Based on interview and record review, the facility failed to ensure a staff member followed the facility policy and procedure related to the use of a gait belt during a transfer which resulted in a resident fall for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in an abrasion on the resident's forehead and a fracture of the right femur. The deficient practice was corrected on 5/5/25, prior to the start of the survey, and therefore was past noncompliance. Findings include: During a telephone interview, on 5/27/25 at 8:47 a.m., Resident B's family indicated the resident was a fall risk. He was in the hall, heard a thump, and entered to find the resident on the floor. The resident had blood coming from her head. The CNA did not have a gait belt. He told the facility to call the paramedics. He indicated the resident sustained a right femur fracture (broken bone in the upper leg) and had emergency surgery the following day. The clinical record for Resident B was reviewed on 5/27/25 at 9:15 a.m. The diagnoses included, but were not limited to, muscle weakness, chronic respiratory failure, and chronic kidney disease with heart failure. A fall risk assessment, dated 4/1/25, indicated Resident B was at a high fall risk. A care plan, dated 4/2/25, indicated Resident B was a new admission and required implementation of services. An intervention, dated 4/2/25, indicated to provide fall prevention interventions. A physician's order, dated 4/23/25, indicated the resident could get up when she wanted with assistance of a staff member. A Minimum Data Set (MDS) assessment, dated 4/29/25, indicated Resident B required substantial/maximal assistance to transfer from sitting to standing and was cognitively intact. A facility falls event document, dated 5/4/25, indicated Resident B had a witnessed fall. The resident hit her head, said her head hurt, and it was decided the resident needed to go to the emergency room for further evaluation. The CNA was transferring the resident from the bed to the wheelchair and the resident fell backwards. A hospital emergency room note, dated 5/4/25 at 4:08 p.m., indicated Resident B presented to the emergency department. The resident's son was present and indicated he knocked on the resident's door at the facility, heard a loud thump from the resident's room, entered, and observed his mother on the floor with the aid standing there. He told the emergency room staff the CNA was transferring his mother to the wheelchair, slipped, and dropped her. The resident had sustained an abrasion to the right side of the forehead and the right leg was resting in an external rotation. A radiology report, dated 5/4/25, indicated Resident B had sustained a nondisplaced intertrochanteric fracture of the proximal right femur. A facility document, titled Approaches on Profile, undated, indicated Resident B was an assistant of 1 person with transfers. A facility document, titled Employee Communication Form, indicated, on 5/4/25, CNA 2 failed to use a gait belt during a transfer which resulted in a fall with injury. CNA 2 was aware all transfers required the use of a gait belt if a mechanical lift was not used. The document was signed by CNA 2 and the Director of Nursing on 5/4/25 and by the Executive Director on 5/5/25. During an interview, on 5/27/25 at 10:15 a.m., the Director of Therapy indicated Resident B's therapy evaluation indicated a stand assist of one (1), standing pivot transfer with a gait belt on. During a telephone interview, on 5/27/25 at 10:56 a.m., CNA 2 indicated Resident B had experienced loose stools all day. The resident wanted to get up and go to the bathroom. The wheelchair was present at the side of the bed. The resident stood up and CNA 2 was holding the resident's pants. The resident fell back onto her side. CNA 2 indicated the resident had a small amount of blood from the right temple area. The resident was a one person transfer per care sheet (a sheet which told the interventions/needs the resident required). CNA 2 indicated she did not have a gait belt on Resident B and there were no care sheets available that day or the day prior. The facility had a policy to use gait belts and told staff to use gait belts. The resident's family member was at the facility when the incident occurred. During an interview, on 5/27/25 at 12:19 p.m., the Director of Nursing indicated the use of a gait belt was standard and CNA 2 should have used a gait belt. Gait belts were provided upon hire as part of the uniform. During an interview, on 5/28/25 at 9:56 a.m., CNA 3 indicated gait belts were to be used anytime a resident needed to stand/transfer if they did not require a mechanical lift. During an interview, on 5/28/25 at 9:49 a.m., RN 4 indicated a gait belt should be used anytime a resident needed to be transferred. During an interview, on 5/28/25 at 9:48 a.m., CNA 5 indicated the gait belt was to be used anytime staff helped a resident transfer. A facility document, titled Nurse Aide/Certified Nurse Aide Job Specific Orientation Plan, dated as completed 6/24/24 and received from the Director of Nursing on 5/28/25 at 9:50 a.m., indicated CNA 2 had completed her CNA training including, but not limited to, .Gait belt policy/Proper body mechanics A current facility procedure, titled Transfer to Wheelchair, dated as last reviewed in 9/2023 and received from the Director of Nursing on 5/27/25 at 12:10 p.m., indicated .Procedure Steps .place gait belt around resident's waist .Grasp belt securely on both sides .Help resident to pivot to front of wheelchair .remove gait belt A current facility policy, titled Gait Belts, dated 2/20/20 and received from the Director of Nursing on 5/27/25 at 12:19 p.m., indicated .Use of gait belts serves to reduce the risk of injury to patient/resident as well as to staff members .It is the policy for all Therapy and Wellness staff to utilize gait belts to assist patients who are not independent with transfers and ambulation .Failure to comply will result in disciplinary action and may lead to termination The deficient practice was corrected by 5/5/25 after the facility implemented a systemic plan which included an investigation, education on gait belt use, and audits were initiated for other residents and for ensuring staff had and were using gait belts. This citation relates to Complaint IN00458980. 3.1-45(a)(2)

Based on interview and record review, the facility failed to ensure a resident received a medication for cancer as ordered, follow-up appointments with an oncologist were scheduled, and the facility's medical director did not discontinue a medication without consulting with the resident's oncologist for 1 of 2 residents reviewed for quality of care. (Resident B) This deficient practice resulted in Resident B having no follow-up oncology care to prevent further spread of the metastasis to the bone related to his prostate cancer. Findings include: An email, dated 1/16/25, indicated there were concerns with Resident B's treatment plan for his metastatic prostate cancer. In February 2023, the resident was placed on docetaxel (chemotherapy) and Nubeqa (a hormone therapy medication used to treat prostate cancer) at the cancer center. In April 2023, his pain was much improved, and his prostate-specific antigen had dropped which indicated the treatment was working well. In September 2023, Resident B continued to receive treatment, and his cancer medications were being provided/covered by the specialty pharmacy. In October 2023, the resident was admitted to the long-term care nursing facility. The clinical record for Resident B was reviewed on 2/11/25 at 2:30 p.m. The diagnoses included, but were not limited to, malignant neoplasm of prostate gland, post traumatic seizures, atrial fibrillation, and systolic heart failure. A hospital document, titled After Visit Summary, dated 10/9/23, indicated the resident was being discharged to a long-term care facility and to schedule a follow-up with oncology related to a cancer diagnosis. A nursing progress note, dated 10/9/23 at 9:56 p.m., indicated the resident was admitted to the facility. The physician on call verified the resident's admission orders, the pharmacy was aware of the orders and the medications which needed sent to the facility. A physician's order, dated 10/9/23, indicated to start Nubeqa (darolutamide) 600 mg (milligram) orally twice a day on 10/10/23 for a diagnosis of malignant neoplasm of the prostate. The order indicated it was a telephone order taken by LPN 1. A nursing progress note, dated 10/11/23 at 3:53 p.m., indicated LPN 2 notified the pharmacy the resident's Nubeqa was missing. The pharmacy technician indicated a script was needed from the physician for the medication. LPN 2 notified the nurse practitioner Nubeqa needed a script. A nursing progress note, dated 10/12/23 at 3:43 p.m., indicated LPN 2 notified the pharmacy regarding the resident's missing Nubeqa. The pharmacy technician indicated the medication was a high-cost medication. A nurse practitioner progress note, dated 10/13/23 at 10:27 a.m., indicated Resident B's medications and orders were reviewed. She indicated he was to be given Nubeqa 600 mg orally twice a day for the diagnosis of metastatic prostate cancer. A physician's order, dated 10/19/23 at 8:17 a.m., indicated to discontinue the resident's Nubeqa 600 mg twice a day. The reason for discontinuing the medication was because it was a High Cost Medication. There was no documentation the physician consulted with the resident's oncologist before discontinuing the medication. There was no documentation the resident had a follow-up appointment or any consultation with the oncologist until 1/16/25 which was 15 months after the resident admitted to the facility. A nursing progress note, dated 1/16/25 at 3:51 p.m., indicated the resident returned from his cancer center appointment. His next appointment with the cancer center would be on 1/30/25 at 12:30 p.m. A nursing progress note, dated 1/30/25 at 1:26 p.m., indicated LPN 1 spoke with Resident B's guardian and the prostate cancer had spread. She was deciding on whether to place the resident on hospice. A social service progress note, dated 2/3/25 at 4:27 p.m., indicated the social worker spoke with the resident's legal guardian who indicated Resident B would transition to hospice related to his cancer diagnosis. A nursing progress note, dated 2/3/25 at 6:46 p.m., indicated the resident was admitted to hospice. During an interview, on 2/11/25 at 1:50 p.m., the Director of Nursing indicated the resident's chemotherapy drug was ordered following his discharge from the hospital. The Medical Director at that time chose to discontinue the medication because it was a high-cost medication. When a resident was on a high-cost medication normally the facility placed the medication on hold until they were dismissed from the facility. She did not know the resident had an oncology referral appointment when he was discharged from the hospital. He had no oncology follow-up appointments as far as she knew until 1/16/25. The Medical Director who discontinued the medication was no longer employed at the facility. The facility had been unable to reach him to obtain any further information related to discontinuing Resident B's cancer medication or his cancer treatment since he was admitted in 2023. A current facility policy, titled Nursing Admission/Return admission Policy and Procedure, dated as revised 07/2024 and provided by the Director of Nursing on 2/11/25 at 1:30 p.m., indicated .Physician orders .Upon admission, physician orders must be obtained .Transcribe the admission orders from the original orders sent from the hospital or physician's office .Transcribe the routine medication orders to include dosage route, frequency and diagnosis to support the use .Inquire about medications that the resident may still have at home prior to admission to the nursing facility and assure the resident/representative consults with the primary care physician or community pharmacist before taking previously prescribed, unused medications, including over-the-counter medications .Verification of orders .The admitting nurse must call the attending physician to verify all orders upon admission. Pharmacy notification .Pharmacy notified of new admit/readmit .Discharge Summary .Residents being admitted from the hospital must have a discharge summary. If not present at admission, contact the transferring facility for a copy Darolutamide (Last revised 9/15/22) and retrieved on 2/18/25 from the National Library of Medicine MedlinePlus website indicated Darolutamide is also used to treat certain types of prostate cancer (cancer that begins in the prostate [a male reproductive gland]) that have spread to other parts of the body in men in combination with docetaxel. Darolutamide is in a class of medications called androgen receptor inhibitors. It works by blocking the effects of androgen (a male reproductive hormone) to stop the growth and spread of cancer cells .Do not stop taking darolutamide without talking to your doctor .Keep all appointments with your doctor and the laboratory. Your doctor may order certain lab tests to check your body's response to darolutamide .Brand names Nubeqa This citation relates to Complaint IN00451659. 3.1-37(a)

Based on interview and record review, the facility failed to administer medications to ensure a resident was free from significant medication errors for 1 of 3 residents reviewed regarding medication errors. (Resident G) Resident G required a hospital admission of five days. Finding includes: A document, titled Intake Information, dated 11/2/23, indicated an anonymous complainant had concerns with Resident G having a critically low potassium level and not being treated with the potassium replacement ordered by the Nurse Practitioner (NP). During an interview, on 11/14/23 at 2:45 p.m., the Director of Nursing (DON) indicated Resident G did miss her dose of Potassium liquid, on 10/24/23, after the NP ordered it to be given that day. Agency Nurse 4 went to get the potassium liquid out of the Emergency Drug Kit, and it was not in there. Instead of calling the NP back, as she should have done to obtain further orders, she asked the other nurse on the unit what she should do. They decided to reschedule the medication for the following day after the pharmacy delivered it. The potassium liquid was rescheduled for 10/25/23. The resident's potassium level had dropped even lower, and the NP ordered for her to be sent to the hospital. The record for Resident G was reviewed on 11/15/23 at 10:45 a.m. Diagnoses included, but were not limited to, Enterocolitis due to Clostridium Difficile-recurrent, type 2 diabetes mellitus, arteriosclerosis of coronary artery bypass graft, hypertension, hypokalemia (low potassium levels), and dehydration. A document, titled Medication/Treatment Error Report, dated 10/25/23, indicated Agency Nurse 4 did not give Resident G's potassium liquid now as ordered by the NP. The effect of the error on the resident was her potassium level was low and she was sent to the ER for evaluation. A handwritten statement, dated 10/25/23, by Agency Nurse 4 indicated while she was placing orders in the computer, on 10/24/23, she came across the potassium orders for Resident G. She asked LPN 5 why Resident G could not have potassium tablets, since she could not find the potassium liquid the NP had ordered for her. LPN 5 indicated if there was no potassium liquid, she could move the order until the following day (10/25/23). LPN 5 changed the date and time of the potassium liquid until 10/25/23, after pharmacy delivered the medication to the facility. She asked about changing the potassium lab order for the following day, since it was ordered for the next morning following the potassium liquid doses. LPN 5 indicated she would also change the lab date and time for her. Resident G's potassium levels were reviewed: On 10/13/23 at 6:40 p.m., the level was 3.0 mEq/L. Normal levels were 3.5 to 5.5 mEq/L (liter). On 10/24/23 at 1:10 p.m., the level was 2.7 mEq/L. On 10/25/23 at 1:57 p.m., the level was 2.5 mEq/L. The Electronic Medication Administration Record (EMAR), dated 10/5/23 through 10/31/23, for Resident G included, but were not limited to, the following orders and documentation: 1. An order, dated 10/10/23 thru 10/12/23, indicated to give Fidaxomicin (an antibiotic used to treat C-Diff) 200 mg (milligrams) by mouth twice a day. a. On 10/10/23 at 8:32 p.m., the medication was documented as not administered as the medication was unavailable due to the pharmacy called indicating the medication was not covered. b. On 10/11/23 at 12:28 p.m., the medication was documented as not administered as the medication was unavailable. c. On 10/11/23 at 9:20 p.m., the medication was documented as not administered and the pharmacy was aware. d. On 10/12/23 at 10:10 a.m., the medication was documented as unavailable and will call the pharmacy. 2. An order, dated 10/24/23 at 3:00 p.m., indicated to give potassium chloride liquid by mouth 20 mEq/15 ml, 20 mEq one time now. a. On 10/24/23 at 3:00 p.m., the documentation box was left blank. The medication was rescheduled by a nurse to be given 10/25/23 at 10:00 a.m. 3. An order, dated 10/24/23, indicated to give potassium chloride liquid 20 mEq/15 ml, 20 mEq every two hours for three doses (80 mEq total). a. This medication was scheduled to be given on 10/24/23 at 6:00 p.m. and 8:00 p.m. (There was no third dose scheduled for 10/24/23). The medication was rescheduled by a nurse to be given on 10/25/23 at 12:00 p.m., 2:00 p.m. and 4:00 p.m. 4. An order, dated 10/25/23, indicated to transport the resident to the emergency room (ER) stat (immediately) for a critical potassium level. Resident G's progress notes included, but were not limited to, the following notes: a. 10/12/23 at 10:51 a.m., the NP note indicated the resident was on isolation for C-Diff. She was still reporting diarrhea. The resident indicated she was not receiving her Fidaxomicin due to insurance not covering it. The NP had documented in her notes the resident was receiving her Fidaxomicin until 10/19/23. b. 10/12/23 at 4:45 p.m., Fidaxomicin was a high-cost antibiotic, and the facility was not able to cover it being $10,000 and over. The antibiotic was changed by the physician. c. 10/12/23 at 5:01 p.m., new orders received to start an Intravenous solution of 1/2 Normal Saline at 150 ml/hr. Potassium chloride 20 mEq by mouth twice a day for 5 days. d. 10/13/23 at 10:56 a.m., the NP progress note indicated the resident was experiencing diarrhea and some dizziness with positional changes. e. 10/13/23 at 12:31 p.m., an order was given for the resident to be sent to the ER for an evaluation and treatment of C-Diff due to the fact that she is not able to receive PO [oral] ATB [antibiotic] therapy that is needed to treat c-diff. The medication needed to treat her C-Diff was very expensive and could not be given at the facility, but the hospital was able to administer it. The recent ordered antibiotic therapy (Flagyl and Vancomycin) had not worked for the resident in the past, so she was being sent to the ER. f. 10/21/23 at 11:33 p.m., the resident was readmitted back into the facility from the hospital. g. 10/22/23 at 4:10 p.m., the resident's antibiotic was not available at the facility. The pharmacy indicated the medication was expensive and sent a form to be faxed back to them indicating the facility would cover the cost of the medication prior to sending. h. 10/22/23 at 11:10 p.m., the facility received the resident's Fidaxomicin medication from the pharmacy. i. 10/24/23 at 4:32 p.m., the resident had a low potassium level of 2.7, which was reported to the NP on site and awaiting new orders. j. 10/25/23 at 3:00 p.m., a NP progress note indicated the resident had a Basic Metabolic Panel (BMP) lab drawn that morning, which revealed a critically low potassium level of 2.5. She was symptomatic with complaints her heart felt like it was racing, tingling, muscle spasms, and weakness. She had a potassium level of 2.7, on 10/24/23, and had orders written on that day to administer potassium chloride liquid 20 mEq one dose now, then administer potassium chloride liquid 20 mEq every two hours for three more doses for a total of 80 mEq of potassium chloride. The resident did not receive the potassium chloride liquid replacement and she was now symptomatic with a critically low potassium level of 2.5, which was drawn five hours ago. She had a history of coronary artery disease. It was in the best interest of the resident to be emergently transferred to the hospital for an electrocardiogram (EKG) heart monitoring and IV potassium chloride replacement. k. 10/30/23 at 5:05 p.m., the resident returned from the hospital to be readmitted to the facility. A document, titled Patient Summary Report, dated 10/26/23 at 1:56 p.m., from the hospital indicated Resident G's number one problem was severe hypopotassemia (low potassium level)/hypomagnesemia (low magnesium level). She had ongoing electrolyte abnormalities most likely from chronic diarrhea. Her potassium level was 2.2. She received 40 mEq of oral potassium in the ER and 20 mEq IV. She was placed on telemetry (continuous heart monitoring) due to her significant hypokalemia (low potassium levels). A document, titled Patient Summary Report, dated 10/26/23 at 2:01 p.m., from the hospital indicated Resident G had multiple hospitalizations over the last couple of months related to a complex infection of her left lower extremity. It was treated with antibiotics, and she developed C. Diff which was initially treated with Vancomycin. She was switched to Fidaxomicin. She had trouble receiving the Fidaxomicin at the facility she resided at and was readmitted to the hospital earlier in the month. She was placed back on the medication with plans to finish it out through October 29, 2023, according to the Gastroenterologist. She had a significantly low potassium level, so she was sent to the ER where her potassium level was 2.2 and was started on medication and further evaluation was being completed. During an interview, on 11/15/23 at 12:05 p.m., the Regional Director of Clinical Support (RDCS) indicated there was no policy for following physician's orders. The nurses knew they were to follow physician orders which were given for the residents. During an interview, on 11/15/23 at 2:22 p.m., the NP indicated Resident G had a potassium level of 2.7, on 10/24/23. She was asymptomatic, so she knew she could treat the level in the facility. She ordered potassium liquid 20 mEq (milliequivalent) to be given as a one-time order stat, then 20 mEq to be given three more times two hours apart from each other. A new lab would be drawn the next morning, (10/25/23), to see where the resident was on her level. She indicated she was shocked to see her level had dropped to 2.5 when she got the potassium result back, on 10/25/23 at 3:00 p.m. She thought either the resident did not absorb the potassium and she was going to be dealing with a bigger issue or the potassium liquid was not given as ordered. The NP went to Agency Nurse 4 who had the resident the day and asked if she got the potassium as ordered, on 10/24/23. She was told no because it was unavailable until 10/25/25, so it was rescheduled to be given that day. She gave the order for her to be sent to the emergency room (ER) stat. She seen in the nursing documentation, on 10/25/23 at 10:00 a.m., the resident had complaints of heart fluttering and generally was not feeling good. She was not notified of these symptoms when the resident complained about them. With her cardiac history, she was concerned she would start having increased cardiac issues. When the resident arrived at the ER, her potassium level was 2.2. Her potassium level had been drawn in the morning at the facility, so it had dropped even lower since it as drawn. During an interview, on 11/15/23 at 2:20 p.m., the Director of Nursing (DON) indicated Resident G did not receive her Fidaxomicin (an antibiotic used to treat Clostridium Difficile) 200 mg twice a day because her insurance would not pay for it. The facility pharmacy did not fill the medication prescription as ordered by the physician because they did not carry the medication due to the cost of the medication. The antibiotic was changed to Flagyl (an antifungal used to treat a variety of fungal infections) and Vancomycin (an antibiotic), which she had previously been treated with these medications prior to being placed on the Fidaxomicin. A current policy, titled Medication Administration, undated and provided by the Executive Director (ED) on 11/16/23 at 10:30 a.m., indicated .Any orders that are ordered STAT must be completed within the 4-hour required time frame. Any orders not completed within that time frame the charge nurse must notify the MD/NP for further orders. 2. When receiving any orders in writing or by telephone, if unable to complete the order as prescribed, the charge nurse will notify the MD/NP for further orders. 3. Failure to complete MD/NP orders, failure to enter labs, failure to transcribe orders correctly are considered medication errors .6. If any concerns with MD/NP orders/care, ED/DNS [Director of Nursing Services] will be notified A current policy, titled Medication Errors, dated 11/2018 and provided by the ED on 11/16/23 at 10:30 a.m., indicated .It is the policy of this provider to ensure residents residing in the facility are free of medication errors .The charge nurse will complete a medication error report, including a brief summary of findings. Documentation in the medical record will include physician/family notification, type of error, and assessment of resident. The licensed nurse/QMA responsible for the error will be required to meet with the DNS (Director of Nursing Services)/designee to review the medication error report This Federal tag relates to Complaint IN00421053. 3.1-48(c)(2)