, and hot chocolate for the residents, yesterday 02/21/25, due to the facility not having any for the residents. The ice machine was rented and was scheduled for repossession next Wednesday, 02/23/25 for non-payment. The nurses had purchased ink cartridges and paper so they could print out packets that needed to be sent with the residents when they go out of the facility. Staff have purchased soap, bodywash, lotion, laundry soap, bleach, bread, gas for the van, and incontinent briefs for the residents. <BR/>Record review of invoices provided by the Human Resource Director indicated unpaid balances for the following:<BR/>1. Telephone and internet vendor invoice dated 2/7/25- Past due balance of $16,985.35. The phone was disconnected on 02/07/25. Internet was disconnected on 03/03/25.<BR/>2. Energy vendor invoice dated 2/6/25 - Past due balance of $41,159.61 with a due date of 02/21/25.<BR/>3. Water vendor invoice undated - Past due balance of $5292.92 with a due date of 03/10/25.<BR/>4. Fire and Security vendor - Past due balance of $11,497.06 as of 03/12/25 - a total of 11 invoices dated 12/26/24 - 3/3/25. Account was suspended on 03/12/25 and 10-day termination notice was to be given. <BR/>5. Ice machine vendor invoice dated 2/1/25- Past due balance of $137.12 with a due date of 2/11/25 and ice machine to be picked up on 02/26/25 if not paid. <BR/>6. Milk vendor invoice dates from 8/7/24-12/31/24 (22 invoices)- Past due balance of $1,360.59. Delivery of milk stopped 01/07/25.<BR/>7. Garbage and waste vendor invoice dated 1/20/25- Past due balance of $1,141.08. Subject to service suspension and/or container removal. <BR/>9. Pharmacy Consultant invoice dated 1/27/25- Past due balance (not disclosed on invoice). Pharmacy services to be terminated on 02/24/25. <BR/>10. Insurance vendor for van undated- Policy cancelled effective date on 02/09/25 for non-payment. Amount unknown. <BR/>In an interview on 02/22/25 at 11:15 am, [NAME] B said the facility had to substitute meals due to not having the required food for the menu. She said they attempt to make sure the residents were receiving the correct nutritional value. She said at times, the facility does not have milk, bread, coffee, artificial sweetener. [NAME] B said she had purchased ketchup, mustard, and artificial sweetener for the residents. <BR/>In an interview on 02/22/25 at 11:30 am, the Maintenance Director stated he could not purchase supplies to fix things at the facility due to the facility having a past due balance at a local hardware store, approximately $7000. The facility had a past due balance with the vendor who serviced the dishwasher, washing machines and dryers and could not get maintenance services. He said the hot water heater for the laundry did not work and could not get it fixed. He stated that he purchased supplies out of his own pocket to fix things at the facility for the residents. He said the facility owed him $125 for supplies he recently purchased, and they have never paid him. <BR/>In an interview on 02/22/25 at 01:45 PM with the Human Resource Director, she stated the facility phone was cut off on 02/07/25 and had never been turned back on. She said an anonymous staff member purchased a prepaid cell phone out of their own pocket on 02/10/25 so that the residents and their families could communicate with each other. She said the facility could not send or receive faxes. The staff had to use their personal cell phones to conduct facility business. <BR/>In an interview on 02/22/25 at 02:10 PM, Housekeeper C stated there was no hot water in the laundry and all laundry was being washed in cold water. She said the washing machine had no chemicals and needed to be serviced. She said staff purchased bleach and laundry soap as the facility had not been purchasing those items due to not paying their bill. <BR/>In an interview on 02/23/25 at 10:10 am, LVN D said that she bought out of her pocket soap, bodywash, lotion, ink, and paper for the printer. She said if she did not purchase these things the residents would go without.<BR/>In an interview on 02/23/25 at 10:15 am, LVN E said that she purchased ink and paper for the printer. She said when a resident was sent out of the facility, they have to print a paper packet to go with them. She said due to the facility not having phone or fax services, she had to use her own cell phone to conduct facility business. She said the facility was unable to receive faxes from doctors and hospitals. She said the residents' families have expressed to her their frustration about not being able to contact the facility or their loved ones. <BR/>In an interview on 02/23/25 at 10:50 am, the DON said she was aware the facility did not have hot water for the laundry. She said when a resident goes out of the facility, they had to print out a packet concerning the resident's information to be sent with them and the nurses had been buying the ink and paper for that. If they did not purchase the items, they would not be able to send out a packet the receiving facility was requesting. <BR/>In an interview with DON on 2/24/25 at 10:00am and a record review of an e-mail dated 02/17/25 at 11:05 am from the Director of Nursing to the CEO, the DON requested Supplies and Payments: We are nearly out of essential supplies, including toilet paper. Could you confirm when the outstanding bills will be settled so that we can restock as needed? Petty Cash: Do we have an estimated timeline for the release of petty cash? Several team members have been using funds to address immediate building needs. Could you advise on the status of these items? The DON said the CEO never responded to the e-mail.<BR/>In an interview on 02/24/25 at 10:45 am, the Dietary Manager stated the residents were budgeted $6 a day for breakfast, lunch, and dinner. She said that amount was not enough to purchase all the food items for the menus. As a result, the facility had to substitute items on the menu. An example for today at lunch, it called for hamburger meat but there wasn't enough money to purchase that, so it was substituted with another item on the menu that was chicken. She said she had purchased coffee, milk, artificial sweetener, and tea bags for the residents. <BR/>In an interview on 02/24/25 at 11:00 am, the Laundry Supervisor stated there was no hot water for the laundry. The resident's laundry was being washed in cold water. She said the hot water heater had been out for over a month. She said the washing machine did not have the correct chemicals to sanitize the resident's laundry properly. She said the washing machine had an error code and needed to be serviced. She said the facility had not paid the bill to the servicer and they would not come to fix it. She said staff purchased bleach and laundry detergent as the facility did not provide laundry soap or bleach. She said she had purchased laundry supplies for the residents out of her own pocket. She stated it had been reported, and maintenance was aware. <BR/>In an interview on 02/24/25 at 2:00 pm, the local Ombudsman reported it was difficult to contact the facility due to having no phone service. Individual facility staff had to be contacted. The ombudsman said she was made aware of the communication with the owner because staff had been forwarding emails from the owner and it is very demeaning, and negative. <BR/>In an interview on 02/24/25 at 2:54 pm, the Maintenance Director stated the facility needed a new hot water heater for the laundry. He said the facility could not get anyone to come out and look at the hot water heater due to the facility owing everyone money. He said the washing machine could not be serviced due to an unpaid bill. He said the facility could not order the proper chemicals for the washing machine due to an unpaid bill. He said the CEO was aware. <BR/> In an interview on 02/25/25 at 9:30 am, Resident #1's POA expressed her concern about the facility not having an Administrator in the building and questioned as if this was causing a delay of Resident #1 being placed on hospice care requested on 02/16/25.<BR/>In an interview on 02/25/25 at 11:23 am with the Activity Director, she stated she was purchasing blow-up calendars for the activity bulletin board out of her own pocket and the facility would reimburse her. She said she purchased a calendar for January and the facility did not reimburse her. She said the facility owed her $30. She said she purchased BINGO winnings for the residents such as coke, candy, and popcorn out of her own pocket. If she did not, the residents would not have any BINGO winnings.<BR/>In an interview on 02/25/25 at 12:00 pm, Facility Physician A said she was aware the facility was not paying its bills. She said it makes communication very difficult as she could not send or receive faxes with the facility. She had to conduct business on staff's individual cell phones. <BR/>In an interview on 02/25/25 at 1:35 pm, CNA F stated she had purchased soap and body wash for the residents so they could have a bath. <BR/>In an interview with the CEO on 02/25/25 at 4:20 pm, he said don't worry about the utilities, they will not get shut off. I will not be able to keep up 30-day payments due to all the Medicaid in the facility and them not paying that much. He said he purchased the facility 6 months ago and it takes time to get everything switched over to a new account. He stated he was not going to pay any back service because he was not responsible for anything before he bought the facility. He said the facility staff had not communicated to him about the food or lack of food, and the best he could do was contact his purchase person. He said he was not aware the washing machine did not have hot water and needed to be serviced. CEO stated there was no Interim Administrator, and the position was posted on job website and no one licensed had applied. <BR/>In an interview with the CEO on 02/25/25 at 4:55 pm, he stated he signed a new contract for the electric vendor. He said the water bill was only 2 months behind and that it was not late enough to be shut off so that was fine. He said the Fire and Security vendor were still within terms and would complete repairs. He said he would get payment sent out tomorrow for the ice machine vendor. He said they had a new pharmacy consultant to start 02/26/25. <BR/>In an interview with the Social Worker on 02/26/25 at 1:00 pm, she stated for the last 3 to 4 weeks, she had received calls from family members 2 to 3 times per week on her personal cell phone upset and worried due to the facility phone number not working. <BR/>In an interview on 03/07/25 at 10:00 am, the Human Resource Director said the internet was disconnected on 03/03/25 in the afternoon for non-payment. The facility did not have any internet service from 03/03/25 to the morning of 03/06/25. She stated the facility had insurance on the van and provided an invoice. <BR/>In an interview on 03/07/25 at 11:25 am, the Activity Director said she was responsible for taking residents to doctor's appointments but had not taken them in February or March due to the van not having insurance or current tags. <BR/>In an interview on 03/09/25 at 12:55 pm, the Dietary Manager said she had to substitute pot roast that was on the menu for chicken due to pot roast being over $200. She said she did not have enough money to purchase the required food items on the menu. <BR/>In an interview on 03/09/25 at 1:00 pm, LVN D and LVN E stated due to the internet being down, the nurses were not able to access the computer for medication administration. They stated the residents on the Yellow [NAME] Hallway did not have TV service due to the internet being out and the facility did not purchase a hot spot for that hallway. They reported the residents did not have any coffee today and they were going to go purchase some. <BR/>In an observation on 03/09/25 at 1:15 pm, the facility van's tag displayed on the front windshield expired on 11/24. <BR/>In an interview on 03/10/25 at 1:30 pm, the DON said due to the facility having no insurance on the van, 3 residents (Resident #2, Resident #9, and Resident #11) had missed their doctors' appointments. One resident missed a cardiology and nephrology appointment; two residents missed an appointment with their primary doctor and 2 residents have been taken to their appointments by their family. The DON said a potential negative outcome would be the residents would not receive the proper treatment they needed. <BR/>In an interview on 03/10/25 at 10:16 am, this writer contacted the van insurance company from the invoice provided by the Human Resource Director and was informed the policy had been cancelled and was not active. <BR/>In an interview on 03/10/25 at 10:45 am, the Dietician said she was concerned about the food budget and not enough money to cover the menu. She said she was not aware the facility had been substituting the menu as frequently as they were doing. She said the facility should not be having to substitute more than 2 meals a week. <BR/>In an interview on 03/11/25 at 1:15 pm, the laundry supervisor said the facility was not using the recommended bleach or detergent for the laundry, and no alkaline is being used. One washing machine is not equipped anymore to receive chemicals and they wash items in that one that doesn't require bleach. She said it had been over 2 years since the washing machines had been serviced. She said as a result the laundry had the potential to not be sanitized properly. <BR/>In an interview on 03/11/25 at 8:24 am, Physician B stated it was very difficult to communicate with the facility due to no phone or fax service. He said a resident had an appointment with him yesterday, but it was cancelled. He was not aware it was cancelled due to the facility not being able to transport residents due to having no insurance on the facility van. <BR/>In an interview on 3/12/25 at 12:00 pm, Facility Physician A said she was not aware residents missed doctor's appointments. She said the resident that missed his cardiology and nephrology appointments were considered important appointments. She said the facility called her about Resident #2 that was having slight bleeding from her vaginal area; She said she asked the facility to bring the resident to her office, but was informed they could not due to no insurance on the van. She said as a result, she was going to go to the facility to evaluate her. <BR/>In an interview and record review on 3/12/25 at 10:10 am, the DON provided documentation the van insurance policy was cancelled on 02/09/25. She said on 03/08/25, Resident #3 sustained a fall. The family requested her to be sent to the ER. DON stated the family took her to the ER and left. The facility had to use the facility van to pick her up from the ER, although there was no insurance on the van. <BR/>In an interview on 3/13/25 at 11:35 am, the DON said Resident #2 was being sent to the ER, via ambulance for a change in condition. She said Facility Physician A did not get to see her prior to being sent. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/14/25 at 3:52 pm. The DON and Human Resource Director were notified. The DON was provided with the IJ template on 03/14/25 at 3:52 pm.<BR/>The following Plan of Removal was submitted by the facility and accepted on 03/17/25 at 12:47 pm and included: <BR/>The facility needs to take immediate action to ensure there is a plan for vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>Plan of Removal<BR/>1). Action: The Chief Executive Officer (CEO) and Managing Partner re-educated the Chief Operating Officer (COO) on the governing board responsibility to ensure management and operation of the facility; emphasis was stressed on the importance of providing oversight of facility care and services in accordance with professional standards of practice and principles, to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. The mode of education was in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administrative Management (Governing Board). The teach-back method was used to assess comprehension. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/14/2025<BR/>Responsible: Chief Executive Officer (CEO) and Managing Partner<BR/>2). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet to review and make payments or payment arrangements for: 1. Telephone and internet vendor on 03/13/2025, $10,000.00 was paid, the remaining payment was made on 3/17/25 in the amount of $7987.28, the amount told to us from the company to activate service.; 2. Insurance vendor for the facility van has been paid in the amount of $141.99 on 3/11/25. 3. Registration tags for the facility van was paid on 3.17.25 in the amount of $74.00 to County Tax Office. 4. Fire and security vendor - have confirmed that we are not on hold and have sent an email confirming so on 3.14.25. <BR/>If the internet is out, the emergency plan to ensure the staff have access to MARs and TARs will be to use the Hot spots for internet. Until Telephone and internet have been restored, while these are out, the facility will continue to use mobile phone and internet Hot Spots to communicate and document as required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>If the hot spots are not working, the DON was educated on the need to obtain paper-printed MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available and printing abilities are not available locally. <BR/>The facility Social Worker will call each family to share the mobile phone number if/when needed. <BR/>The Activity Director will complete resident interviews to identify residents affected by phone interruption and share with them the availability of mobile phone if needed to communicate to people outside the facility. <BR/>The facility's Human Resource Director will contact the facility's vendors to share the phone number if/when required. <BR/>To prevent future service interruptions, the Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet monthly to review the facility's outstanding invoices and ensure vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO)<BR/>3). Action: The Director of Nursing (DON) will complete a Medication Error Form for each of the identified 11 residents in which medication were given at a different time or omission occurred; the form includes communicating with the medical provider, the responsible party, facility management and pharmacist consultant, in addition to type of error and reason for error (Examples of medications errors include: <BR/>a. Omission - a drug is ordered but not administered; <BR/>b. Unauthorized drug - a drug is administered without a physician's order; <BR/>c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given); <BR/>d. Wrong route of administration (e.g., ear drops given in eye); <BR/>e. Wrong dosage form (e.g., liquid ordered, capsule given); <BR/>f. Wrong drug (e.g., vibramycin ordered, vancomycin given); <BR/>g. Wrong time; <BR/>and the corrective action taken and measures to prevent similar error(s) recurrence. The Director of Nursing reviewed the other resident's Medication Administration Records (MARs) and did not reveal further discrepancies or errors. The Chief Nursing Officer (CNO) will confirm completion of Medication Error Forms. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) <BR/>4). Action: The Director of Nursing (DON) will re-educate nurses (RN/s/LVNs) and certified medication aides (CMAs) on the facility's policies: Administering Medications and Medication Errors - the different types and immediate actions to take to prevent adverse consequences. The mode of education will be in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administering Medications and Adverse Consequences and Medications Errors. <BR/>The teach-back method was used to assess comprehension. To evaluate further understanding, the Director of Nursing will complete a weekly Medication Pass Observation to each nurse and medication aide for the next 4 weeks and quarterly thereafter. <BR/>Education is done as well regarding obtaining MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available. Facility will have the hotspots that were purchased available to use if the main internet is to stop working until pharmacy deliver paper MARS and TARs. In the absence of the DON, the Chief Nursing Officer (CNO) will request paper-printed MARs and TARs from the pharmacy vendor. <BR/>Start Date: 03/14/2025.<BR/>Completion Date: 03/17/2025<BR/>Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) <BR/>5). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will post the facility's administrator's vacant position and continue active recruitment to fill the facility administrator's vacant position. With a sign on bonus posted on 3.15.25. <BR/>Until the position is filled, all items needed for resident care are to be communicated to the facility's Director of Nursing (DON), as for ancillary services, such as dietary and environmental services, are to be communicated to the facility's Human Resource Director, <BR/>Both - DON and HR Director will participate in a conference call with the Chief Executive Officer (CEO) and Chief Operating Officer (COO) weekly on Thursdays at 11 am that arrangements can be made to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>This conference call will continue weekly with the new administrator once onboarded and the weekly minutes reviewed monthly during the facility's monthly QAPI to determine if changes in needed supplies, their quantity and/or delivery dates are required in order to be altered to ensure timely ordering and delivery. <BR/>Items to be reviewed weekly will include food needed for the menu, milk, coffee, tea, artificial sweetener, hot chocolate, snacks, condiments, soap, shampoo, conditioner, lotion, laundry soap, bleach, ink for printers, paper for printers, chemicals for laundry, and gas for the van, along with routine service needs/requests for the dishwasher, washing machine, and dryer. <BR/>Staff will be educated on 3.17.25 by HR that when a facility or resident need related to supplies and vendor payments to communicate with HR who will review supply and ensure supply is replenished before the item runs out. <BR/>Laundry staff were educated by HR that when chemical supply becomes low to notify HR who will ensure supply is replenished prior to running out. <BR/>Maintenance director will be educated on 3.17.25 to monitor once a week the supply visually and discuss with staff on site the supply level to see if additional chemicals need to be ordered and will communicate to HR. <BR/>Department heads will be educated on 3.17.25 by HR that each department head will monitor its supplies once a week and communicate to HR any items needed. <BR/>Maintenance director will do housekeeping and laundry, DON will do nursing, HR will do office supplies.<BR/>Start Date: 03/14/2025.<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA)<BR/>6). Action: Staff will be reimbursed for their out-of-pocket expenses per usual procedures, including submitting reimbursement requests and receipts. The Human Resource Director (HR) will instruct line staff not to purchase items for the facility in the absence of the facility administrator; all purchases will be made by the facility administrator and/or the HR Director after the weekly Thursday conference call. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA)<BR/>7). Action: Annual van registration and insurance will be added to the annual maintenance checklist to ensure timely registration renewal; The facility administrator will review the yearly checklist during QAPI to ensure timely review. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Maintenance Director and Facility Administrator<BR/>8). Action: An ad-hoc QAPI meeting will be held, and the facility Medical Director will be notified of the deficient practice and the approved removal plan. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA).<BR/>Verification:<BR/>Record review of receipt payment dated 01/28/25 to Water Department dated 1/28/25 for $1,579.21.<BR/>Record review of receipt payment dated 01/29/25 reflected $1,141.08 to garbage and waste. <BR/>Record review of receipt payment dated 02/20/25 to Water Department for $1,579.21<BR/>Record review of receipt dated 02/25/25 reflected $286.86 for ice machine payment. <BR/>Observation on 2/27/25 at 3:46 pm revealed the fire sprinkler system with tag noted to have been serviced and working. <BR/>In an Interview on 3/7/25 at 11:20am, Resident #1 stated she gets all of her medications as far as she knows and had no concerns. She stated she has her own cell phone so not affected. <BR/>In an Interview on 03/7/25 at 11:22am, Resident #9 stated he gets all of his medications and has no concerns with care. <BR/>In an observation on 03/7/25 at 11:55am, 9 residents were in the dining room. The menu was followed, and no food concerns were noted. <BR/>In an observation on 03/10/25 at 9:20am, the kitchen had 7 days of non-perishable food and 3 days of perishable and no concerns were noted. <BR/>In an Interview on 03/14/25 at 3:17pm, Resident # 11 stated she has access to her visitors and them to her and no concerns of anything about her care at the facility. <BR/>In an Interview on 03/14/25 at 3:27pm, Resident #13 and Resident #10 stated they have access to their visitors and have no issues or concerns with their care and get their doctor appointments. <BR/>A record review of the in-service titled Governing Responsibility dated 03/15/25 and signed by the CEO and COO reflected the importance of paying bills timely and the expectation of them to meet weekly on Thursdays to ensure bills are paid timely. <BR/>Observation on 03/15/25 at 12:23pm revealed 9 residents in the dining room with no portion concerns. Food appears palatable and displayed well. <BR/>Record review of the maintenance checklist on 03/16/25 at 3:15 pm revealed vehicle registration and insurance renewal was added annually with a next review date of March 14th, 2025.<BR/>Record review of Medication Pass Observations for 5 nurses dated 3/16/25-3/19/25 for med pass observation by DON reflected medication pass observations were completed by the DON of her nurses.<BR/>In an interview on 03/16/25 at 12:16 pm, the COO confirmed she had been in-serviced concerning bills must be paid in a timely manner and she is to meet weekly with the CEO and Human Resource Director weekly to review. <BR/>In an interview on 03/16/25 at 1:27 pm, LVN E stated she had received 1:1 instruction from the DON on how to administer medications during an internet outage and how to obtain a copy of the paper MAR if one is not available. She said she had completed 2 in-services regarding medication administration and medication errors. <BR/>In an interview and record review on 03/16/25 at 1:59 pm, the Human Resource Director stated she purchased additional data for the hot spots early today and provided a copy of the receipt dated 03/16/25 that indicated additional data purchased. The Human Resource Director provided the training sheet that was completed with the department heads on the process of communicating supply needs to be completed weekly. Human Resource Director said that 1:1 training with the department heads had been completed and they reviewed the process of communication for supply needs. She said she is to have a meeting weekly, on Thursdays, with the CEO and COO concerning supply needs of the facility. <BR/>In an interview on 03/16/25 at 2:13 pm, the Human Resource Director confirmed weekly meetings were to be held with the CEO and COO on Thursdays to discuss billing and concerns. <BR/>Record review/Observation on 03/16/25 at 2:45 pm of job website revealed the Administrator's position was posted for a salary up to $50,000 yearly with a sign on bonus. <BR/>In an interview on 03/16/25 at 3:37 pm, the Maintenance Director stated he was given the task of monitoring supplies for the laundry weekly. He created a spread sheet weekly for the laundry staff to review needed supplies. Maintenance Director said he had the vehicle insurance and registration task added to his annual checklist.<BR/>In an interview on 03/16/25 at 4:00 pm, the DON reported all the resident's representatives had been contacted regarding the temporary phone number for the facility and documented in the electronic record. The task was completed by the nurses as the Social Worker was not available. The DON said she was given the weekly responsibility to monitor supplies for nursing and is to have a meeting weekly with the CEO and COO on Thursdays.<BR/>[TRUNCATED]

Based on interview and record review the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and reports to the governing body, in that: <BR/>The facility had not had an administrator since 12/20/2024.<BR/>The governing body failed to provide the facility with enough money to keep up services including telephone service, internet service, food services, van registration/insurance, laundry services, and fire and security services.<BR/>An Immediate Jeopardy was identified on 03/14/25 at 3:52 pm. The IJ template was provided to the facility on 3/14/25 at 3:52pm. While the Immediate Jeopardy was removed on 03/19/25 at 4:36 pm, the facility remained out of compliance at a scope of widespread and a severity level of no actual harm with potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems that were put into place. <BR/>This deficient practice could place residents at risk of decreased quality of life and quality of care due to a lack of staff oversight and monitoring of care.<BR/>The findings included:<BR/> During an interview on 02/22/25 at 9:30 am, the DON said the facility had not had an Administrator since December 20, 2024. She said the only administrative staff at the facility were the DON and Human Resource Director. She said the facility had not been paying vendors. The phones/fax were not working. The staff had to utilize their own cell phones to conduct facility business. The facility is not able to send or receive faxes. A staff member bought a pre-paid cell phone, so the residents were able to call their family and vice versa. The staff went and bought milk, coffee, and hot chocolate for the residents, yesterday 02/21/25, due to the facility not having any for the residents. The ice machine was rented and was scheduled for repossession next Wednesday, 02/23/25 for non-payment. The nurses had purchased ink cartridges and paper so they can print out packets that need to be sent with the residents when they go out of the facility. Staff had purchased soap, bodywash, lotion, laundry soap, bleach, bread, gas for the van, and incontinent briefs for the residents. <BR/>Record review of invoices provided by the Human Resource Director indicated unpaid balances for the following:<BR/>1. Telephone and internet vendor invoice dated 2/7/25- Past due balance of $16,985.35. The phone was disconnected on 02/07/25. Internet was disconnected on 03/03/25.<BR/>2. Energy vendor invoice dated 2/6/25 - Past due balance of $41,159.61 with a due date of 02/21/25.<BR/>3. Water vendor invoice undated - Past due balance of $5292.92 with a due date of 03/10/25.<BR/>4. Fire and Security vendor - Past due balance of $11,497.06 as of 03/12/25 - a total of 11 invoices dated 12/26/24 - 3/3/25. Account was suspended on 03/12/25 and 10-day termination notice was to be given. <BR/>5. Ice machine vendor invoice dated 2/1/25- Past due balance of $137.12 with a due date of 2/11/25 and ice machine to be picked up on 02/26/25 if not paid. <BR/>6. Milk vendor invoice dates from 8/7/24-12/31/24 (22 invoices)- Past due balance of $1,360.59. Delivery of milk stopped 01/07/25.<BR/>7. Garbage and waste vendor invoice dated 1/20/25- Past due balance of $1,141.08. Subject to service suspension and/or container removal. <BR/>9. Pharmacy Consultant invoice dated 1/27/25- Past due balance (not disclosed on invoice). Pharmacy services to be terminated on 02/24/25. <BR/>10. Insurance vendor for van undated- Policy cancelled effective date on 02/09/25 for non-payment. Amount unknown. <BR/>In an interview on 02/22/25 at 11:15 am, [NAME] B said the facility had to substitute meals due to not having the required food for the menu. She said they attempt to make sure the residents received the correct nutritional value. She said at times, the facility did not have milk, bread, coffee, artificial sweetener. She said she had purchased ketchup, mustard, and artificial sweetener for the residents. <BR/>In an interview on 02/22/25 at 11:30 am, the Maintenance Director stated he could not purchase supplies to fix things at the facility due to the facility having a past due balance at a local hardware store, approximately $7000. The facility had a past due balance with the vendor who services the dishwasher, washing machines and dryers and could not get maintenance services. He said the hot water heater for the laundry did not work and could not get it fixed. He stated that he purchased supplies out of his own pocket to fix things at the facility for the residents. He said the facility currently owed him $125 for supplies he recently purchased, and they have never paid him. <BR/>In an interview on 02/22/25 at 01:45 PM with the Human Resource Director, she stated the facility phone was cut off on 02/07/25 and had never been turned back on. She said an anonymous staff member purchased a prepaid cell phone out of their own pocket on 02/10/25 so that the residents and their families could communicate with each other. She said the facility could not send or receive faxes. The staff were having to use their personal cell phones to conduct facility business. She said there was no acting interim and that her and the DON were covering. <BR/>In an interview on 02/22/25 at 02:10 PM, Housekeeper C stated there was no hot water in the laundry and all laundry was being washed in cold water. She said the washing machine had no chemicals and needed to be serviced. She said staff had purchased bleach and laundry soap as the facility had not been purchasing those items due to not paying their bill. <BR/>In an interview on 02/23/25 at 10:10 am, LVN D said that she bought out of her pocket soap, bodywash, lotion, ink, and paper for the printer. She said if she did not purchase these things the residents would go without.<BR/>In an interview on 02/23/25 at 10:15 am, LVN E said that she purchased ink and paper for the printer. She said when a resident was sent out of the facility, they had to print a paper packet to go with them. She said due to the facility not having phone or fax services, she had to use her own cell phone to conduct facility business. She said the facility was unable to receive faxes from doctors and hospitals. She said the residents' families had expressed to her their frustration about not being able to contact the facility or their loved ones. <BR/>In an interview on 02/23/25 at 10:50 am, the DON said she was aware the facility did not have hot water for the laundry. She said when a resident goes out of the facility, they had to print out a packet concerning the resident's information to be sent with them and the nurses had been buying the ink and paper for that. If they did not purchase the items, they would not be able to send out a packet the receiving facility was requesting. <BR/>In an interview with the DON on 02/24/25 at 10:00 am and a record review of an e-mail dated 02/17/25 at 11:05 am from the Director of Nursing to the CEO, the DON requested Supplies and Payments: We are nearly out of essential supplies, including toilet paper. Could you confirm when the outstanding bills will be settled so that we can restock as needed? Petty Cash: Do we have an estimated timeline for the release of petty cash? Several team members have been using funds to address immediate building needs. Could you advise on the status of these items? The DON said the CEO never responded to the e-mail.<BR/>In an interview on 02/24/25 at 10:45 am, the Dietary Manager stated the residents were budgeted $6 a day for breakfast, lunch, and dinner. She said that amount was not enough to purchase all the food items for the menus. As a result, the facility had to substitute items on the menu. An example for today at lunch, it called for hamburger meat but there wasn't enough money to purchase that, so it was substituted with another item on the menu that was chicken. She said she had purchased coffee, milk, artificial sweetener, and tea bags for the residents. <BR/>In an interview on 02/24/25 at 11:00 am, the Laundry Supervisor stated there was no hot water for the laundry. The resident's laundry was being washed in cold water. She said the hot water heater had been out for over a month. She said the washing machine did not have the correct chemicals to sanitize the resident's laundry properly. She said the washing machine had an error code and needed to be serviced. She said the facility had not paid the bill to the servicer and they would not come to fix it. She said staff purchased bleach and laundry detergent as the facility did not provide laundry soap or bleach. She said she had purchased laundry supplies for the residents out of her own pocket. She stated it had been reported, and maintenance was aware. <BR/>In an interview on 02/24/25 at 2:00 pm, the local Ombudsman reported it was difficult to contact the facility due to having no phone service. Individual facility staff had to be contacted. The ombudsman stated the facility staff had forwarded emails from the CEO and she stated they appeared demeaning and negative, but no specifics were provided. <BR/>In an interview on 02/24/25 at 2:54 pm, the Maintenance Director stated the facility needed a new hot water heater for the laundry. He said the facility could not get anyone to come out and look at the hot water heater due to the facility owing everyone money. He said the washing machine could not be serviced due to an unpaid bill. He said the facility could not order the proper chemicals for the washing machine due to an unpaid bill. He said the CEO was aware. <BR/>In an interview on 02/25/25 at 9:30 am, Resident #1's POA expressed her concern about the facility not having an Administrator in the building and questioned as if this caused a delay of Resident #1 being placed on hospice care requested on 02/16/25.<BR/>In an interview with the Activity Director, on 02/25/25 at 11:23 am, stated she had purchased blow-up calendars for the activity bulletin board out of her own pocket and the facility would reimburse her. She said she purchased a calendar for January and the facility would not reimburse her. She said the facility owed her $30. She said she purchased BINGO winnings for the residents such as coke, candy, and popcorn out of her own pocket. If she did not, the residents would not have any BINGO winnings.<BR/>In an interview on 02/25/25 at 12:00 pm, Facility Physician A said she was aware the facility was not paying its bills. She said it made communication very difficult as she could not send or receive faxes from the facility. She had to conduct business on staff's individual cell phones. <BR/>In an interview on 02/25/25 at 1:35 pm, CNA F stated she had purchased soap and body wash for the residents so they could have a bath. <BR/>In an interview with the CEO on 02/25/25 at 4:20 pm, he said don't worry about the utilities, they will not get shut off. I will not be able to keep up 30-day payments due to all the Medicaid in the facility and them not paying that much. He said he purchased the facility 6 months ago and it takes time to get everything switched over to a new account. He stated he was not going to pay any back service because he was not responsible for anything before, he bought the facility. He said the facility staff had not communicated to him about the food or lack of food, the best he can do is contact his purchase person. He said he was not aware the washing machine did not have hot water and needed to be serviced. The CEO said the Administrator job was posted on a job website. He said no one that had a license has applied. He said there was no interim administrator at the facility. He said the DON and Human Resource Director were running the facility. <BR/>In an interview with the CEO on 02/25/25 at 4:55 pm, he stated he signed a new contract for electric vendor. He said the water bill was only 2 months behind and that it is not late enough to be shut off so that was fine. He said the Fire and Security vendor were still within terms and would complete repairs. He said he would get payment sent out tomorrow for the ice machine vendor. He said they had a new pharmacy consultant to start 02/26/25. <BR/>In an interview with the Social Worker on 02/26/25 at 1:00 pm, she stated for the last 3 to 4 weeks, she had received calls from family members 2 to 3 times per week on her personal cell phone upset and worried due to the facility phone number not working. <BR/>In an interview on 02/28/25 at 12:30 pm, the DON said possible negative outcomes of not having an Administrator was the facility was not being run effectively, making sure there were supplies in the building, and QAPI was not being done. <BR/>In an interview on 03/07/25 at 10:00 am, the Human Resource Director said the internet was disconnected on 03/03/25 in the afternoon for non-payment. The facility did not have any internet service from 03/03/25 to the morning of 03/06/25. She stated the facility had insurance on the van and provided an invoice. <BR/>In an interview on 03/07/25 at 11:25 am, the Activity Director said she was responsible for taking residents to doctor's appointments but had not taken them in February or March due to the van not having insurance or current tags. <BR/>In an interview on 03/09/25 at 12:55 pm, the Dietary Manager said she had to substitute pot roast that was on the menu for chicken due to post roast being over $200. She said she did not have enough money to purchase the required food items on the menu. <BR/>In an interview on 03/09/25 at 1:00 pm, LVN D and LVN E stated due to the internet being down, the nurses were not able to access the computer for medication administration. They stated the residents on the Yellow [NAME] Hallway did not have TV service due to the internet being out and the facility did not purchase a hot spot for that hallway. They reported the residents did not have any coffee today and they were going to go purchase some. <BR/>In an observation on 03/09/25 at 1:15 pm, the facility van's tag displayed on the front windshield expired on 11/24. <BR/>In an interview on 03/10/25 at 1:30 pm, the DON said due to the facility having no insurance on the van, 3 residents had missed their doctors' appointments. One resident missed a cardiology and nephrology appointment; 2 residents missed an appointment with their primary doctor and 2 residents have been taken to their appointments by their family. The DON said a potential negative outcome would be the residents would not receive the proper treatment they needed. <BR/>In an interview on 03/10/25 at 10:16 am, this writer contacted the van insurance company from the invoice provided by the Human Resource Director and was informed the policy had been cancelled and was not active. <BR/>In an interview on 03/10/25 at 10:45 am, the Dietician said she was concerned about the food budget and not enough money to cover the menu. She said she was not aware the facility had been substituting the menu as frequently as they were doing. She said the facility should not be having to substitute more than 2 meals a week. <BR/>In an interview on 03/11/25 at 1:15 pm, the laundry supervisor said the facility was not using the recommended bleach or detergent for the laundry, and no alkaline was being used. One washing machine was not equipped anymore to receive chemicals and they wash items in that one that doesn't require bleach. She said it had been over 2 years since the washing machines had been serviced. She said as a result the laundry had the potential to not be sanitized properly. <BR/>In an interview on 03/11/25 at 8:24 am, Facility Physician B stated it was very difficult to communicate with the facility due to no phone or fax service. He said a resident had an appointment with him yesterday, but it was cancelled. He was not aware it was cancelled due to the facility not being able to transport residents due to having no insurance on the facility van. <BR/>In an interview on 3/12/25 at 12:00 pm, Facility Physician A said she was not aware residents missed doctor's appointments. She said the resident that missed his cardiology and nephrology appointments, those appointments would be considered important. She said the facility called her about Resident #2 that was having slight bleeding from her vaginal area: She said she asked the facility to bring the resident to her office, but was informed they could not due to no insurance on the van. She said as a result, she was going to go to the facility to evaluate her. <BR/>In an interview and record review on 3/12/25 at 10:10 am, the DON provided documentation the van insurance policy was cancelled on 02/09/25. She said on 03/08/25, Resident #3 sustained a fall. The family requested her to be sent to the ER. Stated the family took her to the ER and left. The facility had to use the facility van to pick her up from the ER, although there was no insurance on the van. <BR/>In an interview on 3/13/25 at 11:35 am, the DON said Resident #2 was being sent to the ER, via ambulance for a change in condition. She said Facility Physician #1 did not get to see her prior to being sent. <BR/>This was determined to be an Immediate Jeopardy (IJ) on 03/14/25 at 3:52 pm. The DON and Human Resource Director were notified. The DON was provided with the IJ template on 03/14/25 at 3:52 pm.<BR/>The following Plan of Removal was submitted by the facility and accepted on 03/17/25 at 12:47 pm and included: <BR/>The facility needs to take immediate action to ensure there is a plan for vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>Plan of Removal<BR/>1). Action: The Chief Executive Officer (CEO) and Managing Partner re-educated the Chief Operating Officer (COO) on the governing board responsibility to ensure management and operation of the facility; emphasis was stressed on the importance of providing oversight of facility care and services in accordance with professional standards of practice and principles, to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. The mode of education was in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administrative Management (Governing Board). The teach-back method was used to assess comprehension. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/14/2025<BR/>Responsible: Chief Executive Officer (CEO) and Managing Partner<BR/>2). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet to review and make payments or payment arrangements for: 1. Telephone and internet vendor on 03/13/2025, $10,000.00 was paid, the remaining payment was made on 3/17/25 in the amount of $7987.28, the amount told to us from the company to activate service.; 2. Insurance vendor for the facility van has been paid in the amount of $141.99 on 3/11/25. 3. Registration tags for the facility van was paid on 3.17.25 in the amount of $74.00 to County Tax Office. 4. Fire and security vendor - have confirmed that we are not on hold and have sent an email confirming so on 3.14.25. <BR/>If the internet is out, the emergency plan to ensure the staff have access to MARs and TARs will be to use the Hot spots for internet. Until Telephone and internet have been restored, while these are out, the facility will continue to use mobile phone and internet Hot Spots to communicate and document as required to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>If the hot spots are not working, the DON was educated on the need to obtain paper-printed MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available and printing abilities are not available locally. <BR/>The facility Social Worker will call each family to share the mobile phone number if/when needed. <BR/>The Activity Director will complete resident interviews to identify residents affected by phone interruption and share with them the availability of mobile phone if needed to communicate to people outside the facility. <BR/>The facility's Human Resource Director will contact the facility's vendors to share the phone number if/when required. <BR/>To prevent future service interruptions, the Chief Executive Officer (CEO) and Chief Operating Officer (COO) will meet monthly to review the facility's outstanding invoices and ensure vendors to be paid timely, so services are not rescinded, and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO)<BR/>3). Action: The Director of Nursing (DON) will complete a Medication Error Form for each of the identified 11 residents in which medication were given at a different time or omission occurred; the form includes communicating with the medical provider, the responsible party, facility management and pharmacist consultant, in addition to type of error and reason for error (Examples of medications errors include: <BR/>a. Omission - a drug is ordered but not administered; <BR/>b. Unauthorized drug - a drug is administered without a physician's order; <BR/>c. Wrong dose (e.g., Dilantin 12 mL ordered, Dilantin 2 mL given); <BR/>d. Wrong route of administration (e.g., ear drops given in eye); <BR/>e. Wrong dosage form (e.g., liquid ordered, capsule given); <BR/>f. Wrong drug (e.g., vibramycin ordered, vancomycin given); <BR/>g. Wrong time; <BR/>and the corrective action taken and measures to prevent similar error(s) recurrence. The Director of Nursing reviewed the other resident's Medication Administration Records (MARs) and did not reveal further discrepancies or errors. The Chief Nursing Officer (CNO) will confirm completion of Medication Error Forms. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) <BR/>4). Action: The Director of Nursing (DON) will re-educate nurses (RN/s/LVNs) and certified medication aides (CMAs) on the facility's policies: Administering Medications and Medication Errors - the different types and immediate actions to take to prevent adverse consequences. The mode of education will be in the form of a one-on-one meeting and memo - a copy of the Policy and Procedures entitled Administering Medications and Adverse Consequences and Medications Errors. <BR/>The teach-back method was used to assess comprehension. To evaluate further understanding, the Director of Nursing will complete a weekly Medication Pass Observation to each nurse and medication aide for the next 4 weeks and quarterly thereafter. <BR/>Education is done as well regarding obtaining MARs and TARs from the pharmacy to be delivered on the medication run if no internet is available. Facility will have the hotspots that were purchased available to use if the main internet is to stop working until pharmacy deliver paper MARS and TARs. In the absence of the DON, the Chief Nursing Officer (CNO) will request paper-printed MARs and TARs from the pharmacy vendor. <BR/>Start Date: 03/14/2025.<BR/>Completion Date: 03/17/2025<BR/>Responsible: Director of Nursing (DON), Chief Nursing Officer (CNO) <BR/>5). Action: The Chief Executive Officer (CEO) and Chief Operating Officer (COO) will post the facility's administrator's vacant position and continue active recruitment to fill the facility administrator's vacant position. With a sign on bonus posted on 3.15.25. <BR/>Until the position is filled, all items needed for resident care are to be communicated to the facility's Director of Nursing (DON), as for ancillary services, such as dietary and environmental services, are to be communicated to the facility's Human Resource Director, <BR/>Both - DON and HR Director will participate in a conference call with the Chief Executive Officer (CEO) and Chief Operating Officer (COO) weekly on Thursdays at 11 am that arrangements can be made to ensure there is a plan for vendors to be paid timely, so services are not rescinded and residents have the services required for the highest practicable physical, mental, and psychosocial well-being of each resident. <BR/>This conference call will continue weekly with the new administrator once onboarded and the weekly minutes reviewed monthly during the facility's monthly QAPI to determine if changes in needed supplies, their quantity and/or delivery dates are required in order to be altered to ensure timely ordering and delivery. <BR/>Items to be reviewed weekly will include food needed for the menu, milk, coffee, tea, artificial sweetener, hot chocolate, snacks, condiments, soap, shampoo, conditioner, lotion, laundry soap, bleach, ink for printers, paper for printers, chemicals for laundry, and gas for the van, along with routine service needs/requests for the dishwasher, washing machine, and dryer. <BR/>Staff will be educated on 3.17.25 by HR that when a facility or resident need related to supplies and vendor payments to communicate with HR who will review supply and ensure supply is replenished before the item runs out. <BR/>Laundry staff were educated by HR that when chemical supply becomes low to notify HR who will ensure supply is replenished prior to running out. <BR/>Maintenance director will be educated on 3.17.25 to monitor once a week the supply visually and discuss with staff on site the supply level to see if additional chemicals need to be ordered and will communicate to HR. <BR/>Department heads will be educated on 3.17.25 by HR that each department head will monitor its supplies once a week and communicate to HR any items needed. <BR/>Maintenance director will do housekeeping and laundry, DON will do nursing, HR will do office supplies.<BR/>Start Date: 03/14/2025.<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA)<BR/>6). Action: Staff will be reimbursed for their out-of-pocket expenses per usual procedures, including submitting reimbursement requests and receipts. The Human Resource Director (HR) will instruct line staff not to purchase items for the facility in the absence of the facility administrator; all purchases will be made by the facility administrator and/or the HR Director after the weekly Thursday conference call. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA)<BR/>7). Action: Annual van registration and insurance will be added to the annual maintenance checklist to ensure timely registration renewal; The facility administrator will review the yearly checklist during QAPI to ensure timely review. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Maintenance Director and Facility Administrator<BR/>8). Action: An ad-hoc QAPI meeting will be held, and the facility Medical Director will be notified of the deficient practice and the approved removal plan. Action items will be reviewed monthly during the QAPI meetings for the next 3 months and ongoing as needed. Meeting minutes will be taken and maintained for 12 months. <BR/>Start Date: 03/14/2025<BR/>Completion Date: 03/17/2025<BR/>Responsible: Chief Executive Officer (CEO) and Chief Operating Officer (COO), Director of Nursing (DON), Human Resource Director (HR), and Administrator (LNFA).<BR/>Verification:<BR/>Record review of receipt payment dated 01/28/25 to Water Department dated 1/28/25 for $1,579.21.<BR/>Record review of receipt payment dated 01/29/25 reflected $1,141.08 to garbage and waste. <BR/>Record review of receipt payment dated 02/20/25 to Water Department for $1,579.21<BR/>Record review of receipt dated 02/25/25 reflected $286.86 for ice machine payment. <BR/>Observation on 2/27/25 at 3:46 pm revealed the fire sprinkler system with tag noted to have been serviced and working. <BR/>In an Interview on 3/7/25 at 11:20am, Resident #1 stated she gets all of her medications as far as she knows and had no concerns. She stated she has her own cell phone so not affected. <BR/>In an Interview on 03/7/25 at 11:22am, Resident #9 stated he gets all of his medications and has no concerns with care. <BR/>In an observation on 03/7/25 at 11:55am, 9 residents were in the dining room. The menu was followed, and no food concerns were noted. <BR/>In an observation on 03/10/25 at 9:20am, the kitchen had 7 days of non-perishable food and 3 days of perishable and no concerns were noted. <BR/>In an Interview on 03/14/25 at 3:17pm, Resident # 11 stated she has access to her visitors and them to her and no concerns of anything about her care at the facility. <BR/>In an Interview on 03/14/25 at 3:27pm, Resident #13 and Resident #10 stated they have access to their visitors and have no issues or concerns with their care and get their doctor appointments. <BR/>A record review of the in-service titled Governing Responsibility dated 03/15/25 and signed by the CEO and COO reflected the importance of paying bills timely and the expectation of them to meet weekly on Thursdays to ensure bills are paid timely. <BR/>Observation on 03/15/25 at 12:23pm revealed 9 residents in the dining room with no portion concerns. Food appears palatable and displayed well. <BR/>Record review of the maintenance checklist on 03/16/25 at 3:15 pm revealed vehicle registration and insurance renewal was added annually with a next review date of March 14th, 2025.<BR/>Record review of Medication Pass Observations for 5 nurses dated 3/16/25-3/19/25 for med pass observation by DON reflected medication pass observations were completed by the DON of her nurses.<BR/>In an interview on 03/16/25 at 12:16 pm, the COO confirmed she had been in-serviced concerning bills must be paid in a timely manner and she is to meet weekly with the CEO and Human Resource Director weekly to review. <BR/>In an interview on 03/16/25 at 1:27 pm, LVN E stated she had received 1:1 instruction from the DON on how to administer medications during an internet outage and how to obtain a copy of the paper MAR if one is not available. She said she had completed 2 in-services regarding medication administration and medication errors. <BR/>In an interview and record review on 03/16/25 at 1:59 pm, the Human Resource Director stated she purchased additional data for the hot spots early today and provided a copy of the receipt dated 03/16/25 that indicated additional data purchased. The Human Resource Director provided the training sheet that was completed with the department heads on the process of communicating supply needs to be completed weekly. Human Resource Director said that 1:1 training with the department heads had been completed and they reviewed the process of communication for supply needs. She said she is to have a meeting weekly, on Thursdays, with the CEO and COO concerning supply needs of the facility. <BR/>In an interview on 03/16/25 at 2:13 pm, the Human Resource Director confirmed weekly meetings were to be held with the CEO and COO on Thursdays to discuss billing and concerns. <BR/>Record review/Observation on 03/16/25 at 2:45 pm of job website revealed the Administrator's position was posted for a salary up to $50,000 yearly with a sign on bonus. <BR/>In an interview on 03/16/25 at 3:37 pm, the Maintenance Director stated he was given the task of monitoring supplies for the laundry weekly. He created a spread sheet weekly for the laundry staff to review needed supplies. Maintenance Director said he had the vehicle insurance and registration task added to his annual checklist.<BR/>In an interview on 03/16/25 at 4:00 pm, the DON reported all the resident's representatives had been contacted regarding the temporary phone number for the facility and documented in the electronic record. The task[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement appropriate plans of<BR/>action to correct identified quality deficiencies and to regularly review and analyze data, including data collected under the QAPI program and act on available data to make improvements for one of one facility.<BR/>The facility failed to follow their Plan of Correction (POC) dated 1/3/25 in utilizing a pool of RNs from neighboring/sister communities to ensure RN coverage at least 8 consecutive hours/day 7 days/week for 28 days since the dated POC. <BR/>The facility failed to follow their POC to review weekly RN coverage in SOC (Standard of Care meeting) by the Administrator and DON to ensure appropriate RN coverage is arranged and provided by the facility or services of facilities or RN telehealth audio and visual capabilities were arranged. <BR/>The facility failed to follow their POC to discuss the quality deficiencies in monthly QAPI meetings for 3 months. <BR/>This failure placed the residents at risk of oversight and management of the residents' healthcare needs and in managing and monitoring of the direct care staff which would ultimately affect resident care.<BR/>Findings included:<BR/>Record review of the POC dated 1/3/25 revealed the facility created a pool of Registered Nurses from neighboring/sister communities to ensure the human resources need to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The POC revealed weekly RN staffing needs would be reviewed weekly in SOC by the Administrator and DON to ensure appropriate RN coverage was arranged or services of facility RN telehealth audio and visual capabilities were arranged. Systematic failures will be discussed monthly in QAPI for 3 months to ensure effectiveness of systematic approaches. <BR/>In an interview on 02/23/25 at 10:50 am, the DON said she was on medical leave and returned to the facility on [DATE]. She said during the time she was off, there was no RN coverage for the building. She said she only works Monday-Friday so there is no RN in the facility on the weekends, but staff can call her if needed. <BR/>In an interview dated 3/13/25 at 10:30 am with the Human Resource Director which provided QAPI notes, stated the Medical Director and Administrator did not attend the meeting. The Human Resource Director stated we talked about it [RN coverage] but there is nothing we can do about it. There was no meeting in February. <BR/>In a follow-up interview dated 3/15/25 at 2:25pm with the Human Resource Director, she stated the facility did have a pool with their sister facility, but that facility had several RNs quit. The Human Resource Director stated she had RN positions posted on a job website and stated she would provide the postings. These postings were not provided prior to exit. HR stated she monitored the coverage and reported to the CEO and COO. One QAPI meeting was held since 1/3/25 and that was on 1/24/25. The Human Resource Director further stated the February QAPI meeting was cancelled because staff had to cover because COVID was in the building. The March QAPI meeting is scheduled for next week. <BR/>In an interview dated 3/15/25 at 2:02pm with the DON stated there is no pool of RNs. The SOC was not happening weekly because there is no Administrator. We [facility] used to have telehealth but that was before Thanksgiving. We are encouraged not to use it and staff don't know how to use it . The DON stated during the meeting on 1/24/25 that there was no discussion of RN coverage, and DON has no knowledge of RN positions posted online or anywhere. <BR/>Record review of the SOC Meeting dated 1/24/25 provided by Human Resource Director as QAPI meeting minutes revealed DON, Human Resource Director, Activity Director, Maintenance Supervisor and Social Worker attended meeting. Meeting minutes revealed Resident Level Quality Measure Report run dated 2/9/25 for period of 1/1/25-1/31/25. No other information. No information regarding RN coverage or next QAPI meeting date. <BR/>In a record review and interview on 02/23/25 at 10:00 am, the Human Resource Director provided the Nurse Staffing Information from January 1, 2025, to February 21, 2025. It revealed there was no RN coverage for dates of 01/01/25, 01/02/25, 01/03/25, 01/04/25, 01/05/25, 01/06/25, 01/07/25, 01/08/25, 01/09/25, 01/10/25, 01/11/25, 01/12/25, 01/13/25, 01/14/25, 01/15/25, 01/16/25, 01/17/25, 01/18/25, 01/19/25, 01/20/25, 01/26/25, 01/27/25, 02/01/25, 02/02/25, 02/08/25, 02/09/25, 02/15/25, and 02/16/25, 03/01/25 and 03/03/25. The Human Resource Director confirmed there was no RN coverage for the dates. She said the DON was out on medical leave and returned on 01/21/25. The DON works Monday-Friday. There is no RN coverage for the weekends , but staff can call the DON if needed. <BR/>Record review of Quality Assurance and Improvement Committee policy undated revealed The committee will meet monthly .The committee shall track the progress of any plans of correction. <BR/>Record review of indeed jobs revealed Administrator and CNA job posting for this facility but no RN posting located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 2 residents (Resident #16) whose care was reviewed in that:<BR/>Resident #16's indwelling urinary catheter bag was not covered.<BR/>These deficient practices could affect residents who had indwelling urinary catheters by contributing to poor self-esteem, lack of information, and unmet needs.<BR/>The findings were:<BR/>Record review of Resident #16's electronic face dated 05/01/2024 sheet revealed he was a [AGE] year-old male that was re-admitted to the facility on [DATE] with a diagnosis that included neuromuscular dysfunction of the bladder (unable to control bladder due to nerve damage) and prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, which includes frequent urination, weak urine stream and inability to urinate).<BR/>Record review of Resident #16's physician's electronic consolidated orders for April 2024 revealed the following: <BR/>Catheter care every shift with soap and water ordered 08/20/2023.<BR/>Access Foley catheter for proper function and ensure proper placement of catheter bag every shift for Foley catheter care every shift related to urinary tract infection ordered 08/20/2023.<BR/>Check for proper function in proper placement of tubing and bag ordered 08/20/2023. <BR/>Record review of Resident #16's Comprehensive Care plan dated 02/09/2024 revealed the following:<BR/>Focus: Resident #16 has long term indwelling Foley catheter: neurogenic bladder, history of long-term catheter use and ongoing follow up by your urologist.<BR/>Goal: Resident #16 will remain free from catheter related trauma through review date.<BR/>Interventions/Tasks: Resident #16 has a Foley catheter. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Foley catheter's privacy bag to Foley catheter drainage bag.<BR/>In an observation and interview on 04/28/2024 at 10:51 AM with Resident #16 revealed a catheter bag hanging from the Resident #16's chair without a privacy bag. The resident's door was open, and the bag was viewable from the hall. He stated that they forget to cover it and that he did not want to make a fuss about it. He stated he would like it covered and that he had a bag to cover it, it was just not on it. <BR/>In an observation on 04/29/2024 at 2:30 PM of Resident #16 revealed a catheter bag hanging from the Resident #16's chair without a privacy bag. The resident's door was open, and the bag was viewable from the hall. <BR/>In an interview on 04/29/2024 at 3:00 PM the LVN A revealed that she was not sure why the Resident #16's catheter bag was not covered. She said that she knew it should be covered and she would talk to her DON about it.<BR/>In an interview on 04/30/2024 at 9:45 AM the DON said that the catheter bag should always be covered with a privacy bag if it was care planned and that Resident #16's care plan stated to have a privacy bag covering the catheter bag. She stated that the failure could place residents at risk for dignity issues if it is not covered. <BR/>In an interview on 04/30/2024 at 9:50 AM with the DON, a copy of the facilities policy and procedures covering dignity and catheter bag covers was requested and was not received at the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure personal privacy by securing signed consents for the use of security cameras for 1 of 2 (Resident #28) residents reviewed for privacy. <BR/>The facility had operational security cameras in a resident's room without obtaining consents from the resident who occupied the room.<BR/>This failure could place residents at risk of embarrassment, and reduction of the self-esteem and self-worth by not being provided desired privacy during personal care or meetings with family or physicians. <BR/>Findings included: <BR/>Record review of Resident #28''s face sheet dated 05/01/2024, revealed that she was [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included the following: bipolar with psychotic features (episodes of mood swings ranging from depressive lows to manic highs with disconnection from reality), Depressive episodes (periods of feeling low), and venous insufficiency (improper functioning of the vein valves in the legs). <BR/>Record review of Resident #28's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 09 indicating moderate cognitive impairment. Section GG revealed her Activities of Daily Living were coded as Independent.<BR/>Record review of Resident #28's Care Plan dated 03/05/2024 revealed there was no documentation for Authorized Electronic Monitoring.<BR/>Record review of Resident #28's Clinical Records from 08/28/2023 to 05/01/2024 revealed there was no documentation of a signed consent for Authorized Electronic Monitoring by Resident #28. <BR/>In an interview and observation on 04/28/2024 at 11:08 AM, Resident #28 was sitting in her room watching a TV in her recliner while wearing a bathrobe to cover her body, she stated it was for privacy. She pointed out the camera that was not pointed at her bed, but that was pointed towards the other side of her room, which was not occupied. She stated she did not want it. She said it was from the elderly lady that was here, but she had been gone awhile. She was wanting the camera out and to have her own privacy. There was not a sign placed in the room or outside of the resident's room that reflected or alerted that the resident's room was being electronically monitored. <BR/>In an interview on 05/01/2024 at 11:25 AM, the DON revealed that the camera that was placed in Resident #28's room was a facility camera that was originally placed for the resident that was in the room prior to her, she was unsure when that resident left or who it was. She stated that they must have forgotten to remove the camera. She stated that she did not realize the resident had not agreed or consented to place the camera in the room. She said the camera could only be viewed from the nurse's station and it was not being recorded, it was only a live feed. She stated that having the camera without proper consent was a privacy issue.<BR/>Record review of the policy and procedure, titled; Authorized Electronic Monitoring dated December 2018, revealed the following:<BR/>Policy Interpretation and implementation:<BR/>1) <BR/>the resident, resident representative, or legal representative is to complete the request for authorized electronic monitoring form.<BR/>2) <BR/>If the resident has a roommate, consent must be obtained, using the consent to authorize electronic monitoring form.<BR/>3) <BR/>Anyone conducting AEM must post and maintain a conspicuous notice at the entrance of the residence room period the notice must state that electronic monitoring device is in use.<BR/>4) <BR/>If I convert electronic monitoring device is discovered by facility, the resident, the resident's representative, or legal representation must meet all requirements for a EM before monitoring can continue.<BR/>5) <BR/>Prior to installation the AEM device must be approved by the executive director. The electronic monitoring device is video only and cannot include audio recording, two-way audio, microphone, or interactive audio components.<BR/>The facility used the DADS Form 0065 as part of their policy. The form was dated November 2004 (Form 0065 Texas Department of Aging and Disability Services) revealed the following:<BR/>Information Regarding Authorized Electronic Monitoring for Nursing Facilities <BR/>A resident's guardian or legal representative is entitled to conduct authorized electronic monitoring (AEM) under subchapter R, Chapter 242, Health and Safety Code. To request AEM, you, your guardian or legal representative must: <BR/>1. Complete the Request for Authorized Electronic Monitoring form. <BR/>2. Obtain the consent of other residents, if any, in your room, using the Consent to Authorized Electronic Monitoring form and <BR/>3. Give the form(s) to the facility administrator or designee.<BR/>Record review of the Consent by Roommate form 0067 for Authorized Electronic Monitoring, Texas Department of Aging and Disability dated January 2015-E revealed it was to be signed by roommates of residents with authorized electronic monitoring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 1 of 2 residents (Resident #16) reviewed for urinary catheters in that:<BR/>The facility failed to ensure that Resident #16's urinary catheter type and size was documented in the Physician order. <BR/>The facility failed to ensure Resident #16's urinary catheter was irrigated as ordered.<BR/>The facility failed to ensure Resident #16's urinary catheter care, every shift as ordered was completed.<BR/>The facility failed to ensure Resident #16's urinary catheter output every shift as ordered was completed.<BR/>This deficient practice could affect residents who had urinary catheters and could result in trauma or urinary tract infections.<BR/>Findings included:<BR/>Record review of Resident #16's electronic Face Sheet dated 05/01/2024 revealed he was a [AGE] year-old male that was re-admitted to the facility on [DATE] with a diagnosis that included neuromuscular dysfunction of the bladder (unable to control bladder due to nerve damage), and prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate, which includes frequent urination, weak urine stream and inability to urinate). <BR/>Record review of Resident #16's Quarterly MDS dated [DATE] revealed the following:<BR/>*Section C- Cognitive Patterns revealed a BIMS score of 10 (moderate cognitive impairment). <BR/>*Section H-Indwelling Catheter revealed that the resident does have an indwelling catheter. <BR/>Record review of Resident #16's Comprehensive Care plan dated 02/09/2024 revealed the following:<BR/>Focus: Resident #16 has long term indwelling Foley catheter: neurogenic bladder, history of long-term catheter use, and ongoing follow up by your urologist.<BR/>Goal: resident #16 will remain free from catheter related trauma through review date.<BR/>Interventions/Tasks: Resident #16 has a Foley catheter. Position catheter bag and tubing below the level of the bladder and away from the entrance room door. Foley catheter's privacy bag to Foley catheter drainage bag.<BR/>Record review of Resident #16's physician's electronic consolidated orders for April 2024 revealed the following: <BR/>-Catheter care every shift with soap and water. Access Foley catheter for proper function and ensure proper placement of catheter bag every shift for Foley catheter care every shift related to urinary tract infection, site not specific. Check for proper function in proper placement of tubing and bag. To be completed on ordered times of 6:00 AM, 2:00 PM, and 8:00 PM, ordered 08/20/2023.<BR/>-Change Foley catheter tubing bag every month on the 10th and PRN for malfunction dislodgment. Document in nursing notes catheter change every night shift starting on the 10th and ending on the 10th of every month, ordered 08/20/2023. <BR/>-Irrigate Foley catheter with 30 milliliters of normal saline irrigation, every week and period every evening shift every Thursday at ordered times of 6:00 AM, 2:00 PM and 8:00 PM, ordered 08/20/2023.<BR/>-Foley catheter output every shift, document amount, urine observation to include color and sediment, ordered times of 6:00 AM, 2:00 PM, and 8:00 PM, ordered 08/20/2023. <BR/>Record review of Resident #16's April 2024 TAR revealed the following orders:<BR/>-To change foley catheter bag and tubing every month on the 10th. Document in Nursing Notes. <BR/>Documentation in Nursing Notes was never on April 10, 2024.<BR/>-Urinary catheter as ordered weekly on Thursday's evening shift was not irrigated on Thursday April 18, 2024's evening shift. <BR/>-Urinary catheter care, every shift at 6:00 AM, 2:00 PM and 8:00PM, <BR/>was not completed as ordered on the following dates and times: <BR/>April 3, 2024, at 2:00 PM<BR/>April 19, 2024, at 2:00 PM<BR/>April 30, 2024, at 6:00 AM<BR/>April 1, 2024, at 2:00 PM<BR/>April 3, 2024, at 2:00 PM<BR/>April 5, 2024, at 6:00 AM and 2:00 PM<BR/>April 9, 2024, at 6:00 AM<BR/>April 10, 2024, at 2:00 PM<BR/>April 12, 2024, at 2:00 PM<BR/>April 13, 2024, at 6:00 AM<BR/>April 14, 2024, at 2:00 PM<BR/>April 17, 2024, at 6:00 AM<BR/>April 18, 2024, at 2:00 PM<BR/>April 19, 2024, at 2:00 PM<BR/>April 23, 2024, at 2:00 PM<BR/>April 25, 2024, at 6:00 AM<BR/>April 29, 2024, at 6:00 Am and 2:00 PM<BR/>April 30, 2024, at 6:00 AM<BR/>In an observation and interview on 04/28/2024 at 10:51 AM, Resident #16 was sitting in his chair watching TV. He stated that his catheter had been bugging him at times. He stated that he felt pressure and uncomfortable at times. He stated it had been like this since it was changed, but he was unsure of the exact date. He stated there were times they did not flush it or clean it; he was unsure how often. He stated that he calls his family member often. The catheter was secured to his leg. On the urine drainage port, it reflects an 18 French. He had clear yellow urine in the drainage bag. <BR/>In a telephone interview on 04/30/2024 at 2:33 PM, Family Member-A revealed that PA-A and MD-A were his attending physicians that seen him regularly. She stated that, Resident #16 called her every night to tell her what all was going on and that he complained periodically about his catheter care not being performed. She stated that she came up to the facility last week to talk to the Administrator, but he was not there. She was wanting to discuss how Resident #16's catheter was irritating him and that she wanted it looked at. She stated that she did not feel like it was checked daily and that she or a family member came to the facility every day to check on the resident. <BR/>In a telephone interview on 04/30/2024 at 3:16 PM, PA-A who was the PA for MD-A stated that Resident #16 has a catheter change ordered every 30 days as standard and PRN, as needed. Expectations were to be changed as ordered or for them to be called back and updated if it was not changed. She stated a 16 French was ordered for the resident, he should not have an 18 French. She said that he was seeing MD-B before he came into the facility and then the facility took over the catheter care and orders. The MD-A was unavailable for interview and referred the call to the PA-A, who had been treating him under MD-A. <BR/>In an interview, on 05/01/2024 at 11:00 AM, the DON revealed that the orders were not documented correctly, and she would correct it and that it should have included the size and type on the order. She revealed that the catheter had been changed as ordered. She stated that the catheter instructions for care, irrigation, size, and output should be completed accurately and documented. She revealed this failure could result in the resident getting an infection such as a urinary tract infection. She revealed that she had updated the orders since they failed to enter the catheter size order correctly. <BR/>A record review of the facility's policy Bowel and Bladder Continence Management dated 05/14.<BR/>Indwelling Catheter Evaluation and Management<BR/>Procedure:<BR/>3. Obtain physician order to include: medical diagnosis, justification for use, length of time for use, catheter type and size.<BR/>6. Utilize the softest and narrowest catheter to possible to effectively drain the bladder.<BR/>- Do not treat leakage around the catheter by utilizing a larger catheter, and less medically justified. Address other factors for leakage including, but not limited to- bladder spasm, Constipation, improper catheter positioning.<BR/>9. Record any catheter related problems.<BR/>11. Monitor for catheter for need for replacement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 3 residents (#1, #5 and #11) reviewed for respiratory care. <BR/>A. The facility failed to ensure oxygen tubing for Residents #1, #5, and #11 were changed weekly. <BR/>B. The facility failed to ensure Resident #11's nasal cannula was kept in a bag while not in use. <BR/>These failures could place residents at risk for infections and transmission of communicable diseases. <BR/>Findings included: <BR/>Resident #1<BR/>Record review of Resident #1's Face Sheet, dated 03/14/2023, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included hypertension (high blood pressure), hypoxemia low blood oxygen level, pneumonia unspecified organism moderate protein calorie malnutrition (a deficient nutritional state caused due to lack of protein and calories), and osteoporosis with pathological fracture ( brittle bones with a fracture caused by this bone disease), and repeated falls.<BR/>Record review of Resident #1's MDS Annual Assessment, dated 02/23/2023 revealed a BIMS score of 15 (cognitively intact). Section O: Respiratory Treatments was marked for Oxygen Therapy. <BR/>In an observation and interview on 03/12/2023 at 10:31 AM during initial rounds, Resident #1 was lying in her bed receiving oxygen via nasal cannula at 2 liters per minute. Her oxygen tubing was not dated. The disposable humidifier bottle was dated 02/08/2023. The resident stated she did not remember when her oxygen tubing was changed. She stated the nurse came in and she is supposed to bring her another water bottle.<BR/>In an observation on 03/12/2023 at 3:00 PM Resident #1's nasal cannula was not dated. The humidifier bottle was dated 02/08/23.<BR/>In an observation on 3/13/23 at 10:51 AM Resident #1's nasal cannula was still not dated. The humidifier bottle was dated 02/12/23. <BR/>Resident #5<BR/>Record review of Resident #5's Face Sheet, dated 03/14/2023 revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnosis include dementia; acute kidney failure; intracranial injury without loss of consciousness (a head injury causing damage to the brain by external force or mechanism); depressive episodes, anxiety disorder, and chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). <BR/>Record review of Resident #5's MDS Quarterly assessment, dated 02/07/2023 revealed a BIMS score of 12 (moderate impaired). Section I: Active diagnosis revealed asthma, chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. <BR/>In an observation and interview on 03/12/23 at 10:31 AM during initial rounds, Resident #5 was sitting in her recliner receiving oxygen via nasal cannula at 2 liters per minute. Her oxygen tubing was not dated. She stated she was good, but the resident failed to answer any questions regarding whether her oxygen tubing had been changed. <BR/>In an observation on 03/12/2023 at 2:17 PM, Resident #5's oxygen tubing was not dated. <BR/>Record review of Resident #5's electronic Physician Orders, accessed on 03/12/2023 revealed an order for Oxygen at 2 liters per minute via nasal cannula. Start 10/09/2022. The Physician Orders failed to have any information regarding when oxygen tubing needed to be changed.<BR/>Record review of Resident #5's Care Plan, last revised on 02/07/2023, revealed a care plan for [Resident #5] has COPD (obstructive pulmonary disease) - Oxygen Dependent. The Care Plan failed to have an intervention regarding when oxygen tubing needed to be changed.<BR/>Resident #11<BR/>Record review of Resident #11's Face Sheet, dated 03/15/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included diabetes, chronic kidney disease, hypertension (high blood pressure), and repeated falls.<BR/>Record review of Resident #11's MDS quarterly assessment, dated 12/27/2022 revealed a BIMS score of 13 (cognitively intact and was receiving hospice services and oxygen therapy).<BR/>Record review of Resident #11's care plan dated revised 03/14/2023 revealed he received oxygen at 2-3 liters/min via nasal cannula continuously related to respiratory illness and disease. Goal: Resident will have no signs or symptoms of poor oxygen absorption through the review date.<BR/>Record review of Resident #11's physician orders dated 03/01/2023 revealed the following: Change oxygen tubing weekly on Sunday. Change oxygen water when empty.<BR/>In an observation and interview on 03/12/2023 at 10:23 AM Resident #11's nasal cannula was not dated. The humidifier bottle was not dated. The O2 tubing was hanging over the railing of the bed uncovered. The resident stated he did not remember when it had been changed.<BR/>In an observation on 03/13/2023 at 2:38 PM Resident #11 was sitting asleep in his chair. His O2 tubing was not dated. It was uncovered and was hanging over the oxygen concentrator with the nose prongs about an inch from the floor. <BR/>In an Interview on 03/13/2023 at 02:45 PM with the Interim DON (who was also the charge nurse on this date) stated oxygen tubing was changed weekly based on the resident's orders, or as needed if they become contaminated or occluded. The interim DON stated oxygen tubing and the humidifier bottle should be dated to indicate when they were changed. If they were not labeled, she stated she would discard them and replace it with a new nasal cannula. She stated she preferred staff do this because you could never be sure of another person's infection control practices. She stated tubing should be stored in a plastic bag when not in use to prevent cross contamination and infection. <BR/>Record review of the facility policy Respiratory Equipment Change Schedule, dated 01/13, revealed the following [in part]:<BR/>Purpose: Routine cleaning and/or changing of disposable respiratory equipment is done to prevent nosocomial infections.<BR/>Procedure: Product: Oxygen delivery devices (no-aerosol producing) Ex: venturi masks, nasal cannulas, oxygen supply tubing.<BR/>Record review of the facility policy Oxygen Administration, Nasal Cannula, dated as revised on 06/15/2021, revealed the following [in part]: <BR/>Purpose: To provide the resident/patient with enhanced oxygen concentration of inspired room air.<BR/>Procedure: 7. Date disposable supplies upon opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication regimen, in that:<BR/>Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, a narcotic medication, and a diuretic medication on 2/29/2024 at approximately 10:20 AM. Resident #1 became unresponsive on 2/29/2024 at 11:15 AM and was transported by ambulance to the local hospital emergency room. Resident #1 was admitted to the hospital on [DATE] with a diagnosis of hypotension (abnormally low blood pressure) due to drugs.<BR/>An Immediate Jeopardy was identified on 03/07/2024. The Immediate Jeopardy Template was provided to the Administrator on 03/07/2024 at 5:15 PM. While the Immediate Jeopardy was removed on 03/08/2024 at 6:55 PM, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. <BR/>This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death.<BR/>The findings included:<BR/>Review of Resident #1's admission Record, dated 3/01/2024, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident had an Out of Hospital DNR Code Status. The resident's diagnoses included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), pneumonia, urinary tract infection, congestive heart failure (the heart's main pumping chamber - left ventricle - becomes stiff and unable to fill properly), hypertension (high blood pressure), dementia (impaired brain function and thought processes), and hypothyroidism (thyroid disorder). <BR/>Review of Resident #1's comprehensive care plan, dated 2/28/2024 revealed it addressed hypertension related to congestive heart failure. The care plan approaches included to give anti-hypertensive medications at ordered and monitor for side effects such as orthostatic hypotension and increased heart rate.<BR/>Review of Resident #1's Medication Administration Record, dated February 2024, revealed LVN A documented a blood pressure of 121/75 on the morning of 2/29/2024. The record documented Resident #1's medication orders included:<BR/>Cozaar 50 mg daily (anti-hypertensive medication)<BR/>Metoprolol succinate 12.5 mg daily (anti-hypertensive medication)<BR/>Furosemide 10 mg daily (diuretic medication)<BR/>Tramadol 50 mg daily at bedtime for pain (opioid pain relief medication).<BR/>Review of the Medication Incident Report, dated 2/29/2024 revealed the DON documented Resident #1 was given the wrong medication by LVN A, who immediately reported she had given Resident #1 another resident's medications by mistake. The resident's physician was called at 10:33 AM and informed Resident #1 received anti-hypertensives and a narcotic. Orders were received to monitor the resident's BP and monitor her closely. At approximately 11:15 AM, LVN A reported Resident #1 was unconscious and non-verbal. The DON found Resident #1 unconscious in the dining area and gave her a sternal rub and called her name in a loud voice. The DON listened to her heart and lung sounds and none were noted. Resident #1 was placed on a mat on the floor, oxygen was applied, and 911 was called. The DON continued sternal rubs and called the resident's name. EMS arrived just as Resident #1 stated she was awake and could hear the DON. The DON assisted EMS with putting Resident #1 onto the gurney. The physician was called at 11:24 AM and was notified Resident #1 was transported to the local hospital. The family was notified by LVN A and LVN B. The DON documented the resident had been alert and oriented that morning.<BR/>Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:33 AM revealed LVN A documented the resident's family and physician were contacted about the wrong medication being given.<BR/>Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:48 AM revealed LVN A documented the resident's physician was called at 10:33 AM and he stated to monitor the resident's BP and monitor the resident closely. The LVN documented she went to check the resident's BP at 11:15 AM in the dining room and found the resident unresponsive. The LVN got the DON. The resident was laid on the floor and oxygen was applied. The DON did sternal rubs and 911 was called. The resident left with EMS. The physician and family were notified.<BR/>Review of Resident #1's hospital medical record, dated 2/29/2024, revealed the following [in part]:<BR/>History of Present Illness<BR/>Patient was given another resident's medications that included:<BR/>Amlodipine 10 mg (blood pressure lowering - calcium channel blocker)<BR/>Carvedilol 25 mg (blood pressure lowering - alpha-beta blocker)<BR/>Isosorbide mononitrate ER (extended release) 60 mg (nitrate - blood vessel widening, preventative for chest pain)<BR/>Norco 7.5 mg (Hydrocodone - opioid for pain relief)<BR/>Spironolactone 25 mg (diuretic - fluid reduction)<BR/>She then went unresponsive with no pulse and no breaths. By the time EMS arrives she was breathing on her own and had a pulse. She was found to be hypotensive and brought in. <BR/>Clinical Impression<BR/>Hypotension due to drugs.<BR/>Chronic anemia associated with chronic disease.<BR/>Triage: 2/29/24 at 11:20 AM - BP 59/24.<BR/>In an interview on 3/01//2024 at 2:18 PM, the DON stated LVN A had made a medication error the prior day on 2/29/2024. She stated LVN A got distracted when someone was talking to her and she grabbed the wrong medication cup and gave Resident #1 the medications for another resident. She stated the medications included a blood pressure pill and Norco. The DON stated LVN A immediately told her at 10:30 AM. She stated LVN A realized what she had done when she did it. The DON stated she called Resident #1's physician at 10:33 AM, and he asked what BP medication Resident #1 had been given, which was Isosorbide 60 mg. The physician stated that was a high amount of blood pressure medication for her and to monitor her BP. The DON stated at 11:15 AM, Resident #1 was unresponsive, had no heartbeat or pulse, and oxygen was applied. The DON stated she did a sternum rub and someone called 911. The DON stated she called the physician at 11:24 AM and notified him Resident #1 was awake, alert, and on her way to the ER. The DON stated she had LVN A call and notify the resident's family. The DON stated the ADON accompanied LVN A on her next medication pass. The DON stated she completed an incident report for the med error. The DON stated LVN A was a new nurse and was hired within the last year. <BR/>In an interview on 3/01/2024 at 3:40 PM, the ADON stated she had made random observations of LVN A during the past few months and there was never anything observed that gave her reason for alarm or concern. The ADON stated she did not know when the medications were being given yesterday morning or if LVN A was passing medications from the medication cart or from the medication room. The ADON stated LVN A told her what happened. LVN A was asked if she had passed any more medications since the incident and she said no. The ADON stated she went through LVN A's next medication pass with her about noon on 2/29/2024. She stated LVN A passed medications from the medication room (carried the medication cup from the medication room rather than pushing the medication cart) due to not having a full medication pass at that time. The ADON stated she observed LVN A through the whole process from start to finish. She stated she observed LVN A review the resident's medication order, open the medication cart and find the correct medication, verify the labeled medication card with the order, pop the medication from the bubble pack card into the medication cup, and take it to the resident and verify, and administered the medication. LVN A initialed the resident's electronic MAR after the medication was administered. The ADON stated the incident with Resident #1 was the only medication error that has been made since she started employment in the facility during November 2023. The ADON stated LVN A was the youngest and newest nurse, and the other licensed nurses have had more experience. The ADON stated she thought LVN A was competent and she made a mistake when she got busy. She stated LVN A needed to slow down and think about what she was doing. The ADON stated the standard of practice was to pop medications from the cards for one resident at a time. <BR/>In an interview on 3/01/2024 at 4:43 PM, LVN A stated when she arrived at work on the morning 2/29/2024, the computer for the medication cart had not been charged and she had it plugged it into the outlet in the medication room. She stated she had taken a resident's vital signs and blood pressure and had placed his medications in a cup on top of the medication cart in the medication room. She stated she gathered her equipment to take Resident #1's vital signs (BP cuff, thermometer, oxygen pulse oximeter) and carried the medication cup and equipment to Resident #1 who was in the sunroom. LVN A stated she had it in her head to give Resident #1 the medications and she gave them to her and then took her vital signs. She stated it was about 10:20 AM. She stated she then went back to the medication room to enter the medications were given on the MAR when she realized what she had done. LVN A stated she immediately reported her error to the DON. Resident #1 was assessed and was later found to be unresponsive. The DON called the doctor. LVN A stated she called the family and said Resident #1 had been given the wrong medications and was on the way to the hospital. She stated the BP medication given was Isosorbide. LVN stated she felt awful about it and became tearful. She stated she would focus on the process of start to finish for one resident at a time. LVN A demonstrated how she reviewed a medication order in the electronic MAR, unlocked the medication cart and to find the medication and compared the card to the order in the computer, signed out the medication in the narcotic book if applicable, popped the medication from the card into a medication cup, replaced the medication card in the cart and locked it, gave the medication to the resident, and then returned and documented Y in the electronic MAR. LVN A stated she learned from this error and would focus and think about what she was doing.<BR/>Observation and interview on 3/04/2024 at 1:45 PM with Resident #1 in the hospital revealed she was laying on her back in bed with the head of the bed elevated. She was using supplemental oxygen via nasal cannula. Resident #1 was awake, alert, and oriented. Resident #1 stated her doctor had been to the hospital to see her. Resident #1 stated she was feeling some better. She stated she had gone to the nursing facility after being in the hospital with pneumonia. Resident #1 stated she found out what had happened to her at the nursing home and stated she did not receive good care there. Resident #1 stated she planned to go to a different nursing home where her family members had both been and she had visited them. She stated she was familiar with the place. Resident #1 stated she could not walk very well anymore and hoped to receive therapy there. Resident #1 stated she took Tramadol and it helped with her hip and leg pain. She stated she had a wheelchair and a power chair and hoped to be able to use it again. <BR/>In an interview on 3/05/2024 at 1:24 PM, the DON stated the ADON had observed LVN A give the entire lunch medication pass on Hall 2 and Hall 3 on 2/29/2024. She stated she did verbal counseling with LVN A on Thursday, 2/29/2024. The DON stated on Saturday, 3/02/2024 she came to the facility and did an in-service training on the medication administration policy and procedure with LVN A and gave her a suspension notice pending investigation. The DON stated the Administrator determined LVN A may need more training and needed to be taken off the schedule. The DON stated she came to the facility on Saturday and suspended LVN A's employment per the Administrator's directive. She stated the Administrator spoke with her corporate boss on 3/04/24 and he gave instruction for LVN A to have additional instruction for the medication pass with the medication pass checklist to be completed for 3 days - Thursday, Friday and Saturday. The DON stated LVN A was scheduled to return to work on Thursday 3/07/24 and the ADON would go with her during the medication pass with a checklist. The DON stated this was the first medication error LVN A had made since she started employment during November 2023.<BR/>In a telephone interview on 3/06/2024 at 12:51 PM, Resident #1's physician stated he was aware of the incident and had been called immediately by a nurse at the facility. The physician stated he had been at the facility the morning of Thursday 2/29/24 before the incident. He stated Resident #1 was fine and was going to therapy. The physician stated Resident #1 became syncopal after being given the other resident's blood pressure medications. He stated she was responsive when the ambulance crew arrived to transport her to the ER. The physician stated the safety concern for Resident #1 was her blood pressure going too low and making her pass out. He stated the other medications did not have huge concerns (pain and diuretic medications). He stated the BP medications were the main concern.<BR/>Review of the facility's policy and procedure for Medication Administration, dated 1/2013 revealed the following [in part]:<BR/>Purpose:<BR/>To administer the following according to the principles of medication administration, including the right medication, to the right resident/patient at the right time, and in the right dose and route.<BR/>Equipment:<BR/>Medication as ordered<BR/>Administration supplies as indicated<BR/>Procedure:<BR/>1. Verify physician's orders for medications to be administered.<BR/>2. Review any special precautions and perform needed evaluations prior to administering medication to the resident/patient.<BR/>Review resident/patient allergies.<BR/>Review pertinent lab results, as indicated .<BR/>Perform needed evaluations prior to administering specific medications (e.g., pulse, blood pressure, blood glucose).<BR/>3. Identify resident/patient via wristband or picture ID.<BR/>4. Explain the procedure to the resident/patient. Include the type of medication ordered, the reason, frequency, and route .<BR/>10. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time .<BR/>13. Verify the following, again, by comparing medication to MAR prior to administering:<BR/>Correct resident/patient<BR/>Correct medication<BR/>Expiration date<BR/>Dose and dosage form<BR/>Route<BR/>Time .<BR/>This was determined to be an Immediate Jeopardy on 3/07/2024. The Administrator was provided the Immediate Jeopardy Template on 3/07/2024 at 5:15 PM and a Plan of Removal was requested. <BR/>The following Plan of Removal submitted by the facility and accepted on 3/08/2024 at 4:37 PM:<BR/>1. Resident #1 was immediately assessed by the Licensed Nurse (LN) on 02/29/24 and the physician was notified of the medication error with a new order to monitor the resident's blood pressure closely. The order was noted by the LN. When the LN went to monitor Resident #1 after receiving the order, the resident was found unresponsive. The LN called EMS which responded quickly, and the resident was discharged to the ER for observation on 02/29/24.<BR/>2. The 24-hour report was reviewed on 3/7/24 by the Assistant Director of Nursing (ADON) for the past 72 hours to ensure there were no further medication errors and/or changes in any resident's condition. Any concerns will be addressed by a LN if identified. The results of the report covering the past 72 hours found no additional medication errors or changes in residents' condition. No further physician notification of actions by the licensed nurse was necessary.<BR/>3. When the Director of Nursing (DON) interviewed the LN on 02/29/24 who made medication error, it was determined that the LN dispensed the medication for a resident other than resident #1. She then realized that she needed to take resident #1's blood pressure, and subsequently also gave the other resident's medication to resident #1. The education provided to this LN by the DON included avoiding distractions and completing the medication pass one resident at a time once starting the medication administration process.<BR/>Beginning 3/6/24, LNs and Certified Medication Aides (CMAs) will have a medication pass observation completed by a Registered Nurse (RN) prior to the beginning of their next shift and receive education as needed for any concerns identified by the RN conducting the observation. The RN will observe a minimum of 50% of the LNs or CMAs medication pass for that scheduled time to validate competency. The RN will stop the LN or CMA if they identify a problem and provide immediate reeducation in real time on the issue identified. The medication administration observations will be documented on the facility's Medication Administration/Technique Observation tool which follows the facility's Medication Management policy. <BR/>On 3/8/24, the LNs and CMAs went through additional medication administration education that was provided by the ADON. This education included avoiding distractions to the medication pass and once starting to dispense medication for a resident, not to stop and perform any other non-emergent tasks. It also included following the facilities procedure on Medication Administration from the facilities Nursing Procedure Manual. The LNs and CMAs understanding of the education will be demonstrated through RN observed medication administration observations previously described.<BR/>All newly hired LNs and CMAs will go through medication pass validations by a LN with the tools mentioned above during their orientation.<BR/>4. The DON, ADON or designee will complete med pass observations weekly for 12 weeks to ensure licensed nurse and medications aides continue to administer medications per physician's orders and to the right resident. The Medical Director was notified of this survey outcome on 3/8/24 and will be involved in the facility QAPI process surrounding this plan. A report of the medication administration audits will be submitted to the QAPI committee for review and recommendations as needed. The facility held an initial QAPI meeting on 3/8/24 to review the outcome of the medication administration observations to this point. Starting the week of March 11, 2024, a QAPI meeting will be conducted weekly for 4 weeks then monthly. The DON is responsible for monitoring and additional actions to this plan if needed.<BR/>Date of Compliance: 03/08/24<BR/>Monitoring and verification of the facility's Plan of Removal began on 3/08/2024 at 4:40 PM as follows:<BR/>Observation on 3/06/2024 at 11:46 AM revealed the DON was observing LVN C passing medications and was using a medication administration competency checklist. <BR/>In an interview on 3/06/2024 at 11:52 AM, the DON stated she did medication administration competency checklist for LVN C. She stated the MDS Coordinator had observed LVN D and did the medication competency on her. The DON stated they were the only 2 LVNs at the facility. She stated 6 more LVNs would be evaluated for medication administration competency. The DON stated LVN A would have 3 days of evaluation using the medication checklists. She stated tomorrow and Friday (3/07/24 and 3/08/24) the ADON would observe LVN A and complete the medication administration checklist and on Saturday, 3/09/24 the weekend RN would observe LVN A and complete the medication administration checklist.<BR/>In an interview on 3/07/2024 at 2:32 PM, the MDS Coordinator stated she had evaluated LVN D and completed the medication checklist with her yesterday on 3/06/2024.<BR/>During an observation and interview on 3/07/2024 at 4:03 PM, MA E was observed during the preparation of medication to administer to a resident. She stated she would not take the medication cart down the hallway, due to only having medication for 1 resident. MA E reviewed the resident's medication orders in the electronic medication administration record, unlocked the medication cart and located the medication card, popped the medication into a medication cup, returned the medication card to the cart, and locked the medication cart. She proceeded to walk down the hallway to the resident's room carrying the medication cup and a glass with water, and stated she identified the resident by her picture on the medication administration record and by her room number. MA E identified herself to the resident, explained the pills she had brought for the resident, tapped the pills from the medication cup into the resident's mouth, and offered her the glass of water. MA E left the resident's room and walked back to the medication cart, pulled up the resident's medication administration record, initialed the medication had been given, and closed the electronic medication administration record.<BR/>During an observation and interview on 3/07/2024 at 4:40 PM, LVN B was observed during the preparation of medication to administer to a resident who was seated at a table in the dining room. The LVN pushed the medication cart from the medication room and positioned the cart against the wall to the right of the entrance to the dining room. LVN B stated she took the medication cart into the halls when she had the main medication pass, but sometimes just carried the medication cup and a glass of water to the resident if it was only one resident. LVN B reviewed the medication order in the resident's electronic medication administration record. The resident's picture was in the upper left-hand corner of the medication administration record. LVN B unlocked the medication cart, found the medication card and compared it to the order on the medication administration record. She popped one tablet from the medication card into a medication cup, returned the medication card into the medication cart, and locked the cart. LVN B hit the screen saver on the computer, took the medication cup and a glass of water to the resident and watched her swallow the medication. She returned to the medication cart and entered the medication administered on electronic medication administration record and closed the record.<BR/>In an interview on 3/08/2024 at 11:02 AM the ADON stated she was accompanying LVN A during the medication passes for the day.<BR/>Review of the fax cover sheet dated 3/08/2024 at 1:41 PM revealed the Administrator had sent the Medical Director a notification letter regarding the medication error, a copy of the IJ Template and the facility's draft Plan of Removal.<BR/>Review of the in-service training record dated 3/08/2024 at 2:00 PM revealed a training was provided to the licensed nurses regarding the topic of medication management and the facility's policy and procedure for medication error preventing and reporting. The attendance sheet was signed by a medication aide, 5 LVNs, and the weekend RN.<BR/>In an interview on 3/08/2024 at 5:37 PM, LVN B stated the ADON had watched her pass medications yesterday on 3/07/2024. LVN B stated the nurses had in-service training that day at 2:00 PM and the topics covered were medication errors, the types of medication errors - giving the wrong medication or transcription errors in orders, using the 5 Rights of Medication administration, and avoiding distractions when preparing medications for administration.<BR/>Observation on 3/08/2024 at 5:48 PM revealed the ADON was accompanying LVN A on the medication pass in Hall 2. The medication cart was in the hallway.<BR/>Review of the QAPI Meeting Sign-in Sheet, dated 3/08/2024 at 3:00 PM, revealed the committee discussed the IJ Plan of Removal for medication error.<BR/>During an interview and record review on 3/08/2024 at 4:26 PM, the ADON provided a copy of the 72 Hour Summary report dated 3/04/24 - 3/07/24. She stated the 24-hour report was printed from the program used for the residents' electronic health records and included new orders, progress notes, weights and vital signs. She stated there was not a way to filter all the information that was included in the report. The ADON stated the MDS Coordinator reviewed the 24-hour report in the morning, Monday through Friday, and she sent an email to the Administrator, DON, ADON, and therapy staff with any concerns or anything that needed follow-up. Review of the copy of the 72 Hour Summary report revealed it consisted of 32 pages and the first page had been signed as reviewed by the ADON on 3/07/24 at 1900 (7 PM). The 72 Hour Summary report had 10 hand-written documented notations for vital signs and weight changes that had been rechecked.<BR/>[This interview and record review were conducted prior to the acceptance of the final draft of the Plan of Removal.]<BR/>The Administrator was informed the Immediate Jeopardy was removed on 3/08/24 at 6:55 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and labeled in accordance with currently accepted professional principles for 1 of 1 med carts (Med Cart # 1) , and 1 of 10 residents ( Resident ID # 16) reviewed for medication pass .<BR/>A. Medication cart #1 contained oral medications, topical medications stored together in one compartment. <BR/>B. Resident # 16's medication did not have a dosage on the label. <BR/>This failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses, cause cross contamination and transmit infection.<BR/>The findings include:<BR/>Med Cart #1 :<BR/>An observation on 01/11/ 2022 at 10:00 AM of Med Cart #1 revealed each drawer of the cart had oral medications, nasal inhalants, and topical medications stored together in the same compartment. <BR/>An observation on 01/11/2022 7:45 AM of med cart #1 revealed Resident ID # 16 had two a had dark orange , round tablet which was labeled: Bidel, (an isosorbide dinitrate-hydralazine combination drug , given to treat high blood pressure by dilating the blood vessels) take 1 tablet by mouth two times daily. The dosage was not listed on the label information for the Bidel. <BR/>Review of Resident ID # 16's face sheet dated01/11/2021, Revealed resident ID # 16 was a [AGE] year-old- male admitted to the facility on [DATE]. <BR/>Review of Resident ID # 16's physician orders dated 01/11/22 included the following order Bidel tablet 20-37.5 mg 1 tablet by mouth two times daily for hypertension (start date 07/26/2021). <BR/>In an interview on 10/08/21 at 2:00 PM LVN E stated she would notify her ADON and hold the medication until the order was clarified by the physician after comparing the label on the medication card to the physicians order. She stated there was no dosage on the blister pack did not match the dosage listed on the medication administration record. LVN E stated a consequence of storing oral medications, topical medications and nasal inhaler in the same compartment could result in the medications being given via the wrong route or result in cross contamination and the spread of infection. She stated that it was each nurse's responsibility to see that medications were labeled correctly, and medications of different routes were not stored in the same compartment during their shift. <BR/>In an interview on 01 /11/2022 at 9:10 AM the ADON revealed it was each nurse's responsibility that medications be properly labeled with the correct medication and dosage according to the physicians orders. She stated it was her expectations that drugs should be stored according to appropriate route . She revealed storing of medications of different routes could cause the spread of infections and unwanted medical side effects. She stated it was her expectation that nurses be responsible for cleaning their own carts and keep the medications stored according to the route they are administered. She stated the pharmacy consultant also checked the carts for cleanliness , proper storage and labeling of medications at each monthly visit. The ADON stated in an interview on 1/10/22 at 11:45 AM that she had noticed this and she had talked to the dispensing pharmacist and he told her that was the only strength he carried of the Bidel and it did not need a dosage on the label label. She stated she would clarify again because she was sure she had not documented this conversation in the nurses progress notes when it occurred. <BR/>In an interview on 1/10/22 at 2:00 PM the DON revealed her expectation that med carts be cleaned by the nurses, and stated it was each shifts responsibility to check carts for cleanliness and see that medications of different routes not be stored together in the same compartment. She also stated the carts are monitored by pharmacy consultant during his monthly visits. <BR/>Interview with the DON on 01/11/22 at 9:30 AM stated the med should not have been given without the proper dosage on the packaging. She stated she did not know how this occurred. <BR/>Record review of the facility policy titled Storage of Medications dated revised August 2020, revealed in part:<BR/>4. Orally administered medications are stored separately from externally used medications and treatments such as suppositories .<BR/>10. Medication storage conditions are monitored on a regular basis by the consultant pharmacist and corrective action is taken if problems are identified. <BR/>Review of the facilities policy titled Medication Administration dated revised February 2020, revealed in part:<BR/>11. Verify the pharmacy prescription label on the drug and the manufacturers identification system match the MAR. If there is a discrepancy check the order and notify the pharmacy ; do not give the medication until clarified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable well-balanced diet that meets daily nutritional and special dietary needs for 1 of 36 (Resident #6) resident reviewed for needs and preferences.<BR/>The facility failed to ensure Resident #6 received a Carbohydrate controlled diet with added protein powder to his food three times a day as ordered. <BR/>This failure placed residents at risk of not having their needs met resulting in delayed healing of pressure ulcer.<BR/>Findings included:<BR/>A record review of Resident #6's face sheet dated 4/30/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease (body doesn't produce enough insulin causing high blood sugar level negatively effecting the kidneys), pressure ulcer to right ankle unstageable (wound to right ankle), essential hypertension (high blood pressure), and muscle weakness.<BR/>A record review of Resident #6's quarterly MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated no cognitive impairment. <BR/>A record review of Resident #6's care plan last revised on 3/18/2024 revealed he had a potential nutritional problem related to diabetes, prior CVA , obesity. 3/14/2024 new diet orders from Dr per dietician recommendation carbohydrate controlled, low potassium foods, no added salt and continue protein powder three times a day with meals. <BR/>A record review of Resident #6's physician orders reflected an order dated 3/15/2024 to continue protein powder three times a day in foods. <BR/>A record review of Diet Type Report dated 4/30/2024 revealed Resident #6's diet to be carbohydrate controlled and continue with protein powder three times a day in foods. <BR/>During an observation and interview on 4/29/2024 at 12:18 PM, Resident #6 was observed sitting in his chair eating lunch on bedside table. No carbohydrate-controlled diet noted per doctor order. Resident had full size dessert on tray. Resident #6 stated that he watched his sugar and did not eat lots of his in-room snacks if he ate a full dessert at mealtimes. When asked about protein powder to food at all meals, Resident #6 stated that he was unaware of need for that and to his knowledge had never received any. <BR/>During an interview on 4/29/2024 at 3:40 PM, the DON stated her expectation was for physician ordered diets to be followed, further stating that if the physician orders were not followed it could result in poor clinical outcomes for residents. <BR/>During an interview on 4/29/2024 at 5:40 PM, the Administrator stated his expectation was that all diets should be per physician order and should be served according to policy. <BR/>During an interview on 4/30/2024 at 11:46 AM the registered dietician stated that the dietary manager should follow diet order. She further stated that failure to follow dietary physician orders would be a liability and needs to be documented and corrected. <BR/>During an observation and interview on 4/30/2024 at 5:17 p.m., revealed LVN B sent tray back to kitchen for incorrect diet (carbohydrate controlled), Dietary supervisor stated, just take the bread off, its fine. LVN B stated she had checked the trays at mealtimes for diet. She further stated that when a tray was incorrect in comparison to order she sent it back to the kitchen. <BR/>During an interview on 4/30/20254 at 5:22 PM, with Resident #6 Physician, he stated that her expectation was for diets to be followed as ordered, further stated that failure to follow dietary orders could result in negative effects such as delayed wound healing, increase in wound occurrence and increase in blood sugar. <BR/>During an interview on 4/30/2024 at 5:27 PM, the Dietary Supervisor stated that she had not been using protein powder in Resident #6's food as ordered, but that she would order some. She further stated that for carbohydrate-controlled diet its discretionary, I just remove the bread.<BR/>A record review of the facility's policy titled Therapeutic Diets dated 5/2014, revised 9/2017 reflected the following: <BR/>Policy Statement<BR/>All residents have a diet order, including, regular, therapeutic and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with the applicable regulatory guidelines.<BR/>Procedures: <BR/>1. The Licensed Nurse accepts the diet order from the authorized prescriber. <BR/>2.The Licensed Nurse completes and signs the diet requisition form including the full diet order, food allergies and specific food preference request. <BR/>3. Diets are prepared in accordance with the guidelines in the approved diet manual and the individualized plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to manage the personal funds of the residents deposited with the facility for 1 of 3 (Resident #6) residents reviewed for personal funds.<BR/>The facility failed to ensure Resident #6's personal funds were properly managed. <BR/>This failure could place residents whose funds were managed by the facility at risk of not receiving funds deposited with the facility and not having their rights and preferences honored.<BR/>Findings included: <BR/>Record review of Resident #6's Facesheet dated 10/25/24 revealed a [AGE] year-old female with a readmission date of 08/23/24. Resident #6 had a diagnosis list that included Bipolar Disorder mixed, severe, with psychotic features. Resident #6 was her own responsible party. <BR/>Record review of Resident #6's MDS assessment dated [DATE] revealed a BIMS of 3 meaning severe cognitive impairment.<BR/>Record review of Resident #6's Trust Statement dated 10/14/24 at 11:00 AM revealed a negative balance of $369.63. The month of September 2024 had credit of $1,146.00 SSA TREAS on 9/3/24 leaving a balance of $1,191.74; debit of $1,441.34 made to Facility on 9/9/24 leaving a balance of negative $249.63; debit of $120.00 cash disbursement on 9/24/24 leaving a closing balance of negative $369.63.<BR/>In an interview on 10/15/24 at 4:22 PM Resident #6's family member stated Around 3:30 PM today [Resident #6] called me upset. We had taken her to eat but she soiled clothes, so we dropped her off to change. She called me immediately and said [family member] I just got my statement that I owe $356 and some change. I said who gave it to you, [Resident #6] said the administrator, so then [Resident #6] took the phone to the administrator and said my [family member] wants to talk to you. Adm then explained to me that there was a problem with the trust fund, they get to draw money out and she has overspent. Let me work this out. <BR/>In an interview on 10/15/24 at 4:52 PM ADM stated that she did not have answers about concerns with Resident #6's trust funds but would check with BOM as she was BOM for three facilities.<BR/>In an interview on 10/25/24 at 10:15AM, ADM stated that she had it all worked out regarding Resident #6's Trust fund and after the next month's payment (November 2024), Resident would have paid back the approximate $300.00 that she owed the facility. ADM explained that as of September 1st of 2024, the BOM was removed from the facility and a position was filled between 3 facilities. She said that before September 1st, 2024 the other BOM kept records accurately at the facility. She said that at one time she believed that Resident #6 may have been either a private pay individual or possibly a Medicaid pending individual and during that time (unknown timeframe) maybe Resident #6 had incurred charges for Room and Board that was not paid to the facility. ADM said she was told that there was an agreement that Resident #6 would pay an additional $15.00 per month towards that outstanding balance. ADM stated she could not find an agreement or an exact balance that Resident #6 might have owed the facility as an outstanding balance. She said the new BOM that took over management of the Trust Fund accounts for the residents of the facility effective September 1st, 2024 had taken out $1441.34 on 09/09/24 after the resident had received her check for the month on 09/03/24 of $1146.00. She said that the new BOM had pulled out all the balance owed for Room and Board at that time and that caught Resident #6 up on any outstanding balance she owed to the facility. ADM then stated that Resident #6 received her check on 09/23/24 for $1146.00 . She said Resident #6 had complained about wanting some money and the facility knew she had a balance of approximately $59.00 but gave Resident #6 approximately $120.00 because they knew she would get a check the next month that could cover it. ADM said then on 10/03/24 the facility BOM took approximately $800.00 out for Room and Board . She said the difference in the amount paid for Room and Board from September to October of 2024 was because Resident #6 had owed an outstanding balance in the previous months. She said the facility was not keeping track accurately of the residents' personal funds during the transition of staff and that caused a lot of problems. ADM said Resident #6 had a negative balance at that time of a little more than $300.00 and that the next month's (November 2024) check that Resident #6 would receive, the facility would just deduct that money and Resident #6 would have no further outstanding balance. ADM said again that the Facility was aware that Resident #6 did not have enough money in her personal fund that was managed by the facility, but the Facility still gave additional money to Resident #6 anyway. <BR/>Record review of facility policy titled Management of Residents' Personal Funds revised April 2017 revealed the following [in-part]: <BR/>Policy Statement: Our facility shall manage the personal funds of residents who request the facility to do so.<BR/>Policy Interpretation and Implementation: <BR/>3. <BR/>Should the facility manage the resident's funds, the facility will act as a fiduciary of the resident funds and hold, safeguard, manage and account for the personal funds of the resident. No service charge will be levied against the resident for the management of personal funds. <BR/>5. <BR/>The resident will be informed in advance of any charges imposed to his or her personal funds. <BR/>8. <BR/>Inquiries concerning the facility's management of resident funds should be referred to the Administrator or to the business office.<BR/>During an interview on 10/25/24 at 4:30PM, ADM stated that she had nothing more to provide regarding management of resident personal funds and trust funds.

Based on observation, interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property for 4 of 5 (LVN A, CNA E, CNA F, and CNA G) employee's files reviewed for abuse protocol. <BR/>A. <BR/>The facility failed to complete criminal background, EMR and NAR check on CNA E before her employment date of 10/12/24.<BR/>B. <BR/>The facility failed to complete criminal background, EMR and NAR checks on CNA F before his employment date.<BR/>C. <BR/>The facility failed to complete criminal background, EMR and NAR checks on CNA G before her employment date.<BR/>D. <BR/>The facility failed to complete criminal background and EMR checks on LVN A before her employment date.<BR/>This failure could place residents at risk for abuse, neglect, and exploitation. <BR/>Findings included:<BR/>Observation on 10/12/24 at 6:20 PM revealed CNA E was in possession of new hire paperwork; it was completely blank except for her name on the first page. <BR/>Observation on 10/12/24 at 9:44 PM revealed CNA E working on new hire paperwork in common area near dining room. At that time ADM informed CNA E that they would review together after ADM break.<BR/>Record review of CNA F's employment file revealed no record of criminal background check pre-employment, no signed job description, no record of NAR or EMR check. No document of date of hire. <BR/>Record review of CNA G's employment file revealed no record of criminal background check pre-employment, no signed job description, no record of NAR or EMR check. No document of date of hire.<BR/>Record review of LVN A's employment file revealed no record of criminal background check pre-employment, no signed job description, no EMR check. No document of date of hire. <BR/>Record review of CNA E's employment file revealed no record of criminal background check pre-employment, no signed job description, no record of NAR or EMR check. No document of date of hire.<BR/>Record review on 10/12/24 at 8:55 PM of information provided by ADM for CNA E revealed the following: <BR/>National Sex offender website revealed search performed 10/12/24 at 8:11:07 PM<BR/>OIG exclusions search revealed Search conducted 10/12/24 at 9:30:11 PM EST on OIG LEIE Exclusions database.<BR/>EMR Texas HHS is date/time stamped 10/12/24 at 20:08 (8:08PM).<BR/>DPS Criminal History Conviction Name Search Results printed 10/12/24 at 8:04:24 PM.<BR/>In an interview on 10/11/24 at 3:40 PM ADM stated that everything she had for the employee files was in the file that was given for review and if it was not there then she did not have it. ADM stated that after looking at employee files she was aware of lack of information required for pre-employment in the files and lack of proof of annual training. She further stated that Human Resources person was shared between 3 facilities and was now running the appropriate checks on all current employees but what they had was all they had. ADM also stated that it was the responsibility of Human Resources to complete background checks.<BR/>In an interview on 10/12/24 at 6:20 PM CNA E stated that this was her first day of work and then stated that she needed to complete her new hire paperwork. CNA E stated that she came to facility at 5 pm today to complete paperwork with ADM, but ADM told her to go ahead and work the floor that she could fill out the paperwork during her shift. CNA E further stated that she had been providing care for residents since arrival this day. <BR/>In an interview on 10/12/24 at 7:56 PM ADM stated CNA E's pre-employment paperwork had not been completed yet. When asked if paperwork needed to be completed prior to physically working in facility , ADM stated No, that is what we are supposed to complete within 10 days of hire: EMR, background check. I-9 E-verify is all that has to be completed prior to being on the floor caring for residents. This is her first shift and within her first shift she will finish her training: the abuse, the fire, and all that. I would expect that done with her new hire paperwork.<BR/>In an interview on 10/12/24 at 8:51 PM ADM stated the following regarding her pre-employment expectation, Is when I hand my paperwork over to my HR person that they run all things before staff come on the floor and when I ask if they have been done and is it ok to put them on the floor then if I am told yes I expect to be told the truth. She continued stating that it was her expectation for the background checks to be completed prior to staff providing care on floor.<BR/>In an interview on 10/21/24 at 2:14 PM Human Resources stated that she was not previously Human Resources of the facility and the files are a mess . She further stated that the files given for review were all the facility had and that she was working on fixing them but had run out of time. <BR/>Record Review of policy titled Subject: Abuse dated 07/17/2021 revealed the following [in-part]:<BR/>POLICY:<BR/>It is the policy of this center to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person.<BR/>PROCEDURE<BR/>1. Screening:<BR/>a. Pre-employment screening will be completed on all employees, to include:<BR/>Criminal History Check<BR/>Background Check<BR/>Reference check from previous employers<BR/>Professional licensure, certification, or registry check as applicable<BR/>Misconduct Registry<BR/>OIG<BR/>b. The center will not hire or retain any employee with a history of abuse or neglect if that information is known to the home.<BR/> .<BR/>Record review of Abuse Prevention Program policy revised December 2016 revealed the following [in-part]: <BR/>Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.<BR/>Policy Interpretation and Implementation:<BR/>2. <BR/>Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has:<BR/>a. Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;<BR/>b. Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or<BR/>c. Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.<BR/>During an interview on 10/24/24 at 9:50AM, ADM stated she had nothing more that she could provide regarding employee files.<BR/>During an interview on 10/25/24 at 4:30PM, ADM stated that she had nothing more to provide regarding employee files.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 4 of 8 residents (Resident #2, #3, #4 and #7) reviewed for incontinent care, in that:<BR/>The facility failed to provide bowel and bladder incontinent care for Resident #2 and it resulted in reddened skin on buttocks area.<BR/>The facility failed to provide bowel and bladder incontinent care for Resident #3 and it resulted in reddened skin on scrotum area.<BR/>The facility failed to provide bowel and bladder incontinent care for Resident #4 and it resulted in reddened skin and an open area to buttock(coccyx) area.<BR/>The facility failed to provide bowel and bladder incontinent care for Resident #7 and it resulted in burning sensation and reddened skin in testicle (scrotum) and buttock (coccyx) area.<BR/>This failure could place residents at risk for skin break down, urinary tract infections, decrease in quality of life and loss of dignity.<BR/>Findings included:<BR/>Resident #2<BR/>Record review of face sheet dated 10/11/24 revealed Resident #2 is an [AGE] year-old female diagnosed with Chronic kidney disease, constipation.<BR/>Record review of Resident #2's Careplan revised on 09/04/24, revealed, The resident needs prompt response to all requests for assistance.<BR/>Record review of Resident #2's MDS assessment dated [DATE] Section C revealed BIMS of 3meaning severe cognitive impairment, Section GG revealed, maximum to moderate assist (meaning 2-person physical assistance) with all ADLs; Section H revealed always incontinent of bowel and bladder.<BR/>Record review of Resident #2's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed.<BR/>Observation on 10/15/24 at 6:29 AM revealed Resident #2 had redness of skin to buttocks and dried feces noted between buttocks.<BR/>Resident #3<BR/>Record review of face sheet dated 10/22/24 revealed Resident # 3 is a [AGE] year-old male with a diagnosis of chronic kidney disease.<BR/>Record review of Resident #3's Careplan revised 10/10/24 revealed, Bladder and Bowel Incontinence; r/t Prior CVA; Diabetes; History of UTI, Impaired Mobility; Recent Traumatic Brain Injury from fall with interventions that included: Check the resident every 2 hrs & and as required for incontinence. Wash, rinse and dry perineum. <BR/>Record review of Resident #3's MDS assessment dated [DATE] Section C revealed BIMS of 15 meaning no cognitive impairment; Section GG revealed maximum to moderate assistance (meaning 2-person physical assistance) with all ADLs; Section H revealed always incontinent of bowel and bladder.<BR/>Record review of Resident #3's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed.<BR/>Observation on 10/15/24 at 7:33 AM revealed Resident #3's scrotum area was red. Strong smell of urine observed in resident room. <BR/>Resident #4 <BR/>Record review of face sheet dated 10/11/24 revealed Resident #4 is a [AGE] year-old female diagnosed with. Functional urinary incontinence, diarrhea.<BR/>Record review of Resident #4's MDS assessment dated [DATE] Section C revealed no BIMS score and resident is rarely/never understood; Section GG revealed Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity; Section H revealed always incontinent for urinary and bowel continence. <BR/>Record review of Resident #4's Careplan dated 07/10/24 revealed INCONTINENT: Check & Change [Resident #4] every 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. She requires Total Assistance for incontinent Care.<BR/>Record review of Resident #4's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed.<BR/>Observation on 10/15/24 at 6:21 AM revealed Resident #4 had dried feces observed between buttock cheeks. Redness to skin was noted to coccyx and bilateral buttocks, 1in x 1in open area noted to top of coccyx. <BR/>Resident #7 <BR/>Record review of face sheet dated 10/21/24 revealed Resident #5 was a [AGE] year-old male diagnosed with muscle wasting. <BR/>Record review of Resident #7's MDS assessment dated [DATE] Section C revealed a BIMS score of 11, indicating moderate cognitive impairment; Section GG revealed Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort regarding toileting hygiene. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort, Regarding toilet transfer; Section H revealed Urinary Incontinence - Occasionally incontinent (less than 7 episodes of incontinence). <BR/>Record review of Resident #7's careplan dated 10/10/24 revealed the following, [Resident #5] has bowel/bladder incontinence r/t impaired mobility and cognition. INCONTINENT: Check the resident[every] 2 hours and as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes.<BR/>Record review of Resident #7's EHR from 09/01/24 through 10/22/24 revealed no skin assessments completed.<BR/>Observation and interview on 10/15/24 at 6:41 AM revealed Resident #7 had yellowish brown stain noted on bed sheet beneath resident bottom; brown smear noted as well on white sheet. Resident stated, my crotch burns.<BR/>Observation on 10/15/24 at 7:04 AM revealed Resident #7 taken to shower/bathroom in hall. Dark red skin was noted to testicles, groin and coccyx area upon incontinent care provided by staff. <BR/>Interview on 10/13/24 at with CNA E regarding how CNAs knew what care or assistance each resident required CNA E stated I am locked out of the tablet, that is where I would normally look but I don't have access since I started yesterday. I just go by what I know from working here before.<BR/>Interview on 10/13/24 at 8:11 PM with DON regarding how new hire CNAs were aware of needs and level of care for each resident, DON stated that's my fault, I am supposed to set her (CNA E) up a log in for the tablet and I haven't had time to do my DON stuff.<BR/>Interview on 10/13/24 at 9:04 PM with ADM regarding training she provided to new hire CNA and how new hire CNA knew individual needs of each resident. ADM stated Oh, I didn't train on that, I just did her new hire paperwork. When asked if she did any resident care training, she stated No I didn't. She had come in a little bit early around 5 pm so I think she worked with the girls.<BR/>Interview on 10/14/24 at 10:35AM with laundry attendant, she stated, laundry comes to me with a brown ring dried on the sheets and smells of urine.<BR/>Record review of policy Resident Rights revised December 2016 revealed the following [in-part]: <BR/>Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.<BR/>Policy Interpretation and Implementation:<BR/>1. <BR/>Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>a. <BR/>a dignified existence; <BR/>b. <BR/>be treated with respect, kindness, and dignity;<BR/>During an interview on 10/24/24 at 9:50AM, ADM stated she had nothing more that she could provide regarding a policy on activities of daily living or providing care to maintain good hygiene.<BR/>During an interview on 10/25/24 at 4:45PM, ADM stated she had nothing more that she could provide regarding a policy on activities of daily living or providing care to maintain good hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and hazards.<BR/>1. <BR/>The facility failed to maintain proper functioning of sit-to-stand mechanical lift. <BR/>This failure could place residents at risk of accidents when using mechanical lift for transfers.<BR/>Findings include:<BR/>Record review of face sheet revealed Resident # 3 is a [AGE] year-old male diagnosed with type 2 diabetes, chronic kidney disease, cerebral infarction (previous blocked blood flow to brain), and muscle weakness.<BR/>Record review of Resident #3's Careplan revised 10/10/24 revealed, Requires Max Assist X 2 staff with [mechanical] Lift for transfers.<BR/>Record review of Resident #3's MDS assessment dated [DATE] Section C revealed BIMS of 15 meaning resident had no cognitive impairment; Section GG revealed maximum to moderate assistance (meaning 2-person physical assistance) with all ADL's; Section H revealed always incontinent of bowel and bladder. <BR/>Interview with Resident #3 on 10/16/24 at 4:20 PM regarding lift revealed he was unaware of lack of locking wheel. <BR/>Observation on 10/17/24 at 7:24 PM of Sit to Stand mechanical lift revealed one wheel locked but one wheel did not lock, therefore it moved and was not able to be secure. Observation of use of mechanical lift with CNA E and MA D for Resident #3, revealed the wheel did not lock for transfer. Staff did attempt to steady lift, but not effectively able to do so, some movement continued. <BR/>Interview with ADM on 10/17/24 at 7:13 PM regarding Sit to Stand mechanical lift broken lock for wheel. She stated that she was not aware of inability to lock. She stated regarding lack of wheel locking well, residents could get hurt. It's not safe, but I bet the staff try to hold it with their foot. We will tell Maintenance Supervisor tomorrow. <BR/>Interview on 10/17/24 at 7:20 PM with CNA E regarding Sit to Stand mechanical lift revealed she uses it for Resident #3. She further stated the wheel doesn't lock, it's dangerous. I just work here. I am not sure how long it's been broken. CNA E did not expand on why it was dangerous. <BR/>Interview on 10/22/24 at 6:30PM with Maintenance supervisor revealed that he was unaware of broken brake for mechanical lift. He further stated, I have contacted the company that does inspections to come fix it. <BR/>Interview on 10/23/2024 at 3:30 PM, with the Maintenance supervisor revealed the contracted company stated the part would have to be ordered and they would fix the lift as soon as it arrived. They did not have an expected arrival date.<BR/>Record review of policy Supplies and Equipment, Environmental Services revised February 2009 revealed [in-part]: 1. Equipment must be ready for use at all times of the day and night to serve the residents' needs. Care should be exercised in the handling and in the use of our equipment to prevent damage or breakage.

Based on interview and record review, the facility failed to provide training to their staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention for 5 of 5 (DON, LVN A, CNA E, CNA F, and CNA G) employees reviewed.<BR/>The facility failed to ensure abuse training including activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention was provided to the DON, LVN A, CNA E, CNA F, and CNA G.<BR/>This failure could negatively affect resident care and place residents at risk of abuse due to lack of staff training.<BR/>The findings included: <BR/>Review of Personnel Files on 10/11/24 revealed <BR/>Record review of DON employment file revealed no record of trainings for 2023 or 2024.<BR/>Record review of LVN A employment file revealed no record of trainings for 2023 or 2024. <BR/>Record review of CNA E employment file revealed no record pre-hire training completions.<BR/>Record review of CNA F employment file revealed no record of pre-hire training completions.<BR/>Record review of CNA G employment file revealed no record of pre-hire training completions. <BR/>In an interview on 10/11/24 at 3:40 PM ADM stated that everything she had for the employee files was in the file that was given for review and if it was not there then she did not have it. ADM stated that after looking at employee files she was aware of lack of proof of annual training.<BR/>In an interview on 10/12/24 at 7:56 PM ADM stated CNA E pre-employment training has not been completed yet. When asked if paperwork needed to be completed prior to physically working in facility , ADM stated This is her (CNA E) first shift and within her first shift she will finish her training: the abuse. I would expect that done with her new hire paperwork.<BR/>In an interview on 10/21/24 at 2:14 PM Human Resources stated that she was not previously Human Resources of this facility and the files are a mess . She further stated that the files given for review were all the facility had and that she was working on fixing them but had run out of time. <BR/>Record Review of policy titled Subject: Abuse dated 07/17/2021 revealed the following [in-part]:<BR/>Procedure:<BR/>2. Training:<BR/>a. All new employees will receive in-service training pertaining to all aspects of abuse prohibition before working a shift. All current employees will receive in-service training pertaining to all aspects of abuse prohibition at least annually. The training will include, but will not be limited to:<BR/>o <BR/>Identification of potential victims of abuse or neglect<BR/>o <BR/>Appropriate interventions to deal with aggressive, stubborn resident, etc.<BR/>o <BR/>How to recognize staff indicator, i.e., stress, burnout and frustration that may lead to<BR/>o <BR/>the potential for abuse.<BR/>o <BR/>How to report allegations without fear of reprisal<BR/>3. Prevention:<BR/>a. All new employees will receive in-service training pertaining to all aspects of reporting of abuse, crimes against residents, concerns, incidents, and grievances without the fear of retribution before working a shift. All current employees will receive in-service training pertaining to all aspects of reporting abuse, crimes against residents, concerns, incidents, and grievances without the fear of retribution at least annually. The training will include, but not be limited to:<BR/>o <BR/>Identification, correction, and intervention in situations in which abuse, crimes<BR/>against residents, neglect and/or misappropriation of resident property is likely to<BR/>occur.<BR/>Record review of Abuse Prevention Program policy revised December 2016 revealed the following [in-part]:<BR/>Policy Interpretation and Implementation: <BR/>4. <BR/>Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior.<BR/>During an interview on 10/24/24 at 9:50AM, ADM stated she had nothing more that she could provide regarding staff training.<BR/>During an interview on 10/25/24 at 4:30PM, ADM stated that she had nothing more to provide regarding staff training

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to consult with the resident's physician, or the resident's representatives regarding a change in condition for one Resident (Resident #1) of 3 residents reviewed for notification of changes. <BR/>The facility did not notify or consult with Resident #1's Physician , or resident representative regarding a burn incident on May 10, 2024, due to spilling coffee on herself. Physician was notified on May 13, 2024 and resident representative was notified on May 14, 2024.<BR/>This failure could affect residents by causing their physician and representative to be unaware of changes in residents' condition.<BR/>Findings were:<BR/>Record review of Resident #1's electronic face sheet dated 06/04/2024 revealed she was a [AGE] year-old female that was admitted to the facility on [DATE] with a diagnosis that included malignant neoplasm of lower lobe (lung cancer), Alzheimer's Disease (disease that destroys memory and other important mental functions) and senile degeneration of brain (cognitive deficits that impair the memory and judgement). <BR/>Record review of Resident #1's Significant Change MDS dated [DATE] revealed the following:<BR/>*Section C- Cognitive Patterns revealed a BIMS score of 03 (severe cognitive impairment). <BR/>*Section M-Revealed that Resident #1 does have burns and is receiving treatment for burns. <BR/>Record review of Resident #1's Comprehensive Care plan dated 05/30/2024 revealed the following:<BR/>Focus: Resident #1 has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's.<BR/>Interventions: Reduce any distractions- turn off TV, radio, close door etc. Resident #1 understands, consistent,<BR/>simple, directive sentences. <BR/>Focus: Resident #1 has burns of bilateral lower extremities due to spilling coffee on herself 05/10/24.<BR/>Interventions: Resident #1 will have no complications resulting from the burns through the review date. Follow treatments as ordered.<BR/>Record review of Resident #1's EMR Incident Audit report dated 06/04/2024, revealed that on 05/14/2024 the following documentation was charted:<BR/>On 05/14/2024 at 5:36 PM, DON charted, at approximately 10:30 in the morning, LVN #1 came to see me with Resident #1 and stated that she got a cup of coffee and spilt it on herself. LVN #1 and DON did a skin assessment. Skin was intact and pink, no blisters. Changed clothes. Resident denies pain. <BR/>On 05/14/2024 at 5:36 PM, the DON charted that on 05/10/2024, changed Resident #1 into dry clothes. <BR/>ON 05/14/2024 at 5:26 PM, the DON charted the following: per my assessment on the 10th, skin is intact and slightly pink. No blisters noted. On Saturday the 11th, LVN A stated, resident only had a small area of pink skin wasn't hacked and still no blisters. On Sunday the 12th area remains pink on one side intact, no blisters. The opposite side was noted to be of normal color for the resident. On Monday when I arrived it was noted that the resident was rubbing her legs and when the nurse went to check her skin both thighs were noted to be peeling with the pink skin underneath.<BR/>Record review of Resident #1's EMR dated 06/04/2024, revealed there was a nursing note completed on 05/13/2024 by LVN B, that revealed the following: Notified the Medical Director of Resident #1's burns to upper bilateral thighs from spilling coffee on herself on Friday, May 10, 2024. Ordered to clean burns to bilateral thighs with wound cleanser, pat dry and apply burn cream to wound bed BID for 1 week. 05/14/2024 by LVN B that revealed the following: Called Resident #1's son and notified him of treatment and bilateral burns. There were no nursing notes, incident notes, or progress notes documented on 05/10/2024, 05/11/2024 and 05/12/2024.<BR/>In an interview on 06/07/2024 at 11:55 AM, the DON stated that she or her nursing staff had not notified the physician after the incident on May 10, 2024, until May 13, 2024. DON stated that she or her nursing staff had not notified the family after the incident on May 10, 2024, until May 14, 2024. She said that with any type of incident or change of condition, the physician and family should be notified immediately. She revealed this failure could result in care issues. <BR/>Record review of facility policy labeled Change in a Resident's Condition or Status, not dated, revealed the following:<BR/>Policy Statement:<BR/>Our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident's representative of changes in the resident's medical mental condition and or status.<BR/>Policy interpretation and implementation:<BR/>1) <BR/>The nurse will notify the resident's attending physician, health care provider or physician on call when there has been an:<BR/>d. significant change in the residence physical, emotional, mental condition.<BR/>e. Need to alter the residence medical treatment significantly.<BR/>2) a significant change of condition is a major decline and improvement in the resident status that:<BR/>a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.<BR/>b. Impacts more than one area of the resident's health status.<BR/>c. Requires interdisciplinary review and or revisions to the care plan.<BR/>3) The nurse will notify the resident's representative when:<BR/>b. there is a significant change in the residence physical, mental, or psychosocial status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 1 resident (Resident #1) was immediately reported to the State Survey Agency.<BR/>1. Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, on [DATE] at approximately 10:20 AM. <BR/>2. Resident #1 became unresponsive on [DATE] at 11:15 AM and was transported by ambulance to the local hospital emergency room.<BR/>3. The facility notified the resident's physician and responsible family member but did not report the incident to the State Survey Agency.<BR/>This failure placed the resident at risk for potential future harm and decline in health status due to the incident not being investigated and corrective measures not being implemented to ensure medications were administered correctly. <BR/>The findings included:<BR/>Review of Resident #1's admission Record, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident had an Out of Hospital DNR Code Status. The resident's diagnoses included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), pneumonia, urinary tract infection, congestive heart failure (the heart's main pumping chamber - left ventricle - becomes stiff and unable to fill properly), hypertension (high blood pressure), dementia (impaired brain function and thought processes), and hypothyroidism (thyroid disorder). <BR/>Review of Resident #1's comprehensive care plan, dated [DATE] revealed it addressed hypertension related to congestive heart failure. The care plan approaches included to give anti-hypertensive medications at ordered and monitor for side effects such as orthostatic hypotension and increased heart rate.<BR/>Review of Resident #1's Nursing Progress Note, dated [DATE] at 10:33 AM revealed LVN A documented the resident's family and physician were contacted about the wrong medication being given.<BR/>Review of Resident #1's Nursing Progress Note, dated [DATE] at 10:48 AM revealed LVN A documented the resident's physician was called at 10:33 AM and he stated to monitor the resident's BP and monitor the resident closely. The LVN documented she went to check the resident's BP at 11:15 AM in the dining room and found the resident unresponsive. The LVN got the DON. The resident was laid on the floor and oxygen was applied. The DON did sternal rubs and 911 was called. The resident left with EMS. The physician and family were notified.<BR/>Review of the Medication Incident Report, dated [DATE] revealed the DON documented Resident #1 was given the wrong medication by LVN A, who immediately reported she had given Resident #1 another resident's medications by mistake. The resident's physician was called at 10:33 AM and informed Resident #1 received anti-hypertensives and a narcotic. Orders were received to monitor the resident's BP and monitor her closely. At approximately 11:15 AM, LVN A reported Resident #1 was unconscious and non-verbal. The DON found Resident #1 unconscious in the dining area and gave her a sternal rub and called her name in a loud voice. The DON listened to her heart and lung sounds and none were noted. Resident #1 was placed on a mat on the floor, oxygen was applied, and 911 was called. The DON continued sternal rubs and called the resident's name. EMS arrived just as Resident #1 stated she was awake and could hear the DON. The DON assisted EMS with putting Resident #1 onto the gurney. The physician was called at 11:24 AM and was notified Resident #1 was transported to the local hospital. The family was notified by LVN A and LVN B. The DON documented the resident had been alert and oriented that morning.<BR/>In an interview on [DATE] at 2:18 PM, the DON stated LVN A was a new nurse and was hired within the last year. The DON did not document any notes regarding the incident. The DON stated the Regional Nurse Consultant told her to verbally counsel LVN A, but not to give her a written disciplinary notice.<BR/>In an interview on [DATE] at 3:11 PM, the Administrator stated she had wanted to report the incident of Resident #1 receiving the wrong medications to the State regulatory agency. She stated it was an avoidable incident. The Administrator stated Resident #1 received 7 medications that were not ordered for her and she could have died. She stated the corporate Regional Nurse Consultant had told the DON to counsel LVN A because she was so upset, she was a young nurse, and everyone made mistakes. The Administrator stated she spoke with her corporate boss and he told her the incident was not reportable. <BR/>Review of the facility's Abuse Prevention Program and Reporting Policy - Risk Management, dated as revised 11/2022 revealed the following [in part]:<BR/>Incidents that a NF Must Report to HHSC and the Time Frames for Reporting.<BR/>A NF must report to HHSC the following types of incidents, in accordance with applicable state and federal requirements:<BR/>Abuse<BR/>Neglect<BR/>Exploitation<BR/>Death due to unusual circumstances<BR/>A missing resident<BR/>Misappropriation<BR/>Drug theft<BR/>Suspicious injuries of unknown sources<BR/>Fire<BR/>Emergency situations that pose a threat to resident health and safety<BR/>The following table describes required reporting timeframes for each incident type:<BR/>Type of Incident When to Report<BR/>Abuse (with or without serious bodily injury); or<BR/>Neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, that result in serious bodily injury.<BR/>Immediately, but not later than two hours after the incident occurs or is suspected

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication regimen, in that:<BR/>Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, a narcotic medication, and a diuretic medication on 2/29/2024 at approximately 10:20 AM. Resident #1 became unresponsive on 2/29/2024 at 11:15 AM and was transported by ambulance to the local hospital emergency room. Resident #1 was admitted to the hospital on [DATE] with a diagnosis of hypotension (abnormally low blood pressure) due to drugs.<BR/>An Immediate Jeopardy was identified on 03/07/2024. The Immediate Jeopardy Template was provided to the Administrator on 03/07/2024 at 5:15 PM. While the Immediate Jeopardy was removed on 03/08/2024 at 6:55 PM, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. <BR/>This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death.<BR/>The findings included:<BR/>Review of Resident #1's admission Record, dated 3/01/2024, revealed a [AGE] year-old female admitted to the facility on [DATE]. The resident had an Out of Hospital DNR Code Status. The resident's diagnoses included sepsis (infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever), pneumonia, urinary tract infection, congestive heart failure (the heart's main pumping chamber - left ventricle - becomes stiff and unable to fill properly), hypertension (high blood pressure), dementia (impaired brain function and thought processes), and hypothyroidism (thyroid disorder). <BR/>Review of Resident #1's comprehensive care plan, dated 2/28/2024 revealed it addressed hypertension related to congestive heart failure. The care plan approaches included to give anti-hypertensive medications at ordered and monitor for side effects such as orthostatic hypotension and increased heart rate.<BR/>Review of Resident #1's Medication Administration Record, dated February 2024, revealed LVN A documented a blood pressure of 121/75 on the morning of 2/29/2024. The record documented Resident #1's medication orders included:<BR/>Cozaar 50 mg daily (anti-hypertensive medication)<BR/>Metoprolol succinate 12.5 mg daily (anti-hypertensive medication)<BR/>Furosemide 10 mg daily (diuretic medication)<BR/>Tramadol 50 mg daily at bedtime for pain (opioid pain relief medication).<BR/>Review of the Medication Incident Report, dated 2/29/2024 revealed the DON documented Resident #1 was given the wrong medication by LVN A, who immediately reported she had given Resident #1 another resident's medications by mistake. The resident's physician was called at 10:33 AM and informed Resident #1 received anti-hypertensives and a narcotic. Orders were received to monitor the resident's BP and monitor her closely. At approximately 11:15 AM, LVN A reported Resident #1 was unconscious and non-verbal. The DON found Resident #1 unconscious in the dining area and gave her a sternal rub and called her name in a loud voice. The DON listened to her heart and lung sounds and none were noted. Resident #1 was placed on a mat on the floor, oxygen was applied, and 911 was called. The DON continued sternal rubs and called the resident's name. EMS arrived just as Resident #1 stated she was awake and could hear the DON. The DON assisted EMS with putting Resident #1 onto the gurney. The physician was called at 11:24 AM and was notified Resident #1 was transported to the local hospital. The family was notified by LVN A and LVN B. The DON documented the resident had been alert and oriented that morning.<BR/>Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:33 AM revealed LVN A documented the resident's family and physician were contacted about the wrong medication being given.<BR/>Review of Resident #1's Nursing Progress Note, dated 2/29/2024 at 10:48 AM revealed LVN A documented the resident's physician was called at 10:33 AM and he stated to monitor the resident's BP and monitor the resident closely. The LVN documented she went to check the resident's BP at 11:15 AM in the dining room and found the resident unresponsive. The LVN got the DON. The resident was laid on the floor and oxygen was applied. The DON did sternal rubs and 911 was called. The resident left with EMS. The physician and family were notified.<BR/>Review of Resident #1's hospital medical record, dated 2/29/2024, revealed the following [in part]:<BR/>History of Present Illness<BR/>Patient was given another resident's medications that included:<BR/>Amlodipine 10 mg (blood pressure lowering - calcium channel blocker)<BR/>Carvedilol 25 mg (blood pressure lowering - alpha-beta blocker)<BR/>Isosorbide mononitrate ER (extended release) 60 mg (nitrate - blood vessel widening, preventative for chest pain)<BR/>Norco 7.5 mg (Hydrocodone - opioid for pain relief)<BR/>Spironolactone 25 mg (diuretic - fluid reduction)<BR/>She then went unresponsive with no pulse and no breaths. By the time EMS arrives she was breathing on her own and had a pulse. She was found to be hypotensive and brought in. <BR/>Clinical Impression<BR/>Hypotension due to drugs.<BR/>Chronic anemia associated with chronic disease.<BR/>Triage: 2/29/24 at 11:20 AM - BP 59/24.<BR/>In an interview on 3/01//2024 at 2:18 PM, the DON stated LVN A had made a medication error the prior day on 2/29/2024. She stated LVN A got distracted when someone was talking to her and she grabbed the wrong medication cup and gave Resident #1 the medications for another resident. She stated the medications included a blood pressure pill and Norco. The DON stated LVN A immediately told her at 10:30 AM. She stated LVN A realized what she had done when she did it. The DON stated she called Resident #1's physician at 10:33 AM, and he asked what BP medication Resident #1 had been given, which was Isosorbide 60 mg. The physician stated that was a high amount of blood pressure medication for her and to monitor her BP. The DON stated at 11:15 AM, Resident #1 was unresponsive, had no heartbeat or pulse, and oxygen was applied. The DON stated she did a sternum rub and someone called 911. The DON stated she called the physician at 11:24 AM and notified him Resident #1 was awake, alert, and on her way to the ER. The DON stated she had LVN A call and notify the resident's family. The DON stated the ADON accompanied LVN A on her next medication pass. The DON stated she completed an incident report for the med error. The DON stated LVN A was a new nurse and was hired within the last year. <BR/>In an interview on 3/01/2024 at 3:40 PM, the ADON stated she had made random observations of LVN A during the past few months and there was never anything observed that gave her reason for alarm or concern. The ADON stated she did not know when the medications were being given yesterday morning or if LVN A was passing medications from the medication cart or from the medication room. The ADON stated LVN A told her what happened. LVN A was asked if she had passed any more medications since the incident and she said no. The ADON stated she went through LVN A's next medication pass with her about noon on 2/29/2024. She stated LVN A passed medications from the medication room (carried the medication cup from the medication room rather than pushing the medication cart) due to not having a full medication pass at that time. The ADON stated she observed LVN A through the whole process from start to finish. She stated she observed LVN A review the resident's medication order, open the medication cart and find the correct medication, verify the labeled medication card with the order, pop the medication from the bubble pack card into the medication cup, and take it to the resident and verify, and administered the medication. LVN A initialed the resident's electronic MAR after the medication was administered. The ADON stated the incident with Resident #1 was the only medication error that has been made since she started employment in the facility during November 2023. The ADON stated LVN A was the youngest and newest nurse, and the other licensed nurses have had more experience. The ADON stated she thought LVN A was competent and she made a mistake when she got busy. She stated LVN A needed to slow down and think about what she was doing. The ADON stated the standard of practice was to pop medications from the cards for one resident at a time. <BR/>In an interview on 3/01/2024 at 4:43 PM, LVN A stated when she arrived at work on the morning 2/29/2024, the computer for the medication cart had not been charged and she had it plugged it into the outlet in the medication room. She stated she had taken a resident's vital signs and blood pressure and had placed his medications in a cup on top of the medication cart in the medication room. She stated she gathered her equipment to take Resident #1's vital signs (BP cuff, thermometer, oxygen pulse oximeter) and carried the medication cup and equipment to Resident #1 who was in the sunroom. LVN A stated she had it in her head to give Resident #1 the medications and she gave them to her and then took her vital signs. She stated it was about 10:20 AM. She stated she then went back to the medication room to enter the medications were given on the MAR when she realized what she had done. LVN A stated she immediately reported her error to the DON. Resident #1 was assessed and was later found to be unresponsive. The DON called the doctor. LVN A stated she called the family and said Resident #1 had been given the wrong medications and was on the way to the hospital. She stated the BP medication given was Isosorbide. LVN stated she felt awful about it and became tearful. She stated she would focus on the process of start to finish for one resident at a time. LVN A demonstrated how she reviewed a medication order in the electronic MAR, unlocked the medication cart and to find the medication and compared the card to the order in the computer, signed out the medication in the narcotic book if applicable, popped the medication from the card into a medication cup, replaced the medication card in the cart and locked it, gave the medication to the resident, and then returned and documented Y in the electronic MAR. LVN A stated she learned from this error and would focus and think about what she was doing.<BR/>Observation and interview on 3/04/2024 at 1:45 PM with Resident #1 in the hospital revealed she was laying on her back in bed with the head of the bed elevated. She was using supplemental oxygen via nasal cannula. Resident #1 was awake, alert, and oriented. Resident #1 stated her doctor had been to the hospital to see her. Resident #1 stated she was feeling some better. She stated she had gone to the nursing facility after being in the hospital with pneumonia. Resident #1 stated she found out what had happened to her at the nursing home and stated she did not receive good care there. Resident #1 stated she planned to go to a different nursing home where her family members had both been and she had visited them. She stated she was familiar with the place. Resident #1 stated she could not walk very well anymore and hoped to receive therapy there. Resident #1 stated she took Tramadol and it helped with her hip and leg pain. She stated she had a wheelchair and a power chair and hoped to be able to use it again. <BR/>In an interview on 3/05/2024 at 1:24 PM, the DON stated the ADON had observed LVN A give the entire lunch medication pass on Hall 2 and Hall 3 on 2/29/2024. She stated she did verbal counseling with LVN A on Thursday, 2/29/2024. The DON stated on Saturday, 3/02/2024 she came to the facility and did an in-service training on the medication administration policy and procedure with LVN A and gave her a suspension notice pending investigation. The DON stated the Administrator determined LVN A may need more training and needed to be taken off the schedule. The DON stated she came to the facility on Saturday and suspended LVN A's employment per the Administrator's directive. She stated the Administrator spoke with her corporate boss on 3/04/24 and he gave instruction for LVN A to have additional instruction for the medication pass with the medication pass checklist to be completed for 3 days - Thursday, Friday and Saturday. The DON stated LVN A was scheduled to return to work on Thursday 3/07/24 and the ADON would go with her during the medication pass with a checklist. The DON stated this was the first medication error LVN A had made since she started employment during November 2023.<BR/>In a telephone interview on 3/06/2024 at 12:51 PM, Resident #1's physician stated he was aware of the incident and had been called immediately by a nurse at the facility. The physician stated he had been at the facility the morning of Thursday 2/29/24 before the incident. He stated Resident #1 was fine and was going to therapy. The physician stated Resident #1 became syncopal after being given the other resident's blood pressure medications. He stated she was responsive when the ambulance crew arrived to transport her to the ER. The physician stated the safety concern for Resident #1 was her blood pressure going too low and making her pass out. He stated the other medications did not have huge concerns (pain and diuretic medications). He stated the BP medications were the main concern.<BR/>Review of the facility's policy and procedure for Medication Administration, dated 1/2013 revealed the following [in part]:<BR/>Purpose:<BR/>To administer the following according to the principles of medication administration, including the right medication, to the right resident/patient at the right time, and in the right dose and route.<BR/>Equipment:<BR/>Medication as ordered<BR/>Administration supplies as indicated<BR/>Procedure:<BR/>1. Verify physician's orders for medications to be administered.<BR/>2. Review any special precautions and perform needed evaluations prior to administering medication to the resident/patient.<BR/>Review resident/patient allergies.<BR/>Review pertinent lab results, as indicated .<BR/>Perform needed evaluations prior to administering specific medications (e.g., pulse, blood pressure, blood glucose).<BR/>3. Identify resident/patient via wristband or picture ID.<BR/>4. Explain the procedure to the resident/patient. Include the type of medication ordered, the reason, frequency, and route .<BR/>10. Read the Medication Administration Record (MAR) for the ordered medication, dose, route, and time .<BR/>13. Verify the following, again, by comparing medication to MAR prior to administering:<BR/>Correct resident/patient<BR/>Correct medication<BR/>Expiration date<BR/>Dose and dosage form<BR/>Route<BR/>Time .<BR/>This was determined to be an Immediate Jeopardy on 3/07/2024. The Administrator was provided the Immediate Jeopardy Template on 3/07/2024 at 5:15 PM and a Plan of Removal was requested. <BR/>The following Plan of Removal submitted by the facility and accepted on 3/08/2024 at 4:37 PM:<BR/>1. Resident #1 was immediately assessed by the Licensed Nurse (LN) on 02/29/24 and the physician was notified of the medication error with a new order to monitor the resident's blood pressure closely. The order was noted by the LN. When the LN went to monitor Resident #1 after receiving the order, the resident was found unresponsive. The LN called EMS which responded quickly, and the resident was discharged to the ER for observation on 02/29/24.<BR/>2. The 24-hour report was reviewed on 3/7/24 by the Assistant Director of Nursing (ADON) for the past 72 hours to ensure there were no further medication errors and/or changes in any resident's condition. Any concerns will be addressed by a LN if identified. The results of the report covering the past 72 hours found no additional medication errors or changes in residents' condition. No further physician notification of actions by the licensed nurse was necessary.<BR/>3. When the Director of Nursing (DON) interviewed the LN on 02/29/24 who made medication error, it was determined that the LN dispensed the medication for a resident other than resident #1. She then realized that she needed to take resident #1's blood pressure, and subsequently also gave the other resident's medication to resident #1. The education provided to this LN by the DON included avoiding distractions and completing the medication pass one resident at a time once starting the medication administration process.<BR/>Beginning 3/6/24, LNs and Certified Medication Aides (CMAs) will have a medication pass observation completed by a Registered Nurse (RN) prior to the beginning of their next shift and receive education as needed for any concerns identified by the RN conducting the observation. The RN will observe a minimum of 50% of the LNs or CMAs medication pass for that scheduled time to validate competency. The RN will stop the LN or CMA if they identify a problem and provide immediate reeducation in real time on the issue identified. The medication administration observations will be documented on the facility's Medication Administration/Technique Observation tool which follows the facility's Medication Management policy. <BR/>On 3/8/24, the LNs and CMAs went through additional medication administration education that was provided by the ADON. This education included avoiding distractions to the medication pass and once starting to dispense medication for a resident, not to stop and perform any other non-emergent tasks. It also included following the facilities procedure on Medication Administration from the facilities Nursing Procedure Manual. The LNs and CMAs understanding of the education will be demonstrated through RN observed medication administration observations previously described.<BR/>All newly hired LNs and CMAs will go through medication pass validations by a LN with the tools mentioned above during their orientation.<BR/>4. The DON, ADON or designee will complete med pass observations weekly for 12 weeks to ensure licensed nurse and medications aides continue to administer medications per physician's orders and to the right resident. The Medical Director was notified of this survey outcome on 3/8/24 and will be involved in the facility QAPI process surrounding this plan. A report of the medication administration audits will be submitted to the QAPI committee for review and recommendations as needed. The facility held an initial QAPI meeting on 3/8/24 to review the outcome of the medication administration observations to this point. Starting the week of March 11, 2024, a QAPI meeting will be conducted weekly for 4 weeks then monthly. The DON is responsible for monitoring and additional actions to this plan if needed.<BR/>Date of Compliance: 03/08/24<BR/>Monitoring and verification of the facility's Plan of Removal began on 3/08/2024 at 4:40 PM as follows:<BR/>Observation on 3/06/2024 at 11:46 AM revealed the DON was observing LVN C passing medications and was using a medication administration competency checklist. <BR/>In an interview on 3/06/2024 at 11:52 AM, the DON stated she did medication administration competency checklist for LVN C. She stated the MDS Coordinator had observed LVN D and did the medication competency on her. The DON stated they were the only 2 LVNs at the facility. She stated 6 more LVNs would be evaluated for medication administration competency. The DON stated LVN A would have 3 days of evaluation using the medication checklists. She stated tomorrow and Friday (3/07/24 and 3/08/24) the ADON would observe LVN A and complete the medication administration checklist and on Saturday, 3/09/24 the weekend RN would observe LVN A and complete the medication administration checklist.<BR/>In an interview on 3/07/2024 at 2:32 PM, the MDS Coordinator stated she had evaluated LVN D and completed the medication checklist with her yesterday on 3/06/2024.<BR/>During an observation and interview on 3/07/2024 at 4:03 PM, MA E was observed during the preparation of medication to administer to a resident. She stated she would not take the medication cart down the hallway, due to only having medication for 1 resident. MA E reviewed the resident's medication orders in the electronic medication administration record, unlocked the medication cart and located the medication card, popped the medication into a medication cup, returned the medication card to the cart, and locked the medication cart. She proceeded to walk down the hallway to the resident's room carrying the medication cup and a glass with water, and stated she identified the resident by her picture on the medication administration record and by her room number. MA E identified herself to the resident, explained the pills she had brought for the resident, tapped the pills from the medication cup into the resident's mouth, and offered her the glass of water. MA E left the resident's room and walked back to the medication cart, pulled up the resident's medication administration record, initialed the medication had been given, and closed the electronic medication administration record.<BR/>During an observation and interview on 3/07/2024 at 4:40 PM, LVN B was observed during the preparation of medication to administer to a resident who was seated at a table in the dining room. The LVN pushed the medication cart from the medication room and positioned the cart against the wall to the right of the entrance to the dining room. LVN B stated she took the medication cart into the halls when she had the main medication pass, but sometimes just carried the medication cup and a glass of water to the resident if it was only one resident. LVN B reviewed the medication order in the resident's electronic medication administration record. The resident's picture was in the upper left-hand corner of the medication administration record. LVN B unlocked the medication cart, found the medication card and compared it to the order on the medication administration record. She popped one tablet from the medication card into a medication cup, returned the medication card into the medication cart, and locked the cart. LVN B hit the screen saver on the computer, took the medication cup and a glass of water to the resident and watched her swallow the medication. She returned to the medication cart and entered the medication administered on electronic medication administration record and closed the record.<BR/>In an interview on 3/08/2024 at 11:02 AM the ADON stated she was accompanying LVN A during the medication passes for the day.<BR/>Review of the fax cover sheet dated 3/08/2024 at 1:41 PM revealed the Administrator had sent the Medical Director a notification letter regarding the medication error, a copy of the IJ Template and the facility's draft Plan of Removal.<BR/>Review of the in-service training record dated 3/08/2024 at 2:00 PM revealed a training was provided to the licensed nurses regarding the topic of medication management and the facility's policy and procedure for medication error preventing and reporting. The attendance sheet was signed by a medication aide, 5 LVNs, and the weekend RN.<BR/>In an interview on 3/08/2024 at 5:37 PM, LVN B stated the ADON had watched her pass medications yesterday on 3/07/2024. LVN B stated the nurses had in-service training that day at 2:00 PM and the topics covered were medication errors, the types of medication errors - giving the wrong medication or transcription errors in orders, using the 5 Rights of Medication administration, and avoiding distractions when preparing medications for administration.<BR/>Observation on 3/08/2024 at 5:48 PM revealed the ADON was accompanying LVN A on the medication pass in Hall 2. The medication cart was in the hallway.<BR/>Review of the QAPI Meeting Sign-in Sheet, dated 3/08/2024 at 3:00 PM, revealed the committee discussed the IJ Plan of Removal for medication error.<BR/>During an interview and record review on 3/08/2024 at 4:26 PM, the ADON provided a copy of the 72 Hour Summary report dated 3/04/24 - 3/07/24. She stated the 24-hour report was printed from the program used for the residents' electronic health records and included new orders, progress notes, weights and vital signs. She stated there was not a way to filter all the information that was included in the report. The ADON stated the MDS Coordinator reviewed the 24-hour report in the morning, Monday through Friday, and she sent an email to the Administrator, DON, ADON, and therapy staff with any concerns or anything that needed follow-up. Review of the copy of the 72 Hour Summary report revealed it consisted of 32 pages and the first page had been signed as reviewed by the ADON on 3/07/24 at 1900 (7 PM). The 72 Hour Summary report had 10 hand-written documented notations for vital signs and weight changes that had been rechecked.<BR/>[This interview and record review were conducted prior to the acceptance of the final draft of the Plan of Removal.]<BR/>The Administrator was informed the Immediate Jeopardy was removed on 3/08/24 at 6:55 PM. The facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of four residents (Resident #1) reviewed for Comprehensive Care Plans.<BR/>The facility failed to address Resident #1's preference for privacy and to not have staff with him while he was using the bathroom. <BR/>This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care.<BR/>The findings included:<BR/>Record review of Resident #1's Face Sheet, dated 02/09/24, revealed a [AGE] year-old-male, admitted to the facility on [DATE], with admitting diagnoses of dementia (a decline in cognitive abilities that impacts a person's ability to perform everyday activities), spondylolysis lumbar region (a small crack between two vertebrae - the bones in your spine), fracture of first cervical vertebra (commonly called a broken neck, is a fracture of any of the seven cervical vertebrae in the neck), and repeated falls. <BR/>Record review of Resident #1's MDS Significant Change Assessment, dated 01/16/24, revealed Resident #1 had a BIMS score of 7 (severe impairment). He ambulated with a wheelchair. He was accessed as dependent for toileting and toilet transfer. <BR/>Record review of Resident #1's Care Plan, dated as revised on 02/09/24, failed to address Resident #1's preference for privacy while he used the restroom. <BR/>Record review of Resident #1's Post Fall Assessment, dated 02/08/24, revealed resident stated he was going to the toilet and slipped. Vital signs were all within normal limits.<BR/>In an interview on 02/08/24 at 3:00 p.m., Resident #1 said he did not want anyone in the room with him while he used the toilet. <BR/>In an interview on 02/08/24 at 3:15 p.m., Resident #1's family member said he did not think Resident #1 liked staff with him while he uses the bathroom. <BR/>In an interview 02/08/24 at 3:30 p.m., CNA C said she was familiar with Resident #1 and that he refused to use the bathroom if staff were in the room with him, so they placed him on the toilet, stayed in the area, and would tell him to ring the bell when he was ready. <BR/>In an interview on 02/08/24 at 3:35 p.m., CNA D said Resident #1 did not want anyone in the room while he was using the bathroom, not even standing behind the privacy curtain. <BR/>In a follow-up interview on 02/08/24 at 4:20 p.m., Resident #1 was sitting in the dining room in his wheelchair, drinking coffee. He said he was very independent and did not like staff to be with him while he used the bathroom.<BR/>In an interview on 02/08/24 at 4:29 p.m., RN F stated she was familiar with Resident #1, and he did not want staff with him while he used the bathroom. <BR/>In an interview on 02/09/24 at 10:00 a.m., the MDS Coordinator said she was responsible for resident's care plans. She said she did not remember putting Resident #1's preference for privacy but he was very independent. She said she did not see the need to have it in Resident #1's care plan about that particular thing because we respect everyone's privacy. <BR/>In an interview on 02/09/24 at 12:04 p.m., CNA A said Resident #1 does not like anyone to stay in the bathroom with him. <BR/>In an interview on 02/09/24 at 1:25 p.m., the DON said Resident #1's preference of not wanting anyone in his room while he was on the toilet should have been care planned, but she never knew that. <BR/>Record review of the facility's policy Fall Risk Reduction and Management, dated as revised 12/2015, revealed the following [in part]: Each resident/patient is evaluated upon admission, with change in clinical condition and quarterly to determine indicators of fall risk. Individualized interventions are implemented to decrease the risk of fall.<BR/>A facility policy and procedure for comprehensive care plans was not received at the time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment and failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment including both the comprehensive assessment and quarterly review assessments for 9 (Resident #1, #2, #5, #6, #9, #11 , #18 #22, and #23) of 11 residents who were reviewed for comprehensive care plans. <BR/>1. The facility failed to develop a comprehensive care plan within seven days for Resident #1, #5, #9, #18 and #23.<BR/>2. The interdisciplinary team failed to review and revise the plan of care for Residents #1 #2, #5, #6, #9, #11, #18, #22, and #23.<BR/>These failures could affect residents by placing them at risk for not having their individual needs met. <BR/>Findings include:<BR/>Resident #1<BR/>Record review of Resident #1's Face Sheet, dated 03/14/2023, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis included hypertension (high blood pressure), hypoxemia low blood oxygen level, moderate protein calorie malnutrition (a deficient nutritional state caused due to lack of protein and calories), and osteoporosis with pathological fracture (brittle bones with a fracture caused by this bone disease), and repeated falls.<BR/>Record review of Resident #1's MDS Annual Assessment, dated 02/23/2023 revealed a BIMS score of 15 (cognitively intact).<BR/>Record review of Resident #1's care plans revealed the facility developed a care plan on 11/23/2022 . The facility failed to develop a care plan after the MDS annual assessment dated [DATE]. There was no documentation in the electronic record that an IDT Care Plan Meeting was conducted.<BR/>Interview with Resident #1 on 03/13/23 at 10:43 AM revealed she had not attended or been invited to a care plan meeting at the facility. <BR/>In an interview with the Social Worker on 03/14/2023 at 3:18 PM, she stated she was responsible for scheduling the care plan meetings and sending invitations to the residents and their family. She stated she sends a letter but does not document whether the family or resident refuses to attend. She stated she was unable to provide a care conference attendance sheet for Resident #1.<BR/>Resident #2<BR/>Record review of Resident #2's Face Sheet, dated 03/14/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE] with the latest admission date of 11/29/2022. Diagnosis include dementia; cerebral infarction (stroke); fracture of shift of humerus, right arm; type 2 diabetes with diabetic chronic kidney disease; anxiety disorder, and repeated falls. <BR/>Record review of Resident #2's MDS Quarterly assessment, dated 01/18/2023 revealed a BIMS score of 6 (severe cognitive impairment). <BR/>Record review of Resident #2's care plans revealed the facility developed a care plan on 01/16/23 with the next care plan dated 02/28/23. The facility failed to develop a care plan after MDS quarterly assessment of 01/18/23. There was no documentation in the electronic record of an IDT Care Plan Meeting was conducted.<BR/>Resident #5<BR/>Record review of Resident #5's Face Sheet, dated 03/14/2023 revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnosis include dementia; acute kidney failure; intracranial injury without loss of consciousness (a head injury causing damage to the brain by external force or mechanism); depressive episodes, anxiety disorder, and repeated falls. <BR/>Record review of Resident #5's MDS Quarterly assessment, dated 02/07/2023 revealed a BIMS score of 12 (moderate cognitive impairment). <BR/>Record review of Resident #5's care plans revealed the facility developed a care plan on 02/06/2023. The facility failed to develop a care plan after the MDS Quarterly Assessment on 02/07/2023. There was no documentation in the electronic record of an IDT Care Plan meeting being conducted. The facility conducted an IDT Care Plan Meeting on 02/16/2023 (after the MDS quarterly assessment) with only the Resident's family member and Social Worker in attendance. There was no documentation of a nurse in attendance.<BR/>Resident #6<BR/>Record review of Resident #6's Face Sheet, dated 03/14/2023 revealed an [AGE] year-old female, admitted to the facility on [DATE] with the latest admission date of 09/14/2022. Diagnosis include vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), unspecified psychosis (a collection of symptoms, including delusions and hallucinations), Parkinson's Disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), depressant disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that includes symptoms of nervousness, panic and fear as well as sweating and a rapid heartbeat).<BR/>Record review of Resident #6's Quarterly MDS Assessment, dated 12/19/2022, revealed a BIMS score of 10 (moderate cognitive impairment). <BR/>Record review of Resident #6's care plans revealed the facility developed a care plan on 12/19/2022. There was no documentation in the electronic record of an IDT Care Plan meeting being conducted. <BR/>Resident #9<BR/>Record review of Resident #9's Face Sheet, dated 03/15/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included pressure induced deep tissue injury, cerebral infarction (death of brain tissue due to disrupted blood flow), pressure ulcer (injury to skin and underlying tissue) and repeated falls.<BR/>Record review of Resident #9's MDS admission assessment, dated 02/02/2023 revealed a BIMS score of 15 (cognitively intact).<BR/>Record review of Resident #9's care plans revealed the facility held a care plan meeting on 03/07/2023. The facility failed to have an interdisciplinary care plan after the MDS quarterly assessment dated [DATE] and the admission comprehensive MDS dated [DATE]. There was no documentation in the electronic record that an IDT care plan meeting was held that included a member of nursing. The meeting documented on 03/07/2023 was only attended by the resident, his family by phone and the social worker.<BR/>Resident #11<BR/>Record review of Resident #11's Face Sheet, dated 03/15/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included diabetes, chronic kidney disease, hypertension (high blood pressure), and repeated falls.<BR/>Record review of Resident #11's MDS quarterly assessment, dated 12/27/2022 revealed a BIMS score of 13 (no cognitive impairment and was receiving hospice services and oxygen therapy).<BR/>Record review of Resident #11's care plan revealed the facility held a care plan meeting on 01/05/2023. It was attended by the social worker and a family member. There was no documentation to indicate the care plan meeting was attended by a hospice representative or nursing services.<BR/>Resident #18<BR/>Record review of Resident #18's MDS significant change assessment, dated 01/18/2023, revealed a [AGE] year-old male, re-admitted to the facility on [DATE]. Diagnosis included anemia, atrial fibrillation (irregular, often rapid heartbeat that causes poor blood flow), hypertension (high blood pressure), benign prostatic hypertrophy (noncancerous enlargement of the prostate) and neurogenic bladder (lack of bladder control due to a brain, spinal cord, or nerve problem). <BR/>Resident #18's MDS Assessment, dated 12/27/2022 revealed a BIMS score of 13 (no cognitive impairment).<BR/>Record review of Resident #18's electronic medical record revealed the facility did not document they held an IDT care plan meeting after the comprehensive significant change assessment dated [DATE]. <BR/>Resident # 22<BR/>Record review of Resident #22's Quarterly MDS Assessment, dated 02/16/2023, revealed a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses included cerebrovascular accident (stroke), hemiparesis (a condition that causes weakness or paralysis on one side of the body), depression, and diabetes mellitus. <BR/>Record review of Resident #22's care plan revealed the facility developed a care plan on 02/08/2023. There was no documentation in the electronic record of an IDT Care Plan meeting conducted until 02/23/2022. <BR/>Resident #23<BR/>Record review of Resident #23's face sheet, dated 03/15/2023, revealed a [AGE] year-old female, admitted to the facility on [DATE]. Diagnosis included anemia, hypertension (high blood pressure), renal failure (failure of the kidneys) diabetes, and dementia.<BR/>Record review of Resident #23's MDS significant change comprehensive assessment, dated 01/31/2023 revealed a BIMS score of 9 (moderate cognitive impairment). <BR/>Record review of Resident #23's progress notes revealed Resident had a new diagnosis of cellulitis of her left lower extremity and was started on an antibiotic for which the significant change MDS was completed on 01/31/2023. There was no documentation of an interdisciplinary care plan meeting held at the time the assessment was completed.<BR/>In an interview on 03/13/2023 Resident #23 revealed she had never been invited to a care plan meeting. <BR/>In an interview on 03/14/2023 at 10:15 AM the MDS coordinator said the Social Worker was responsible for planning the care plan conferences, sending out invitations, and documenting them. She stated she was aware that the comprehensive assessment and care plans needed to be updated after the MDS was completed. She stated she did not realize this was not being done.<BR/>In an interview on 03/14/2023 at 03:18 pm, the Social Worker revealed the care plan meetings were not all documented. She stated she had not consistently been documenting the care plans or resident/family refusal if they did not attend. She stated the previous DON usually attended, but stated she was not good about signing the attendance sheet. She stated she was responsible for the documentation of the meetings and meeting attendance, but she just stopped doing it. She said the failure could place the residents at risk for unmet needs. <BR/>In an interview with the social worker and the MDS nurse on 3/15/2023 at 8:48 AM both stated the care plan meetings had not been scheduled to coincide with the MDS comprehensive and quarterly assessments. They stated they could not provide documentation that the meetings were attended by the required members of the IDT. The MDS nurse stated she should have a care plan meeting when a comprehensive assessment was done and it should be scheduled within 14 days of the completion of the comprehensive assessment. She stated not having a care plan meeting could result in a decline in the resident from not receiving the needed care.<BR/>Record review of the facility policy Care Plan Development, dated 08/15, revealed the following [in part]:<BR/>An individualized, comprehensive care plan using the result of the RAI/MDS assessment, resident/family/legal representative and interdisciplinary input will be developed for each resident in the facility within 21 days or 7 days after the completion date of a comprehensive MDS assessment and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan will include measureable objectives, interventions, goals, and timelines. The care plan will be reviewed and revised on an as needed basis and at least every 92 days.<BR/>Procedure:<BR/>2. The comprehensive care plan is developed by the interdisciplinary team with input from the resident/family/legal guardian and information derived from the MDS/CAA assessment . <BR/>3. The interdisciplinary team includes but not limited to:<BR/>a. Attending Physician.<BR/>b. RN, LPN, CNA.<BR/>c. Dietary Manager/Registered Dietician.<BR/>d. Activity/Recreational Director.<BR/>e. Therapist (OT, PT, ST).<BR/>f. Social Worker.<BR/>g. Director of Nursing.<BR/>h. Consultants.<BR/>i. Others as necessary to meet the needs of the resident.<BR/>5. The resident's/family/legal guardians are encouraged to attend care meetings and will be notified in writing via postal service of date and time of meeting. The Social Worker/MDS Coordinator will send invitations to the meeting and scheduled times for the care plan meeting which will be held on a specific date and start time as designated by the facility . In the event the resident does not have family/legal guardian, the resident will be asked who if any that they would prefer to attend.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 1 resident (Resident #9) reviewed for pressure ulcers.<BR/>The facility failed to provide wound care services for Resident #9 on the date of 03/13/2023 as ordered by the resident's physician. <BR/>This failure could lead to an increased and unnecessary risk of complications including worsening of existing wounds, development of new wounds, and infection. <BR/>Findings Included:<BR/>Record review of Resident #9's Face Sheet, dated 03/15/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included pressure induced deep tissue injury, cerebral infarction (death of brain tissue due to disrupted blood flow), pressure ulcer (injury to skin and underlying tissue) and repeated falls.<BR/>Record review of Resident #9's MDS admission assessment, dated 02/02/2023 revealed a BIMS score of 15 (cognitively intact). The MDS assessment indicated that the resident had two unstageable pressure ulcers and was at risk for developing new pressure ulcers. <BR/>Record review of Resident #9's active physician orders, dated 3/10/2023, indicated the resident had an active physician order with a start date of 03/10/2023 that read Wound care treatment to right lateral (side) hip & right lateral (side) knee; Cleanse with NSS, pat dry, apply no-sting skin prep to peri wound, apply Santyl Ointment to wound bed nickel thick layer, cover with gauze and secure with paper tape to be done Q Day on 2-10 shift (do not apply Santyl to healthy tissue).<BR/>Record review of Resident #9's current care plan, not dated, revealed in part:<BR/>Focus: I have two unstageable ( pressure ulcers with full thicknes tissue loss, depth is completely obscured by dead tissue in the wound bed) pressure ulcers (right knee and right thigh) at time of admit.<BR/>Goal: My pressure ulcer will show signs of healing and remain free from infection by/through review date.<BR/>Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD.<BR/>Record review of Resident #9's TAR for the month of March 2023, dated 03/01/2023 through 03/31/2023, revealed that there was no documentation of the resident's wound care and/or dressing change on the date of 03/13/2023. <BR/>Record review of LVN B's nursing progress notes on Resident #9 from 03/13/2023 at 8:30 PM revealed the following: Resident was already in bed with eyes closed. Attempted to awaken patient to complete wound care and did not awaken. No distress noted. resp even and unlabored.<BR/>During an observation and interview of Resident #9 and RN A on 03/14/2023 at 1:40 PM, Resident #9 was in his room sitting in a chair. He had a clean, dry, and intact dressing to his right knee and right thigh. The dressings were dated 03/12/2023 and were initialed by DD. Resident #9 reported he received wound care and dressing changes for the wounds on his right knee and right thigh, although he could not recall how often it was completed. He reported his bandage was last changed the night before which was 03/13/2023. He stated he did not know if staff had ever missed any bandage changes. He reported that he thought the wound was getting better, but he was not certain. The wound care was completed at that time by RN A. RN A stated the initials on the bandage dated 03/12/2023 were the initials of the Interim DON. She stated the dressing should have been changed on 03/13/2023 but the date on the bandages, which was 03/12/2023 indicated the treatment was not done on 03/13/2023.<BR/>During an interview on 03/15/2023 at 12:45 PM, the Interim DON reported that charge nurses were typically responsible for completing wound care for the patients on their assigned hallway. The Interim DON reported that LVN B was the charge nurse on Resident #9's hallway and would have been responsible for the dressing change ordered for Resident #9 on 03/13/2023. <BR/>During an interview on 03/15/2023 at 1:00 PM, LVN B reported that she worked on Resident #9's hallway on 03/13/2023. She stated she did not do the wound care or dressing change on Resident #9 on that day because she had not been told in report that Resident #9's wound care had been scheduled to be done daily and on the 2 PM to 10PM shift. She reported when she took over the shift, she began passing medications and serving the evening meal. She stated she did not realize until 8:30 PM the treatment needed to be done. She stated the resident was asleep. She stated failure to do the ordered wound care for Resident #9 could result in delayed healing time and infection to the wound. <BR/>During an interview on 03/15/2023 at 1:28 PM, the Interim DON reported that the wound care for Resident #9 was not completed as ordered on 03/13/2023. The Interim DON reported that she did not know why the resident's wound care was not completed on that day and LVN B should have attempted to awaken the resident again or told the oncoming shift so that they could attempt to do the ordered wound care. The Interim DON reported that the potential consequences of not performing ordered wound care for residents include worsening conditions of a wound.<BR/>Record review of facility provided policy titled Skin Care and Wound Management dated 06/2015, stated in Part:<BR/>Overview<BR/>The facility staff strives to prevent resident skin impairment and to promote the healing of existing wounds.<BR/>Components of the skin care and wound management program include, but are not limited to, the following: Daily monitoring of existing wounds, application of treatment protocols based on best practice standards for promotion of wound healing and communicate interventions and risk factors to the caregiving team.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 3 residents (#1, #5 and #11) reviewed for respiratory care. <BR/>A. The facility failed to ensure oxygen tubing for Residents #1, #5, and #11 were changed weekly. <BR/>B. The facility failed to ensure Resident #11's nasal cannula was kept in a bag while not in use. <BR/>These failures could place residents at risk for infections and transmission of communicable diseases. <BR/>Findings included: <BR/>Resident #1<BR/>Record review of Resident #1's Face Sheet, dated 03/14/2023, revealed she was a [AGE] year-old female, admitted to the facility on [DATE]. Diagnoses included hypertension (high blood pressure), hypoxemia low blood oxygen level, pneumonia unspecified organism moderate protein calorie malnutrition (a deficient nutritional state caused due to lack of protein and calories), and osteoporosis with pathological fracture ( brittle bones with a fracture caused by this bone disease), and repeated falls.<BR/>Record review of Resident #1's MDS Annual Assessment, dated 02/23/2023 revealed a BIMS score of 15 (cognitively intact). Section O: Respiratory Treatments was marked for Oxygen Therapy. <BR/>In an observation and interview on 03/12/2023 at 10:31 AM during initial rounds, Resident #1 was lying in her bed receiving oxygen via nasal cannula at 2 liters per minute. Her oxygen tubing was not dated. The disposable humidifier bottle was dated 02/08/2023. The resident stated she did not remember when her oxygen tubing was changed. She stated the nurse came in and she is supposed to bring her another water bottle.<BR/>In an observation on 03/12/2023 at 3:00 PM Resident #1's nasal cannula was not dated. The humidifier bottle was dated 02/08/23.<BR/>In an observation on 3/13/23 at 10:51 AM Resident #1's nasal cannula was still not dated. The humidifier bottle was dated 02/12/23. <BR/>Resident #5<BR/>Record review of Resident #5's Face Sheet, dated 03/14/2023 revealed a [AGE] year-old female, who was admitted to the facility on [DATE]. Diagnosis include dementia; acute kidney failure; intracranial injury without loss of consciousness (a head injury causing damage to the brain by external force or mechanism); depressive episodes, anxiety disorder, and chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). <BR/>Record review of Resident #5's MDS Quarterly assessment, dated 02/07/2023 revealed a BIMS score of 12 (moderate impaired). Section I: Active diagnosis revealed asthma, chronic pulmonary disease, or chronic lung disease. Section O: Respiratory Treatments was marked for Oxygen Therapy. <BR/>In an observation and interview on 03/12/23 at 10:31 AM during initial rounds, Resident #5 was sitting in her recliner receiving oxygen via nasal cannula at 2 liters per minute. Her oxygen tubing was not dated. She stated she was good, but the resident failed to answer any questions regarding whether her oxygen tubing had been changed. <BR/>In an observation on 03/12/2023 at 2:17 PM, Resident #5's oxygen tubing was not dated. <BR/>Record review of Resident #5's electronic Physician Orders, accessed on 03/12/2023 revealed an order for Oxygen at 2 liters per minute via nasal cannula. Start 10/09/2022. The Physician Orders failed to have any information regarding when oxygen tubing needed to be changed.<BR/>Record review of Resident #5's Care Plan, last revised on 02/07/2023, revealed a care plan for [Resident #5] has COPD (obstructive pulmonary disease) - Oxygen Dependent. The Care Plan failed to have an intervention regarding when oxygen tubing needed to be changed.<BR/>Resident #11<BR/>Record review of Resident #11's Face Sheet, dated 03/15/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. Diagnosis included diabetes, chronic kidney disease, hypertension (high blood pressure), and repeated falls.<BR/>Record review of Resident #11's MDS quarterly assessment, dated 12/27/2022 revealed a BIMS score of 13 (cognitively intact and was receiving hospice services and oxygen therapy).<BR/>Record review of Resident #11's care plan dated revised 03/14/2023 revealed he received oxygen at 2-3 liters/min via nasal cannula continuously related to respiratory illness and disease. Goal: Resident will have no signs or symptoms of poor oxygen absorption through the review date.<BR/>Record review of Resident #11's physician orders dated 03/01/2023 revealed the following: Change oxygen tubing weekly on Sunday. Change oxygen water when empty.<BR/>In an observation and interview on 03/12/2023 at 10:23 AM Resident #11's nasal cannula was not dated. The humidifier bottle was not dated. The O2 tubing was hanging over the railing of the bed uncovered. The resident stated he did not remember when it had been changed.<BR/>In an observation on 03/13/2023 at 2:38 PM Resident #11 was sitting asleep in his chair. His O2 tubing was not dated. It was uncovered and was hanging over the oxygen concentrator with the nose prongs about an inch from the floor. <BR/>In an Interview on 03/13/2023 at 02:45 PM with the Interim DON (who was also the charge nurse on this date) stated oxygen tubing was changed weekly based on the resident's orders, or as needed if they become contaminated or occluded. The interim DON stated oxygen tubing and the humidifier bottle should be dated to indicate when they were changed. If they were not labeled, she stated she would discard them and replace it with a new nasal cannula. She stated she preferred staff do this because you could never be sure of another person's infection control practices. She stated tubing should be stored in a plastic bag when not in use to prevent cross contamination and infection. <BR/>Record review of the facility policy Respiratory Equipment Change Schedule, dated 01/13, revealed the following [in part]:<BR/>Purpose: Routine cleaning and/or changing of disposable respiratory equipment is done to prevent nosocomial infections.<BR/>Procedure: Product: Oxygen delivery devices (no-aerosol producing) Ex: venturi masks, nasal cannulas, oxygen supply tubing.<BR/>Record review of the facility policy Oxygen Administration, Nasal Cannula, dated as revised on 06/15/2021, revealed the following [in part]: <BR/>Purpose: To provide the resident/patient with enhanced oxygen concentration of inspired room air.<BR/>Procedure: 7. Date disposable supplies upon opening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Residents #6) reviewed for unnecessary medications. <BR/>Resident #6 had an order and administered Seroquel (an antipsychotic medication) for a diagnosis of behaviors, which was not an appropriate indication for use.<BR/>This failure placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status.<BR/>Findings include:<BR/>Record review of Resident #6's Face Sheet, dated 03/14/2023, revealed an [AGE] year-old female last admitted to the facility on [DATE]. Diagnoses included: vascular dementia (problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), unspecified psychosis (a collection of symptoms, including delusions and hallucinations), Parkinson's Disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), depressant disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a mental health condition that includes symptoms of nervousness, panic and fear as well as sweating and a rapid heartbeat).<BR/>Record review of Resident #6's current Physician Orders, accessed on 03/14/2023, revealed an order for Seroquel 25mg at bedtime for the diagnosis of behaviors, with a start date of 10/01/2022. <BR/>Record review of Resident #6's Quarterly MDS Assessment, dated 12/19/2022, revealed Psychiatric/Mood Disorder diagnosis selected were Anxiety Disorder, Depression, and Psychotic Disorder; and antipsychotic, antianxiety, and antidepressant medications were given daily during the 7-day review period. <BR/>Record review of Resident #6's Medication Administration Records for the months of January 2023, February 2023, and March 1-15, 2023, revealed Seroquel 25mg was administered as ordered for the diagnosis of behaviors. <BR/>Record review of the monthly Medication Regimen Review dated 02/21/2023, revealed Resident #6 was receiving Seroquel for the diagnosis of Behaviors. The licensed pharmacist recommended to evaluate and document diagnosis. <BR/>In an interview on 03/15/23 at 12:09 PM, the interim DON said Resident #6 was under the care of hospice who ordered the medication. She said the order must have slipped past her as it was coded wrong. She said it was her expectation every nurse was responsible to make sure that a physician's order was correct and was given for the right diagnosis, and if it was not, it was to be communicated to the physician. She said the facility had mostly temporary nurses which can cause a lack of consistency in resident care. The potential harm of his failure was the resident could experience side effects to the medication given. <BR/>Record review of the facility's policy Medication Management Policy 11.4, Effective Date 08-2020, revealed the following [in part]:<BR/>F. When a resident receives a new medication, the medication order is evaluated for the following:<BR/>i) The dose, route of medication, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use.<BR/>ii) A written diagnosis, an indication, and/or documented objective findings support each medication.<BR/>Review of the website drugs.com, https://www.drugs.com/pro/seroquel.html, accessed on 03/15/2023, revealed Seroquel was an antipsychotic medication that is used to treat psychotic conditions such as schizophrenia (a severe brain disorder that affects how people perceive and interact with reality, often causing hallucinations, delusions, and social withdrawal) and bipolar disorder (manic depression). Seroquel had a black box warning for Increased mortality in elderly patients with dementia-related psychosis. Seroquel was not approved for the treatment of patients with dementia-related psychosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews , the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 2 residents (Residents #1) whose records were reviewed for assessments.<BR/>The facility failed to recognize and re-assess Resident #1 after a significant weight loss and a decline in ADL function. <BR/>This failure placed residents at risk for not developing interventions to meet their needs for care assistance and treatments.<BR/>The findings included:<BR/>Record review of Resident #1's Face Sheet, dated 09/06/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE] with an admitting diagnosis of Hemiplegia and Hemiparesis (weakness or inability to move on one side of the body, making it hard to perform everyday activities), Cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), and vascular dementia (brain damage due to multiple strokes). <BR/>Record review of a Quarterly MDS assessment, dated 11/16/2022, revealed the following:<BR/>Section G (Activities of daily living)- Bed mobility: limited, locomotion on unit: limited, locomotion off unit: limited, eating: independent. <BR/>Section K (Weight) Showed a weight of 153 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen. <BR/>Record review of a Quarterly MDS, dated [DATE], revealed the following:<BR/>Section G (Activities of daily living)- Bed mobility:limited, locomotion on unit: limited, locomotion off unit: limited, eating: supervisoin.<BR/>Section K (Weight)- Showed a weight of 150 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen.<BR/>Record review of a Quarterly MDS, dated [DATE], revealed the following:<BR/>Section G (Activities of daily living)- Bed mobility: extensive, locomotion on unit: entensive, locomotion off unit: extensive, eating: supervision.<BR/>Section K (Weight)- Showed a weight of 145 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen. <BR/>Record review of an Annual MDS, dated [DATE], revealed the following:<BR/>Section K (Weight)- Showed a weight of 145 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen. <BR/>Record review of Resident #1's Care Plan, last revised on 08/15/2023, revealed care plans for: <BR/>Problem: Weight loss- has nutritional potential problem with weight loss due to Terminal prognosis related to multiple CVA'S.<BR/>Goal: will maintain adequate nutritional status as evidenced by maintaining weight, no signs, or symptoms of malnutrition, and consuming at least 50% of .at least X 3 meal s<BR/>Record review of Resident #1's weight and vital summary revealed the following weights, dates, and warnings:<BR/>08/10/2022- 165lbs- No warnings<BR/>09/04/2022- 154lbs- 6.7% change (-11lbs since 08/10/2022)<BR/>10/09/2022- 148lbs- 10.3% change (- 17lbs since 08/10/2022)<BR/>01/15/2023- 144lbs- 12.7% change (-12.7lbs since 08/10/2022)<BR/>02/12/2023- 148lbs- 10.3% change (-17lbs since 08/10/2022)<BR/>04/09/2023- 142lbs- 10% change (-10lbs since 11/06/2022)<BR/>During an observation and interview on 09/06/2023 at 12:30 PM, Resident #1 was in the dayroom in his wheelchair , he appeared thin and frail. He came into the office where surveyor was working to complete the interview. He revealed that he had a significant weight loss since he was admitted into the facility. He revealed that it had been 20 pounds from August of last year to May of this year; he was unsure of the exact amounts. He revealed it was due to him being on hospice and having a decline. He said that he was receiving supplements. <BR/>In an interview on 09/06/2023 at 1:00 PM, the MDS Coordinator revealed the resident had a significant weight loss and decline in ADL function for the months of November 2022 through May 2023. She revealed that the resident was admitted into the facility in August 2022 weighing 165 pounds and in November 2022 he weighed 153 pounds. She revealed in November 2022, February 2023 and the May 2023, the MDS assessments should have also been Significant change MDS assessments due to the resident continuing to lose weight and triggering on the weight report. She revelaed that he required more assistance with ADL's after his weight loss. She revealed this failure could place the resident at risk for not having his dietary needs met for weight loss. <BR/>Interview with the DON on 09/06/2023 at 2:00 PM revealed that the MDS Coordinator was responsible for creating and completing Significant Change Assessments. She said that the resident did have a significant decline since she started treating the resident for it once he triggered on the weight loss report in September 2022. <BR/>Record review of the facility's policy covering resident significant changes and assessments was requested to the MDS coordinator on 09/06/2023. She revealed that she uses the RAI manual for guidance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess each resident's status for 1 of 3 (Resident #1) reviewed for assessment accuracy in that: <BR/>Resident #1's MDS assessment records, after admission, was not coded yes for weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months.<BR/>This failure could place residents at risk of not receiving the proper care and services due to inaccurate records.<BR/>Finding included: <BR/>Record review of Resident #1's Face Sheet, dated 09/06/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE] with an admitting diagnosis of Hemiplegia and Hemiparesis (weakness or inability to move on one side of the body, making it hard to perform everyday activities), Cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (high blood pressure), and vascular dementia (brain damage due to multiple strokes). <BR/>Record review of a Quarterly MDS assessment, dated 11/16/2022, revealed the following:<BR/>Section K (Weight) Showed a weight of 153 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen. <BR/>Record review of a Quarterly MDS, dated [DATE], revealed the following:<BR/>Section K (Weight)- Showed a weight of 150 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen. <BR/>Record review of a Quarterly MDS, dated [DATE], revealed the following:<BR/>Section K (Weight)- Showed a weight of 145 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen. <BR/>Record review of an Annual MDS, dated [DATE], revealed the following:<BR/>Section K (Weight)- Showed a weight of 145 pounds.<BR/>Section K (Weight loss)- No, Loss of 5% or more in the last month or loss of 10% or more in last 6 months, resident not a physician prescribed weight regimen. <BR/>Record review of Resident #1's Care Plan, last revised on 08/15/2023, revealed care plans for: <BR/>Problem: Weight loss- has nutritional potential problem with weight loss due to Terminal prognosis related to multiple CVA'S.<BR/>Goal: will maintain adequate nutritional status as evidenced by maintaining weight, no signs, or symptoms of malnutrition, and consuming at least 50% of .at least X 3 meal s<BR/>Record review of Resident #1's weight and vital summary revealed the following weights, dates, and warnings:<BR/>08/10/2022- 165lbs- No warnings<BR/>09/04/2022- 154lbs- 6.7% change (-11lbs since 08/10/2022)<BR/>10/09/2022- 148lbs- 10.3% change (- 17lbs since 08/10/2022)<BR/>01/15/2023- 144lbs- 12.7% change (-12.7lbs since 08/10/2022)<BR/>02/12/2023- 148lbs- 10.3% change (-17lbs since 08/10/2022)<BR/>04/09/2023- 142lbs- 10% change (-10lbs since 11/06/2022)<BR/>During an observation and interview on 09/06/2023 at 12:30 PM, Resident #1 was in the dayroom in his wheelchair. He came into the office where I was working to complete the interview. He revealed that he had a significant weight loss since he was admitted into the facility. He revealed that it has been 20lbs from August of last year to May of this year, he was unsure of the exact amounts. He revealed it was due to him being on hospice and having a decline. He said that he was receiving supplements. <BR/>In an interview on 09/06/2023 at 1:00 PM, the MDS coordinator revealed the resident had a significant weight loss in the months of November 2022 and May 2023. She revealed that the resident was admitted into the facility in August 2022 weighing 165lbs and in November 2022 he weighed 153. She revealed that she should have coded yes, the resident had a weight loss that was not physician prescribed in section K. She revealed the February 2023 and the May 2023 MDS's should have also been yes, resident had a weight loss that was not physician prescribed in section K. <BR/>In an interview on 09/06/2023 at 2:00 PM, the DON revealed that it was the MDS's responsibility to complete the MDS assessment accurately. She revealed that the resident had a significant weight loss, and he was currently being treated for weight loss despite what the MDS was coded. <BR/>Record review of the facility's policy covering MDS inaccuracies was requested to the MDS coordinator on 09/06/2023. She revealed that she uses the RAI manual for guidance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs, that meet the needs of each resident for 4 of 10 residents ( Resident #'s 2, 9 ,12, 15, and 16) reviewed for pharmacy services. <BR/>The facility failed to follow pharmaceutical procedures to accurately and timely complete documentation of controlled drug administration for 3 residents (Resident #'s 9, 12, and 15). LVN D signed out for narcotic medications at the start of the shift, not after she administered the medications over the course of the shift.<BR/>The facility failed to ensure Resident #2 did not have medications left at the bedside.<BR/>The facility failed to ensure that Resident 16's medication was the same dosage.<BR/>This failure could place residents at risk of medication overdose, medication under-dose, ineffective therapeutic outcomes and residents receiving the wrong medications.<BR/>Findings included:<BR/>Resident ID #2<BR/>Record review of Resident #2's MDS, dated [DATE], revealed Resident ID #2 was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia without behavioral disturbances, diabetes, coronary artery disease and anemia. His BIMS score was 14, which indicated the resident was cognitively intact.<BR/>Observation on 1/10/2022 at 11:15 AM revealed a tube of Cream labeled Clotrim-Betameth 1-0.5% Cream ( an antifungal and steroid combination cream) on the resident's bedside table. <BR/>Observation on 1/11/2022 at 9:30 AM revealed a tube of Cream labeled Clotrim-Betameth 1-0.5% Cream ( an antifungal and steroid combination cream) on the resident's bedside table. <BR/>Record review of Resident #2's active physician orders dated 01/10/2022, at 11:15 2021 AM included the following prescription medication Clotrim-Betameth 1-0.5% Cream 2 times daily, scheduled AM and PM to rash on perineal area. <BR/>In an interview with Resident ID # 2 on 1/11/22 at 11:20 AM he stated he did not know how the medication got on his bedside table. He denied having applied the medication himself . <BR/>In an interview with LVN D 01/11/2022 at 1:10 PM she revealed she did not recall leaving the medication at Resident' #2's bedside.<BR/>Resident ID # 9 <BR/>Record review of Resident # 9's Quarterly MDS dated [DATE], revealed Resident ID # 9 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, age related cognitive decline, anxiety disorder, repeated falls and altered mental status. <BR/>Record review of Resident #9's active physician orders as of 01/10/22, included the following controlled drugs lorazepam 0.5 mg 1 by mouth 2 times daily.<BR/>Observation of Resident ID # 9's med pass on at 11:30 AM revealed Resident ID # 9 received lorazepam 0.5 mg 1 tablet by mouth at 11:30 AM and this was documented on the MAR at that time. LVN D did not sign the narcotic count sheet when she prepared and administered this medication.<BR/>Interview with LVN D at 11:30 AM revealed that she did not sign the narcotic count sheet for this medication because she had signed for all of her narcotics for her shift when she arrived at the facility to begin her shift at 6:00 AM. LVN D stated she is aware the correct pharmacy procedure is to sign the narcotic count sheet when she pulls the medication to be administered. She stated by signing hours before the medication was pulled would cause a discrepancy in the narcotic count she stated she knew this was not the correct way to document a narcotic and stated she did it because she was in a hurry. She revealed she often did this if she thought it was going to be a busy day and there were people that had called in for her shift. She stated not signing for narcotics at the time of administration could lead to the resident receiving the wrong dose of medication or drug diversion. <BR/>Record review of Resident ID # 9's narcotic count sheet for Lorazepam 0.5 mg on 1/10/2022 revealed the documented count of the Lorazepam 0.5 mg was 32 . <BR/> Observation of the medication card on 1/10/22 @ 11:30 AM that contained the Lorazepam revealed a total count of 33 tablets before the drug was administered <BR/> Resident ID # 12<BR/>Record review of Resident # 12's quarterly MDS dated [DATE], revealed Resident ID #4 was admitted to the facility on [DATE] with the following diagnoses: dementia, urinary tract infection, anxiety disorder and depression.<BR/>Record review of Resident #12's active physician orders dated 01/10/2022, included the following controlled drug Norco 10/325 mg 1 by mouth every 6 hours.<BR/>Observation of LVN D conducting Resident # 12's med pass on at 11:30 AM revealed Resident ID # 12 was administered Norco 10/325 mg 1 tablet by mouth and LVN D documented on the MAR at the time of administration. <BR/>Observation and interview with LVN D on 1/10/22 at 11:30 AM revealed she did not sign the narcotic count sheet at the time the Norco was administered.<BR/>Record review of Resident #12's narcotic count sheet for Norco 10/325 mg revealed the documented count for the Norco 10/325 mg was 102 . <BR/>Observation of the medication card containing the Norco on 1/10/22 at 11:30 AM tablets revealed a total count of 103 tablets before administration . <BR/>Resident ID #15<BR/>Record review of Resident # 15's Annual MDS dated [DATE], revealed Resident ID #15 was admitted to the facility on [DATE] with the following diagnoses: Weight loss, depression and protein calorie malnutrition. H <BR/>Record review of Resident #15's active physician orders dated 01/10/2022, included the following controlled drug Tramadol 50 mgs 2 tablets by mouth 2 times a day. <BR/>Observation of LVN D conducting Resident # 15's med pass on 01/10/2022 at 11:30 AM revealed Resident ID #15 received Tramadol 50 mg 2 tablets which was documented on the MAR at the time of administration. <BR/>Interview with LVN [NAME] at 11:30 AM on 1/10/22 revealed that she had signed for the narcotic at the beginning of her shift. <BR/>Record review of Resident #15's narcotic count sheet for revealed the documented count of the Tramadol was 62 . <BR/> Observation of the medication card containing the Tramadol at 11:30 AM on 1/10/22 tablets revealed a total count of 64 tablets before administration . <BR/>An interview with the DON on 6/22/2020 at 3:00 PM revealed that she expected nurses to sign for controlled medication immediately when administering them, she stated she did not know that LVN D had not signed for her controlled drugs when administering them. <BR/>Resident #16<BR/>An observation on 01/11/2022 7:45 AM of med cart #1 revealed Resident ID # 16 had a medications that was the incorrect dosage. Resident ID # 16 had a light orange oval tablet in a blister pack labeled : Spironolactone 50 mg 1 tablet by mouth every evening. (A medication to treat high blood pressure and edema). <BR/>Review of the Medication administration Record gave the following instructions: Spironolactone 25 mg give one tablet in the morning <BR/>Review of Resident ID # 16's face sheet dated 01/11/2021, revealed resident ID # 16 was a [AGE] year-old- male admitted to the facility on [DATE]. <BR/>Review of Resident ID # 16's physician orders dated 01/11/22 included the following orders: Spironolactone 25 mg give one tablet by mouth in the morning for congestive heart failure, ( start date 07/26/2021).<BR/>In an interview on 10/08/21 at 2:00 PM LVN E stated she would notify her ADON and hold the medications until the order was clarified by the physician after comparing the label on the medication card to the physicians order. She stated the dosage on the blister pack did not match the dosage listed on the medication administration record She stated that it was each nurse's responsibility to see that medications were the correct dosag , <BR/>In an interview on 01 /11/2022 at 9:10 AM the ADON revealed it was each nurse's responsibility that medications be properly labeled with the correct medication and dosage according to the physicians orders. She stated the pharmacy consultant also checked the carts for cleanliness , proper storage and labeling of medications at each monthly visit. <BR/>Interview with the DON on 01/11/22 at 9:30 AM stated the med should not have been given without the proper dosage on the packaging. She stated she did not know how this occurred. <BR/>In a review of the facility's Policy and Procedure, provided by the DON, dated 9/2018 ,titled Controlled Substances, documented [in part]:<BR/>Accurate inventory of all controlled medications at all times. <BR/> The nurse administering the medication will record the following information immediately : date and time drug is administered on the MAR and accountability record (control drug individual count sheet), amount of drug administered ( accountability record) , remaining balance of drug (accountability record), and signature of nurse administering drug ( accountability record) . Initials of the nurse administering the dose, completed after the medication has been administered. (MAR)<BR/>Review of the facilities policy titled Medication Administration dated revised February 2020, revealed in part:<BR/>11. Verify the pharmacy prescription label on the drug and the manufacturers identification system match the MAR. If there is a discrepancy check the order and notify the pharmacy ; do not give the medication until clarified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured and labeled in accordance with currently accepted professional principles for 1 of 1 med carts (Med Cart # 1) , and 1 of 10 residents ( Resident ID # 16) reviewed for medication pass .<BR/>A. Medication cart #1 contained oral medications, topical medications stored together in one compartment. <BR/>B. Resident # 16's medication did not have a dosage on the label. <BR/>This failure could affect residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses, cause cross contamination and transmit infection.<BR/>The findings include:<BR/>Med Cart #1 :<BR/>An observation on 01/11/ 2022 at 10:00 AM of Med Cart #1 revealed each drawer of the cart had oral medications, nasal inhalants, and topical medications stored together in the same compartment. <BR/>An observation on 01/11/2022 7:45 AM of med cart #1 revealed Resident ID # 16 had two a had dark orange , round tablet which was labeled: Bidel, (an isosorbide dinitrate-hydralazine combination drug , given to treat high blood pressure by dilating the blood vessels) take 1 tablet by mouth two times daily. The dosage was not listed on the label information for the Bidel. <BR/>Review of Resident ID # 16's face sheet dated01/11/2021, Revealed resident ID # 16 was a [AGE] year-old- male admitted to the facility on [DATE]. <BR/>Review of Resident ID # 16's physician orders dated 01/11/22 included the following order Bidel tablet 20-37.5 mg 1 tablet by mouth two times daily for hypertension (start date 07/26/2021). <BR/>In an interview on 10/08/21 at 2:00 PM LVN E stated she would notify her ADON and hold the medication until the order was clarified by the physician after comparing the label on the medication card to the physicians order. She stated there was no dosage on the blister pack did not match the dosage listed on the medication administration record. LVN E stated a consequence of storing oral medications, topical medications and nasal inhaler in the same compartment could result in the medications being given via the wrong route or result in cross contamination and the spread of infection. She stated that it was each nurse's responsibility to see that medications were labeled correctly, and medications of different routes were not stored in the same compartment during their shift. <BR/>In an interview on 01 /11/2022 at 9:10 AM the ADON revealed it was each nurse's responsibility that medications be properly labeled with the correct medication and dosage according to the physicians orders. She stated it was her expectations that drugs should be stored according to appropriate route . She revealed storing of medications of different routes could cause the spread of infections and unwanted medical side effects. She stated it was her expectation that nurses be responsible for cleaning their own carts and keep the medications stored according to the route they are administered. She stated the pharmacy consultant also checked the carts for cleanliness , proper storage and labeling of medications at each monthly visit. The ADON stated in an interview on 1/10/22 at 11:45 AM that she had noticed this and she had talked to the dispensing pharmacist and he told her that was the only strength he carried of the Bidel and it did not need a dosage on the label label. She stated she would clarify again because she was sure she had not documented this conversation in the nurses progress notes when it occurred. <BR/>In an interview on 1/10/22 at 2:00 PM the DON revealed her expectation that med carts be cleaned by the nurses, and stated it was each shifts responsibility to check carts for cleanliness and see that medications of different routes not be stored together in the same compartment. She also stated the carts are monitored by pharmacy consultant during his monthly visits. <BR/>Interview with the DON on 01/11/22 at 9:30 AM stated the med should not have been given without the proper dosage on the packaging. She stated she did not know how this occurred. <BR/>Record review of the facility policy titled Storage of Medications dated revised August 2020, revealed in part:<BR/>4. Orally administered medications are stored separately from externally used medications and treatments such as suppositories .<BR/>10. Medication storage conditions are monitored on a regular basis by the consultant pharmacist and corrective action is taken if problems are identified. <BR/>Review of the facilities policy titled Medication Administration dated revised February 2020, revealed in part:<BR/>11. Verify the pharmacy prescription label on the drug and the manufacturers identification system match the MAR. If there is a discrepancy check the order and notify the pharmacy ; do not give the medication until clarified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received food that accommodates resident preferences for 11 (eight confidential residents, and Residents #19, #22, and #26) of 32 residents reviewed for food preferences. <BR/>The facility failed to offer alternative meals and/or honor residents like and dislike food preferences. <BR/>This failure could place residents who ate their meals from the facility's only kitchen at risk of not having their choices and food preferences honored, weight loss, altered nutritional status and a diminished quality of life. <BR/>Findings included:<BR/>Review of the facility's weekly menu, dated 01/10/22 through 01/13/22, reflected an alternative was listed on the menu but was not prepared. <BR/>Observations on 01/10/22 at 12:06 pm, 01/11/22 at 10:04 am, 01/12/22 at 12:00 pm, and 01/13/22 at 12:00 pm, revealed no menus were posted in the dining room or any area in the facility.<BR/>In an interview on 01/10/22 at 12:39 PM, Resident #19 was a [AGE] year-old with a BIMS of 11, and Resident #22 was a [AGE] year-old with a BIMS of 13, both stated they have not seen a menu and menus were not posted. They do not know what they were eating until the food arrives. They said they are not offered alternatives. <BR/>In an interview on 01/10/22 at 12:45 PM, Resident #26 was a [AGE] year-old with a BIMS of 13, stated she has never seen a menu and she never knows what she is going to eat. The resident was not offered an alternative. <BR/>In an interview on 01/11/22 at 11:54 AM, Dietary Aid G and Dietary Aid H both said they do not prepare the alternative selection on the menu. They said they would fix the alternative on the menu if they were told to do so. <BR/>In the confidential Resident Council meeting on 01/12/22 at 1:54 PM, the 8 Residents that attended said they have never seen a menu posted so they are unsure of what will be served for that day. The Residents said they were not offered an alternative. None of the residents knew they could ask for something different. The residents said they would just eat it, since that what was cooked. <BR/>In an interview on 01/13/22 at 12:00 PM, the Administrator said menus had not been posted in a long time. She acknowledged the residents did not know what was being served for each meal. When asked why the alternative were not being prepared, she said if a resident said they do not like something, they would always be offered soup, cottage cheese, or a sandwich. The Administrator said the Dietary Manager were currently out sick this week. <BR/>The policy provided entitled: Nutrition Services Manual, Menu Production, 2015 5.6, documented [in-part]:<BR/>Menu Substitutions/Alternatives:<BR/>Menu substitutions and alternatives are provided to accommodate resident/patient food preferences and assure missed or refused meal items are replaced. <BR/>Procedure:<BR/>Menus Alternatives<BR/>1. Honor resident/patient likes and dislikes.<BR/>2. Provide an alternative main meat entr&eacute;e and vegetable per menu.<BR/>4. Provide substitutions/alternatives that meet the resident/patient preferences. <BR/>5. Accommodate resident/patient when refusing or missing a meal by offering a reasonable substitution or alternative as desired. <BR/>The facility CMS form 672 dated 01/10/22 revealed 34 residents consumed food from the facility's kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for 1 of 1 laundry carts observed for infection control practices.<BR/>The facility failed to ensure clean laundry was protected from dust and contamination while being transported to resident's rooms. <BR/>This failure could place residents at risk for healthcare associated cross-contamination and infections. <BR/>The findings include:<BR/>Observation on 01/02/2025 at 11:20 am the HK L was observed delivering clean laundry using a cart that was not covered. The HK L was observed delivering clean laundry to rooms #12 and 14 on the hall labeled Zone 2 on facility map, then moving uncovered cart past lobby and through dining room to Hall labeled Zone 6 to room [ROOM NUMBER].<BR/>Interview on 01/02/2025 at 11:30 am the HK L stated she does not have a cover for cart and did not know a cover was required during transport.<BR/>Interview on 01/02/2025 at 12:10pm the LVN C who was in-charge of facility at time of survey , stated she was unaware that clean laundry was being transported back into the building and deliveries needed to be covered to protect from cross-contamination. <BR/>Interview on 01/03/25 at 1:00pm LVN C stated the facility did not have a policy for delivery of clean laundry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to provide a safe, clean, comfortable and homelike environment for 1 (Resident #23) of 5 observed in that:<BR/>The bed sheets of Resident #23's contained an area of dried blood that was present for during the days of 01/10/2022 to 01/12/2022.<BR/>This deficient practice could affect residents by decreasing their sense of self-worth and increasing their risk of infection. <BR/>The findings included:<BR/>Review of Resident #23's electronic face sheet dated 12/12/2022 revealed she was admitted to the facility on [DATE] with diagnoses of Chronic Obstruction Pulmonary Disease, Bradycardia, Heart Disease and Dementia. <BR/>Review of Resident #23's quarterly MDS dated [DATE] revealed she had severe cognitive impact with a BIMS score of 5.<BR/>Observation on 01/10/2022 at 10:28 a.m., revealed Resident #23 was lying in her bed with a small white dog. The bed sheets contained dried blood, approximately the size of a foot in width and a foot in length. <BR/>Observation on 01/12/2022 at 3:27 p.m., revealed Resident #23 was sitting on the side of her bed, her bedsheets visible with dried blood, approximately the size of a foot in width and a foot in length. <BR/>Interview on 01/12/2022 at 3:40 p.m., with the ADON, revealed Resident #23 should have had the bedding changed when she provided her wound care on 01/12/2022. She was the nurse working the floor that day and was responsible for her care. She did not see the dried blood on the sheets and was unsure how other staff did not see the dried blood. She said that she could see it being an infection control issue and that the resident has a right to a clean environment. The ADON verified that the bed sheets had not been changed when she provided wound care for Resident #23. <BR/>Interview on 01/22/2022 at 3:55 p.m., with the DON she said she was not sure how it was not seen. She saw the sheets were dirty after the ADON reported it. She said she would be doing additional training with the ADON, who was responsible for the mistake. They have only 2 CNAs for the building, which is resulting in nursing having to do additional stuff such as this. A copy of the Company's Policy and Procedures was unavailable upon request<BR/>The DON and ADON was able to provide an in-house policy dated 11/18/2021 from the Administrator. It sates, Effective Thursday 11/18/2021 all residents are to have lined changed 3X per week and PRN.<BR/>Information provided by the Administrator revealed there was a census of 34 residents.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #23) reviewed for wound care. <BR/>Resident #23's Treatment Administration Record (TAR) and Medication Administration Record (MAR) reflected the administration of wound care on RLE was inaccurately entered into the TAR as LLE. The order was not accurately documented.<BR/>This deficient practice could place residents at risk for inaccurate documentation of skin assessments and orders. <BR/>Findings include:<BR/>Review of Resident #23's TARs for January 2022 revealed the following diagnoses: COPD, Heart Disease, Muscle Atrophy and Dementia.<BR/>Review of Resident 23's orders for January 2022 revealed an order placed 01/08/2022 for dressing changes for RLE, instead of LLE. <BR/>During interview on 1/12/2022 at 9:35 a.m., the Director of Nurses (DON) stated that the person who entered the order and was responsible for the wound care was the ADON. She reviewed the order and both legs and said that there was an error. She would have the ADON correct the order and would be contacting the doctor to see if there would be any additional orders. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>During an interview on 1/12/2021 at 1:35 p.m. the ADON she said that the mistake was hers. She said that she was responsible for the order and wound care. She entered the wrong order by putting it under the wrong leg. She said that after it was brought to her attention today, she entered a new order and completed a new skin assessment. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>Review of Resident #23's Progress Note for January 12, 2022 revealed a new note, order was place on January 12, 2022 at 9:40 a.m., for Order for correction, after realizing the old order was inaccurate- Noted that order for wound care to skin tear caused by dog scratches from 1/08/2022 was written in error to be applied to RLE. Wound care to LLE with occlusive dressing is being provided daily and order corrected to reflect correct site. Nurses are accessing wound daily as per documentation to monitor for changes in the wound- completed by ADON. <BR/>The DON was able to provide a Nursing Documentation Guidelines dated 08/2015 that says, Change in condition should be reported at 24hrs. Charting for skin injury falls under change of condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for 1 of 1 laundry carts observed for infection control practices.<BR/>The facility failed to ensure clean laundry was protected from dust and contamination while being transported to resident's rooms. <BR/>This failure could place residents at risk for healthcare associated cross-contamination and infections. <BR/>The findings include:<BR/>Observation on 01/02/2025 at 11:20 am the HK L was observed delivering clean laundry using a cart that was not covered. The HK L was observed delivering clean laundry to rooms #12 and 14 on the hall labeled Zone 2 on facility map, then moving uncovered cart past lobby and through dining room to Hall labeled Zone 6 to room [ROOM NUMBER].<BR/>Interview on 01/02/2025 at 11:30 am the HK L stated she does not have a cover for cart and did not know a cover was required during transport.<BR/>Interview on 01/02/2025 at 12:10pm the LVN C who was in-charge of facility at time of survey , stated she was unaware that clean laundry was being transported back into the building and deliveries needed to be covered to protect from cross-contamination. <BR/>Interview on 01/03/25 at 1:00pm LVN C stated the facility did not have a policy for delivery of clean laundry.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #23) reviewed for wound care. <BR/>Resident #23's Treatment Administration Record (TAR) and Medication Administration Record (MAR) reflected the administration of wound care on RLE was inaccurately entered into the TAR as LLE. The order was not accurately documented.<BR/>This deficient practice could place residents at risk for inaccurate documentation of skin assessments and orders. <BR/>Findings include:<BR/>Review of Resident #23's TARs for January 2022 revealed the following diagnoses: COPD, Heart Disease, Muscle Atrophy and Dementia.<BR/>Review of Resident 23's orders for January 2022 revealed an order placed 01/08/2022 for dressing changes for RLE, instead of LLE. <BR/>During interview on 1/12/2022 at 9:35 a.m., the Director of Nurses (DON) stated that the person who entered the order and was responsible for the wound care was the ADON. She reviewed the order and both legs and said that there was an error. She would have the ADON correct the order and would be contacting the doctor to see if there would be any additional orders. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>During an interview on 1/12/2021 at 1:35 p.m. the ADON she said that the mistake was hers. She said that she was responsible for the order and wound care. She entered the wrong order by putting it under the wrong leg. She said that after it was brought to her attention today, she entered a new order and completed a new skin assessment. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>Review of Resident #23's Progress Note for January 12, 2022 revealed a new note, order was place on January 12, 2022 at 9:40 a.m., for Order for correction, after realizing the old order was inaccurate- Noted that order for wound care to skin tear caused by dog scratches from 1/08/2022 was written in error to be applied to RLE. Wound care to LLE with occlusive dressing is being provided daily and order corrected to reflect correct site. Nurses are accessing wound daily as per documentation to monitor for changes in the wound- completed by ADON. <BR/>The DON was able to provide a Nursing Documentation Guidelines dated 08/2015 that says, Change in condition should be reported at 24hrs. Charting for skin injury falls under change of condition.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed in that, raw hamburger was stored in the freezer above other foods.<BR/>This failure by the facility could place residents in the facility at risk of acquiring food borne illnesses and a decline in health status.<BR/>Findings include:<BR/>On 03/12/2023 at 09:50 AM, during the Kitchen Initial Tour, an observation was made of raw hamburger and raw hamburger patties stored above bread dough and a box labeled Tony's Deep Dish Pizza, both hamburger products were in the left side of the freezer on the second-to-the bottom wire shelf.<BR/>On 03/13/2023 at 04:10 PM, during the comprehensive kitchen inspection, the same boxes of raw hamburger and hamburger patties were observed in the same location within the freezer, above bread dough and frozen pizzas.<BR/>On 03/13/2023 at 04:20 PM, in an interview with the Dietary Manager, the Dietary Manager said raw hamburger should not be stored above bread and other types of food. She was responsible and she knew better but had not looked at the freezer after a recent food delivery. The Dietary Manager said the meat should have been on the bottom rack and not placed about the dough to eliminate drippings on the other food. <BR/>On 03/14/2023 at 10:23 AM, in an interview with the Administrator, the Administrator said she was aware of how raw hamburger was to be stored properly in the refrigerator and she also knew that the raw hamburger meat should have been placed on the bottom or below other foods. <BR/>Record review of a facility policy titled; NUTRITION SERVICES MANUAL, Sanitation, original Date: 06/2015, Storage, Freezer Storage reflected it did not mention about how raw meats should be stored in specific locations within the freezer.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed in that, raw hamburger was stored in the freezer above other foods.<BR/>This failure by the facility could place residents in the facility at risk of acquiring food borne illnesses and a decline in health status.<BR/>Findings include:<BR/>On 03/12/2023 at 09:50 AM, during the Kitchen Initial Tour, an observation was made of raw hamburger and raw hamburger patties stored above bread dough and a box labeled Tony's Deep Dish Pizza, both hamburger products were in the left side of the freezer on the second-to-the bottom wire shelf.<BR/>On 03/13/2023 at 04:10 PM, during the comprehensive kitchen inspection, the same boxes of raw hamburger and hamburger patties were observed in the same location within the freezer, above bread dough and frozen pizzas.<BR/>On 03/13/2023 at 04:20 PM, in an interview with the Dietary Manager, the Dietary Manager said raw hamburger should not be stored above bread and other types of food. She was responsible and she knew better but had not looked at the freezer after a recent food delivery. The Dietary Manager said the meat should have been on the bottom rack and not placed about the dough to eliminate drippings on the other food. <BR/>On 03/14/2023 at 10:23 AM, in an interview with the Administrator, the Administrator said she was aware of how raw hamburger was to be stored properly in the refrigerator and she also knew that the raw hamburger meat should have been placed on the bottom or below other foods. <BR/>Record review of a facility policy titled; NUTRITION SERVICES MANUAL, Sanitation, original Date: 06/2015, Storage, Freezer Storage reflected it did not mention about how raw meats should be stored in specific locations within the freezer.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #23) reviewed for wound care. <BR/>Resident #23's Treatment Administration Record (TAR) and Medication Administration Record (MAR) reflected the administration of wound care on RLE was inaccurately entered into the TAR as LLE. The order was not accurately documented.<BR/>This deficient practice could place residents at risk for inaccurate documentation of skin assessments and orders. <BR/>Findings include:<BR/>Review of Resident #23's TARs for January 2022 revealed the following diagnoses: COPD, Heart Disease, Muscle Atrophy and Dementia.<BR/>Review of Resident 23's orders for January 2022 revealed an order placed 01/08/2022 for dressing changes for RLE, instead of LLE. <BR/>During interview on 1/12/2022 at 9:35 a.m., the Director of Nurses (DON) stated that the person who entered the order and was responsible for the wound care was the ADON. She reviewed the order and both legs and said that there was an error. She would have the ADON correct the order and would be contacting the doctor to see if there would be any additional orders. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>During an interview on 1/12/2021 at 1:35 p.m. the ADON she said that the mistake was hers. She said that she was responsible for the order and wound care. She entered the wrong order by putting it under the wrong leg. She said that after it was brought to her attention today, she entered a new order and completed a new skin assessment. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>Review of Resident #23's Progress Note for January 12, 2022 revealed a new note, order was place on January 12, 2022 at 9:40 a.m., for Order for correction, after realizing the old order was inaccurate- Noted that order for wound care to skin tear caused by dog scratches from 1/08/2022 was written in error to be applied to RLE. Wound care to LLE with occlusive dressing is being provided daily and order corrected to reflect correct site. Nurses are accessing wound daily as per documentation to monitor for changes in the wound- completed by ADON. <BR/>The DON was able to provide a Nursing Documentation Guidelines dated 08/2015 that says, Change in condition should be reported at 24hrs. Charting for skin injury falls under change of condition.

Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing (RN, LVN and CNA) staff directly responsible for resident care per shift daily.<BR/>The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, and CNAs.<BR/>The facility's failure could affect the residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily.<BR/>The findings included:<BR/>In an observation on 04/28/2024 at 9:45 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type.<BR/>In an observation on 04/29/2024 at 9:00 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type.<BR/>In an observation on 04/30/2024 at 10:00 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type.<BR/>In an observation on 05/01/2024 at 11:00 a.m. the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type.<BR/>In an interview on 05/01/2024, the DON said the daily nursing posting was not correct. She further stated the form should have been filled out completely and noted it had several blanks and it did not have the total number and actual hours worked. She stated that it should be posted per policy. She said failure to post the actual hours worked had the potential to prevent residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily.<BR/>In an interview on 05/01/2024 at 1:32 PM, the Administrator stated his expectation was to follow policy and that the policy was not followed due to the total numbers of actual hours worked for RN's, LVN's and CNA's, and the census at beginning of each shift were not on the posting. He further stated that they would modify the form to include the required posting information. <BR/>Record review of the facility's policy Staffing Information Posting, dated as revised September 2014, reviewed November 2019 revealed the following [in part]:<BR/>Overview: In accordance with federal regulation, facility census and nursing staff information is posted on each shift.<BR/>Information required to be posted includes: facility name and date, facility census at the start of each shift, number of RN's, LVN and CNA's providing direct care, actual number of hours of direct care provided, total number of staff and total actual hours of direct care provided.

Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 3 of 10 (RN B, CNA D, CNA E) reviewed for behavioral health training.<BR/>The facility failed to ensure all staff were trained for Behavioral Health.<BR/>This failure could place residents at risk at receiving care from of incompetent/untrained staff. <BR/>Findings included:<BR/>Record Review of Personnel Files revealed the following staff did not receive training for Behavioral health:<BR/>*RN B hired 08/22/2022<BR/>*CNA D hired 03/15/2024 <BR/>*CNA E rehired on 12/15/2023 <BR/>In an interview with HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. <BR/>In an interview with DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. <BR/>Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. <BR/>Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2024, November 2024, December 2024) reviewed for RN coverage. <BR/>The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 34 days of 92 days in October 2024, November 2024, and December 2024.<BR/>This failure could place residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.<BR/>Findings included: <BR/>Record review of the PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2025 (October 1, 2024 - November 30, 2024, December 31, 2024), run date 01/6/25, revealed no evidence of RN coverage for 34 of 92 days:<BR/>1. 10/26/2024 with no RN coverage.<BR/>2. 10/27/2024 with no RN coverage. <BR/>3. 11/3/2024 with no RN coverage.<BR/>4. 11/5/2024 with no RN coverage. <BR/>5. 11/13/2024 with no RN coverage.<BR/>6. 11/16/2024 with no RN coverage.<BR/>7. 11/20/2024 with no RN coverage.<BR/>8. 11/21/2024 with no RN coverage.<BR/>9. 11/22/2024 with no RN coverage.<BR/>10. 11/25/2024 with no RN coverage.<BR/>11. 11/26/2024 with no RN coverage.<BR/>12. 11/27/2024 with no RN coverage.<BR/>13. 11/28/2024 with no RN coverage.<BR/>14. 11/29/2024 with no RN coverage.<BR/>15. 12/2/2024 with no RN coverage.<BR/>16. 12/3/2024 with no RN coverage.<BR/>17. 12/4/2024 with no RN coverage.<BR/>18. 12/5/2024 with no RN coverage.<BR/>19. 12/6/2024 with no RN coverage. <BR/>20. 12/9/2024 with no RN coverage.<BR/>21. 12/10/2024 with no RN coverage.<BR/>22. 12/11/2024 with no RN coverage.<BR/>23. 12/12/2024 with no RN coverage.<BR/>24. 12/13/2024 with no RN coverage.<BR/>25. 12/16/2024 with no RN coverage.<BR/>26. 12/17/2024 with no RN coverage.<BR/>27. 12/18/2024 with no RN coverage.<BR/>28. 212/19/024 with no RN coverage.<BR/>29. 12/20/2024 with no RN coverage.<BR/>30. 12/23/2024 with no RN coverage.<BR/>31. 12/26/2024 with no RN coverage.<BR/>32. 12/27/2024 with no RN coverage.<BR/>33.12/30/2024 with no RN coverage.<BR/>34. 12/31/2024 with no RN coverage.<BR/>In an interview and record review on 01/02/2025 at 2:30pm, the Human Resource (HR) provided the timecard reports for the months of October 2024, November 2024, and December 2024. The HR verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for the dates of : <BR/>10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024. 10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024.<BR/>In an interview on 01/02/2025 at 9:35am, the facility's CNO D said her understanding of the facility policy was an RN was to be on staff 8 hours a day. The CNO D stated the facility has weekend coverage for RN hours, and at this point the CNO D stated she can be reached by facility 24/7 by phone if needed. <BR/>Record review of a policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on observation, interview, and record review, the facility failed to provide a working telephone for the residents to use. <BR/>The facility failed to pay their phone vendor and phone services were terminated on 02/07/25.<BR/>This failure could leave residents without the contact from their family/representative which could make them feel isolated. <BR/>Findings included:<BR/>Interview on 02/22/25 at 01:45 PM with the Human Resource Director, she stated the facility phone was cut off on 02/07/25 and has never been turned back on. She said an anonymous staff member purchased a prepaid cell phone out of their own pocket on 02/10/25 so that the residents and their families could communicate with each other. She said the residents did not have access to a facility phone from 02/07/25 to 02/10/25.<BR/>Interview on 2/22/25 at 02:50 PM with family member of Resident #5 stated she has difficulty getting through to the facility as the phone will ring and no one will answer. She was not aware the phone service had been disconnected. <BR/>Interview on 2/23/25 at 10:15am with LVN E stated resident's families have expressed frustration about not being able to contact the facility or their loved ones. <BR/>Interview on 2/24/25 at 2:00pm with Ombudsman stated it is hard to contact the facility. She said family members have contacted her regarding their concern about the inability to call the facility. <BR/>Interview on 2/27/25 at 10:25am with Social Worker stated she had resident families call her personal cell phone 2- 3 times per week for the past 3-4 weeks complaining about not being able to contact family members in the facility and stated many of them very worried about loved ones.<BR/>Observation on 2/28/25 at 12:40pm this investigator tried to contact facility phone number and it gave a busy signal. <BR/>Interview on 3/10/25 at 2:23pm with family member of resident #7 stated the facility phones are not working and it has made it difficult to contact her family member. <BR/>Interview on 3/13/25 at 3pm with resident #14 stated the phones don't work and she cannot call her mom. <BR/>Observation on 3/16/25 at 9:43am this investigator tried to contact facility phone number and it gave a busy signal. <BR/>Interview on 3/17/25 at 9:05am with DON stated she calls the facility phone number from her personal cell every day to see if the phone is working because the CEO says he paid the bill, but it is not on.<BR/>Observation on 3/17/25 at 9:50am investigator tried to contact facility phone number and it gave a busy signal. <BR/>Record review of Resident Rights policy dated December 2016 revealed f. communication with and access to people and services, both inside and outside the facility .cc. access to a telephone, mail and email.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2024, November 2024, December 2024) reviewed for RN coverage. <BR/>The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 34 days of 92 days in October 2024, November 2024, and December 2024.<BR/>This failure could place residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.<BR/>Findings included: <BR/>Record review of the PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2025 (October 1, 2024 - November 30, 2024, December 31, 2024), run date 01/6/25, revealed no evidence of RN coverage for 34 of 92 days:<BR/>1. 10/26/2024 with no RN coverage.<BR/>2. 10/27/2024 with no RN coverage. <BR/>3. 11/3/2024 with no RN coverage.<BR/>4. 11/5/2024 with no RN coverage. <BR/>5. 11/13/2024 with no RN coverage.<BR/>6. 11/16/2024 with no RN coverage.<BR/>7. 11/20/2024 with no RN coverage.<BR/>8. 11/21/2024 with no RN coverage.<BR/>9. 11/22/2024 with no RN coverage.<BR/>10. 11/25/2024 with no RN coverage.<BR/>11. 11/26/2024 with no RN coverage.<BR/>12. 11/27/2024 with no RN coverage.<BR/>13. 11/28/2024 with no RN coverage.<BR/>14. 11/29/2024 with no RN coverage.<BR/>15. 12/2/2024 with no RN coverage.<BR/>16. 12/3/2024 with no RN coverage.<BR/>17. 12/4/2024 with no RN coverage.<BR/>18. 12/5/2024 with no RN coverage.<BR/>19. 12/6/2024 with no RN coverage. <BR/>20. 12/9/2024 with no RN coverage.<BR/>21. 12/10/2024 with no RN coverage.<BR/>22. 12/11/2024 with no RN coverage.<BR/>23. 12/12/2024 with no RN coverage.<BR/>24. 12/13/2024 with no RN coverage.<BR/>25. 12/16/2024 with no RN coverage.<BR/>26. 12/17/2024 with no RN coverage.<BR/>27. 12/18/2024 with no RN coverage.<BR/>28. 212/19/024 with no RN coverage.<BR/>29. 12/20/2024 with no RN coverage.<BR/>30. 12/23/2024 with no RN coverage.<BR/>31. 12/26/2024 with no RN coverage.<BR/>32. 12/27/2024 with no RN coverage.<BR/>33.12/30/2024 with no RN coverage.<BR/>34. 12/31/2024 with no RN coverage.<BR/>In an interview and record review on 01/02/2025 at 2:30pm, the Human Resource (HR) provided the timecard reports for the months of October 2024, November 2024, and December 2024. The HR verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for the dates of : <BR/>10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024. 10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024.<BR/>In an interview on 01/02/2025 at 9:35am, the facility's CNO D said her understanding of the facility policy was an RN was to be on staff 8 hours a day. The CNO D stated the facility has weekend coverage for RN hours, and at this point the CNO D stated she can be reached by facility 24/7 by phone if needed. <BR/>Record review of a policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for 1 of 1 laundry carts observed for infection control practices.<BR/>The facility failed to ensure clean laundry was protected from dust and contamination while being transported to resident's rooms. <BR/>This failure could place residents at risk for healthcare associated cross-contamination and infections. <BR/>The findings include:<BR/>Observation on 01/02/2025 at 11:20 am the HK L was observed delivering clean laundry using a cart that was not covered. The HK L was observed delivering clean laundry to rooms #12 and 14 on the hall labeled Zone 2 on facility map, then moving uncovered cart past lobby and through dining room to Hall labeled Zone 6 to room [ROOM NUMBER].<BR/>Interview on 01/02/2025 at 11:30 am the HK L stated she does not have a cover for cart and did not know a cover was required during transport.<BR/>Interview on 01/02/2025 at 12:10pm the LVN C who was in-charge of facility at time of survey , stated she was unaware that clean laundry was being transported back into the building and deliveries needed to be covered to protect from cross-contamination. <BR/>Interview on 01/03/25 at 1:00pm LVN C stated the facility did not have a policy for delivery of clean laundry.

Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 2 of 10 (RN B, CNA D) reviewed for Quality Assurance and Performance Improvement(QAPI) training.<BR/>The facility failed to ensure all staff were trained for QAPI.<BR/>This failure placed residents at risk of at receiving care from incompetent/untrained staff. <BR/>Findings included:<BR/>Record Review of Personnel Files revealed the following staff did not receive training for Quality assurance and performance improvement:<BR/>*RN B hired 08/22/2022 <BR/>*CNA D hired 03/15/2024 <BR/>In an interview with HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. <BR/>In an interview with DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. <BR/>Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. <BR/>Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend.

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2024, November 2024, December 2024) reviewed for RN coverage. <BR/>The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 34 days of 92 days in October 2024, November 2024, and December 2024.<BR/>This failure could place residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.<BR/>Findings included: <BR/>Record review of the PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1, 2025 (October 1, 2024 - November 30, 2024, December 31, 2024), run date 01/6/25, revealed no evidence of RN coverage for 34 of 92 days:<BR/>1. 10/26/2024 with no RN coverage.<BR/>2. 10/27/2024 with no RN coverage. <BR/>3. 11/3/2024 with no RN coverage.<BR/>4. 11/5/2024 with no RN coverage. <BR/>5. 11/13/2024 with no RN coverage.<BR/>6. 11/16/2024 with no RN coverage.<BR/>7. 11/20/2024 with no RN coverage.<BR/>8. 11/21/2024 with no RN coverage.<BR/>9. 11/22/2024 with no RN coverage.<BR/>10. 11/25/2024 with no RN coverage.<BR/>11. 11/26/2024 with no RN coverage.<BR/>12. 11/27/2024 with no RN coverage.<BR/>13. 11/28/2024 with no RN coverage.<BR/>14. 11/29/2024 with no RN coverage.<BR/>15. 12/2/2024 with no RN coverage.<BR/>16. 12/3/2024 with no RN coverage.<BR/>17. 12/4/2024 with no RN coverage.<BR/>18. 12/5/2024 with no RN coverage.<BR/>19. 12/6/2024 with no RN coverage. <BR/>20. 12/9/2024 with no RN coverage.<BR/>21. 12/10/2024 with no RN coverage.<BR/>22. 12/11/2024 with no RN coverage.<BR/>23. 12/12/2024 with no RN coverage.<BR/>24. 12/13/2024 with no RN coverage.<BR/>25. 12/16/2024 with no RN coverage.<BR/>26. 12/17/2024 with no RN coverage.<BR/>27. 12/18/2024 with no RN coverage.<BR/>28. 212/19/024 with no RN coverage.<BR/>29. 12/20/2024 with no RN coverage.<BR/>30. 12/23/2024 with no RN coverage.<BR/>31. 12/26/2024 with no RN coverage.<BR/>32. 12/27/2024 with no RN coverage.<BR/>33.12/30/2024 with no RN coverage.<BR/>34. 12/31/2024 with no RN coverage.<BR/>In an interview and record review on 01/02/2025 at 2:30pm, the Human Resource (HR) provided the timecard reports for the months of October 2024, November 2024, and December 2024. The HR verbally confirmed there was no RN coverage or a full 8 hours of RN coverage for the dates of : <BR/>10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024. 10/26/2024, 10/27/2024, 11/3/2024, 11/5/2024, 11/13/2024, 11/16/2024, 11/20/2024, 11/21/2024, 11/22/2024, 11/25/2024, 11/27/2024, 11/28/2024, 11/29/2024, 12/2/2024, 12/3/2024, 12/4/2024, 12/5/2024, 12/6/2024, 12/9/2024, 12/10/2024, 12/11/2024, 12/12/2024, 12/13/2024, 12/16/2024, 12/17/2024, 12/18/2024, 12/19/2024, 12/20/2024, 12/23/2024, 12/26/2024, 12/27/2024, 12/30/2024, 12/31/2024.<BR/>In an interview on 01/02/2025 at 9:35am, the facility's CNO D said her understanding of the facility policy was an RN was to be on staff 8 hours a day. The CNO D stated the facility has weekend coverage for RN hours, and at this point the CNO D stated she can be reached by facility 24/7 by phone if needed. <BR/>Record review of a policy statement was provided that states A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #23) reviewed for wound care. <BR/>Resident #23's Treatment Administration Record (TAR) and Medication Administration Record (MAR) reflected the administration of wound care on RLE was inaccurately entered into the TAR as LLE. The order was not accurately documented.<BR/>This deficient practice could place residents at risk for inaccurate documentation of skin assessments and orders. <BR/>Findings include:<BR/>Review of Resident #23's TARs for January 2022 revealed the following diagnoses: COPD, Heart Disease, Muscle Atrophy and Dementia.<BR/>Review of Resident 23's orders for January 2022 revealed an order placed 01/08/2022 for dressing changes for RLE, instead of LLE. <BR/>During interview on 1/12/2022 at 9:35 a.m., the Director of Nurses (DON) stated that the person who entered the order and was responsible for the wound care was the ADON. She reviewed the order and both legs and said that there was an error. She would have the ADON correct the order and would be contacting the doctor to see if there would be any additional orders. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>During an interview on 1/12/2021 at 1:35 p.m. the ADON she said that the mistake was hers. She said that she was responsible for the order and wound care. She entered the wrong order by putting it under the wrong leg. She said that after it was brought to her attention today, she entered a new order and completed a new skin assessment. Policy and Procedure on Nursing Documentation was not available up on request.<BR/>Review of Resident #23's Progress Note for January 12, 2022 revealed a new note, order was place on January 12, 2022 at 9:40 a.m., for Order for correction, after realizing the old order was inaccurate- Noted that order for wound care to skin tear caused by dog scratches from 1/08/2022 was written in error to be applied to RLE. Wound care to LLE with occlusive dressing is being provided daily and order corrected to reflect correct site. Nurses are accessing wound daily as per documentation to monitor for changes in the wound- completed by ADON. <BR/>The DON was able to provide a Nursing Documentation Guidelines dated 08/2015 that says, Change in condition should be reported at 24hrs. Charting for skin injury falls under change of condition.

Based on record reviews and interviews, the facility failed to maintain a general training program to ensure staff were trained for 4 of 10 (RN B, LVN C, CNA D, CNA E) reviewed for general training.<BR/>The facility failed to ensure all staff were trained for communication.<BR/>The facility failed to ensure all staff were trained for QAPI.<BR/>The facility failed to ensure all staff were trained for Behavioral Health.<BR/>The facility failed to ensure all staff were trained for HIV.<BR/>The facility failed to ensure all staff were trained for Restraint Reduction.<BR/>The facility failed to ensure all staff were trained for Falls.<BR/>These failures could place residents at risk of at receiving care from incompetent/untrained staff. <BR/>Findings included:<BR/>Record Review of Personnel Files revealed the following staff did not receive the following training: <BR/>*RN B hired 08/22/2022- <BR/>Communication<BR/>QAPI<BR/>Behavioral Health<BR/>HIV<BR/>Restraint Reduction<BR/>Falls<BR/>*LVN C hired on 06/11/2022- <BR/>HIV.<BR/>*CNA D hired 03/15/2024 <BR/>QAPI<BR/>Behavioral Health<BR/>Restraint Reduction<BR/>*CNA E rehired on 12/15/2023<BR/>Communication<BR/>Behavioral Health<BR/>Restraint Reduction<BR/>In an interview with the HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. <BR/>In an interview with the DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. The DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. <BR/>Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. <BR/>Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend.

Based on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses or the facility's resident population in accordance with the facility assessment for 1 of 1 (the Dietary Supervisor) reviewed for dietary manager <BR/>The facility failed to ensure the Dietary Supervisor completed an approved dietary manager training course.<BR/>This failure could place the residents at risk for compromised nutritional status, weight loss, and compromised health conditions and not being accurately assessed for nutritional status, needs, and preferences.<BR/>The findings include:<BR/>Record review of the dietary employee safe food handling training certificates revealed the Dietary Supervisor had a food handler's certificate but did not have manager's safe food handling training. There was no documented evidence the Dietary Supervisor had a certificate for completing a certified dietary manager course.<BR/>In an interview on 04/30/2024 at 11:50 PM with the BOM revealed training and completions for dietary supervisor had not been completed. The BOM revealed that dietary supervisor had a food handler's card on record but not a food safety training program, nor had she completed a certified food manager program. <BR/>In an interview on 04/30/2024 at 2:00 PM the Dietary Supervisor stated she had not completed the manager food safety training program nor the food service director course with diabetic training. She has been employed in this position since February 2023 and started the dietary manager course in July of 2023. <BR/>Record review of Dietary Supervisor job description dated 11/2022 was signed by dietary supervisor February 10,2023. <BR/>Job description for Dietary Supervisor revealed the following (in part): <BR/>Essential Duties: Ensures food is nutritional, appetizing, prepared as planned and served in a timely and pleasant manner. Education and Experience: Be a graduate of an accredited course in diabetic training approved by the American Diabetic Association. Must be registered as a Food Service Director in the state.<BR/>Record review of Professional Staffing policy dated 5/2014, revised 9/2017 revealed the following (in part):<BR/>A qualified director of food and nutrition services is one who: Is a certified dietary manager, or Is a certified food service manager.<BR/>The U.S. Food and Drug Administration, 2022 Food Code specified:<BR/>2-102.12 Certified Food Protection Manager<BR/>(A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM.

Based on interviews and record reviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies and review and update the assessment at least annually for 1 of 1 facility reviewed for facility assessment. <BR/>The facility failed to update a facility-wide assessment to determine what resources was necessary to care for its residents competently during both day-to-day operations and emergencies.<BR/>This failure could place residents at risk for not receiving necessary care and services required.<BR/>The findings included:<BR/>During an interview on 10/12/24 at 8:50 PM, the Administrator stated the only form of facility assessment she could find was whatever is in the emergency preparedness book. She further stated that information regarding resident acuity level for evacuation in emergency preparedness book was not accurate. She stated that the facility assessment was the responsibility of the Administrator and she had been working on it. <BR/>During an interview on 10/22/24 at 1:03 PM the Administrator stated that she found another document titled Facility Assessment in the DON office. She further stated that it was out of date and did not know if it was accurate. <BR/>During an interview on 10/22/24 at 1:47 PM the DON stated that the facility assessment the Administrator found in her office was all she had and that she was not sure who was responsible for maintaining it. She also stated that it was not accurate or up to date with her current resident census. The DON stated that she did not have access to policies and procedures.<BR/>A record review of the facility's CMS 802 Resident Matrix dated 10/16/2024 revealed the facility census to be 29 residents. <BR/>Record review of Emergency Preparedness book given to surveyor as Facility Assessment revealed the following:<BR/>Acuity Levels for evacuation purposes dated 2019 revealed:<BR/>Independent Ambulation - 2<BR/>Independent Ambulation with assist devices (w/c, cane, walker) - 14<BR/>Ambulation with one-person stand-by assistance - 2<BR/>Ambulation with two-person assistance - 0<BR/>W/c with assistance - 24<BR/>Bed bound unresponsive and/or paralysis - 0<BR/>Bed bound with feeding tube - 0<BR/>Bed bound with central line - 0<BR/>Bed bound with oxygen - 0<BR/>Bed bound with ventilator - 0<BR/>Bed bound with IV - 0 <BR/>Bariatric Residents - 0<BR/>Total Resident Census - 42<BR/>Record review of document provided on 10/22/24 by Administrator revealed that document was titled Facility Assessment dated 2022-2023. <BR/>Requested facility policy regarding Facility Assessment on 10/10/24 at 8:00PM, 10/12/24 at 8:40PM, 10/16/24 at 9:40AM, <BR/>During an interview on 10/24/24 at 9:50AM, ADM stated she had nothing more that she could provide regarding a policy for the facility assessment.<BR/>During an interview on 10/25/24 at 4:30PM, ADM stated that she had nothing more to provide regarding a policy for the facility assessment.

Based on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 2 of 10 (RN B, CNA E) reviewed for communication training.<BR/>The facility failed to ensure all direct care staff were trained on communication.<BR/>This failure could place residents at risk at receiving care from incompetent/untrained staff.<BR/>Findings included:<BR/>Record Review of Personnel Files revealed the following staff did not receive training for communication:<BR/>*RN B hired 08/22/2022<BR/>*CNA E rehired on 12/15/2023<BR/>In an interview with HR on 04/30/2024 at 10:00AM revealed that she was responsible for orientation training and each department head was responsible for all other trainings. She said she had specific trainings that the facility did each month throughout the year, and she would ensure those in attendance signed the in-service training sheets; however, after the meetings those in-service trainings were the responsibility of each department head to ensure their staff received the trainings. <BR/>In an interview with DON on 05/01/2024 at 10:30AM, she said she was responsible for ensuring her staff received all the required training. She said there were staff that did not attend the meetings to get the in-service trainings, so she would take the book with her and tell the staff that they had in-service training and the staff needed to read over the material and sign the sheets that they received the information. DON said staff would say they would get to it later, they needed to go answer call lights or were too busy at that time. <BR/>Record review of facility policy labeled Training Compliance undated revealed: Orientation All newly hired employees will attend new employee orientation within the first 5 days of employment. The department head or designated department representative will conduct specific department and job orientation. Compliance Training The Corporate Compliance Program is legally required under federal law and is aimed at educating employees on appropriate policies, practices and procedures that comply with all applicable laws. All employees must read and acknowledge receipt of the Corporate Compliance Guidelines within the first week of employment and annually thereafter. All employees are also required to participate in the general compliance training and depending upon their position, HIPPA, and other job-specific trainings. Initial compliance training must take place within 30 days of your employment, and as necessary thereafter. <BR/>Record review of facility Handbook dated 8/18/2022 revealed: Meetings: You are expected to attend designated meetings to foster communications about issues. Some in-services are mandatory, and employees must attend.<BR/>?