**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1), whose physician's orders included the administration of a medication with a black box warning, the facility failed to ensure the dispensing Pharmacist and the Pharmacy Consultant identified and reported a medication that was prescribed and administered at an excessive frequency, which resulted in Resident #1 experiencing an overall decline in condition, requiring transfer and admission to the hospital.Findings include:Review of the facility's policy, titled Pharmacy Services Overview, with a revision date of 04/2019, included the following:-Pharmaceutical services consist of:*the processes of receiving and interpreting prescriber's orders; receiving, reconciling, and dispensing.all medications.*the process of identifying, evaluating and addressing medication-related issues including the prevention and reporting of medication errors.-The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements.Review of the website, accessdata.fda.gov, approved by the U.S. Food and Drug Administration (FDA) indicated the following:-The recommended frequency to administer Methotrexate for both the treatment of psoriasis and rheumatoid arthritis, is weekly.-Methotrexate has a black box warning (the most serious warning the FDA uses to alert consumers and providers of possible risks associated with the use of this medication).-Taking more Methotrexate than prescribed or taking Methotrexate more often than prescribed, can lead to severe side effects and cause death.-If too much Methotrexate is consumed, immediate medical care is required to help reduce side effects that could be severe and could cause death.Resident #1 was admitted to the facility in July 2025, diagnoses included Antiphospholipid Syndrome (an autoimmune, hypercoagulable state which can lead to blood clots in both arteries and veins, and other symptoms like low platelets) and CREST syndrome (also known as the limited cutaneous (skin) form of systemic sclerosis which causes the body to destroy healthy tissue).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was to receive Methotrexate 2.5 milligram (mg) tablets, 10 tablets by mouth [once] every 7 days (5 tablets in the morning and 5 tablets in the evening, for a total dose of 25 mg). Review of Resident #1's Physician's Orders for the month of July 2025, indicated there was order to administer Methotrexate 2.5 mg, give 5 tablets by mouth two times a day (9:00 A.M. and 5:00 P.M.) for RA (Rheumatoid Arthritis). The order also included the following information: hazardous drug, wear gloves and wash hands thoroughly after handling. Pregnant women should avoid contact with this medication. During an interview on 09/03/25 at 1:04 P.M., Nurse #1 said he reconciled Resident #1's medications upon his/her admission to the facility and entered the medications in his/her Electronic Medical Record (EMR). Nurse #1 said that Physician #1 had previously reviewed and approved Resident #1's medications which were listed on his/her Hospital Discharge Summary.Nurse #1 said he made an error when he entered the medication in Resident #1's EMR and instead of entering the Methotrexate to be given in the morning and at night once per week, he entered for it to be given in the morning and at night every day.Review of Resident #1's Medication Administration Record (MAR) for the month of July 2025 indicated for the Methotrexate he/she received 25 mg total on the following:-07/23/25 to 07/25/25, 25 mg daily-07/26/25, 12.5 mg daily-07/27/25 to 07/30/25, 25 mg daily-07/31/25, 12.5 mg dailyDuring a telephone interview on 09/04/25 at 12:16 P.M., the Pharmacy Director said that 120 tablets of Methotrexate were dispensed for Resident #1 upon receiving his/her admission orders from the Facility.The Pharmacy Director said that Resident #1's Methotrexate order was flagged for a Drug Utilization Review (DUR) and the Pharmacist who dispensed the medication, overrode the DUR alert. The Pharmacy Director said the DUR alert was triggered to alert the dispensing Pharmacist to contact the Facility to verify the dose and frequency of the Methotrexate order.The Pharmacy Director said, had the contact with the Facility taken place and the medication verified, this error would likely have been discovered before the medication was sent out to the Facility.Review of Resident #1's Interim Medication Regimen Review, dated 07/24/25, indicated a Pharmacy Consultant reviewed Resident #1's physician's orders and did not identify or report the order for Resident #1 to receive Methotrexate 25 milligrams (total dose) by mouth daily.During a telephone interview on 09/04/25 at 12:16 P.M., the Pharmacy Director said the Pharmacy Consultant reviewed Resident #1's medications on 07/24/25 and the excessive dosing in the Methotrexate order should have been identified and reported as inappropriate.Review of Resident #1's Nursing Progress Note, dated 07/31/25, indicated he/she had acute respiratory distress, increased congestion, decreased blood oxygen level despite the use of oxygen, loose bowel movements, and decreased food/fluid intake. The Note indicated he/she was transferred to the Hospital Emergency Department (ED) for an evaluation.Review of Resident #1's Hospital Progress Note, dated 08/03/25, indicated he/she had pancytopenia (low red blood cells-carry oxygen; low white blood cells- fight infection, and low platelets- for blood clotting) likely due to chronic methotrexate toxicity. The Note indicated pancytopenia occurred acutely within the span of 10 days (7/21/25 through 07/31/25); and his/her Methotrexate level that day was 0.29, (levels greater than 0.10 after 24 hours of administration of the medication would be considered toxic).Further review of the Note indicated that Poison Control recommended to continue to administer leucovorin 25 milligrams every six hours and obtain daily methotrexate levels until the level was <0.01.During an interview on 09/03/25 at 3:24 P.M., the Director of Nurses (DON) said that the Pharmacy did not identify the error related to Resident #1's Methotrexate order at any point and should have. The DON said that he had received the Pharmacy's investigation related to this medication error, including their action plan.On 09/03/25, the Facility was found to be in Past Non-Compliance, with an effective date of 08/30/25, and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by:A) On 08/08/25 and 08/12/25, the Pharmacy Director educated the Pharmacists on the appropriate dose and frequency for the administration for Methotrexate.B) On 08/11/25 the Pharmacy Director educated all Pharmacy order entry staff on Methotrexate dosing guidelines and when to report to the staff pharmacist on duty.C) All Pharmacists will complete two continuing education hours on preventing medication errors with their annual requirements.D) On 08/04/25 through 08/20/25, the Staff Educator educated the nursing staff on accurately transcribing medication orders for new admissions and readmissions to the facility, and the new system/process regarding Que orders.E) On 08/04/25, the Facility implemented a new system, the admitting nurse will enter the orders in the Electronic Medical Record, a second nurse will verify with the discharge summary and activate the orders.F) On 08/04/25 an audit was initiated for all current new admissions and readmissions for the previous 30 days for admissions medication transcription accuracy.G) A weekly monitoring audit on new admissions and re-admissions was completed on 08/20/25 by the Director of Nurses and will continue monthly for two months to ensure compliance.H) On 08/04/25 through 08/30/25, the Director of Nurses and Staff Educators educated all staff nurses, unit managers, supervisors, and department heads on the Facility policy for medication verification and reconciliation for all new admissions and re-admissions.I) On 08/04/25, the unit managers or designee will review the medication reconciliation forms within 24 hours of admission or readmission to ensure they are complete, accurate, and all areas of conflict were addressed with the MD or provider.J) On 08/04/25 through 08/30/25, the licensed staff will review resident admitted in the last 30 days to ensure the medication reconciliation is completed and any potential conflicts are reported and resolved.K) The Director of Nurses reviews the medication reconciliation forms during morning clinical meeting to ensure completion.L) On 08/15/25, audits to ensure the medical reconciliation was completed were initiated and are on-going by the Director of Nurses or designee.M) Audits to be reviewed at the quarterly QAPI meetings by the QAPI committee.N) The Director of Nurses and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose physician's orders included administration of a potentially toxic medication (oral chemotherapy agent used to treat rheumatoid arthritis) the facility failed to ensure he/she was free from a significant medication error, when upon admission, the medication was inaccurately reconciled from his/her Hospital Discharge Summary by nursing and he/she was administered the medication for consecutive days in error. Resident #1 experienced an overall decline in condition, was transferred and admitted to the Hospital, and was treated for toxic levels of the medication. Findings include:Review of the Facility's policy, titled Adverse Consequences and Medication Errors, with a revision date of 06/2025, indicated the following:-A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with provider's orders, manufacturer specifications, or accepted professional standards and principles of the professional (s) providing services.-A significant medication-related error is defined as requiring medication discontinuation; requiring hospitalization; requiring treatment with a prescription medication; life threatening and/or resulting in death.-Evaluate the resident for possible medication-related adverse consequences when the resident has a significant change in clinical condition/status including unexplained decline in function, cognition or behavior; or worsening of an existing problem or condition.Review of the Facility's policy, titled Medication Reconciliation, with a revision date of 12/2014, indicated the following:-The Center will accurately reconcile medications of newly admitted residents to contribute to the creation of an accurate medication list.-Prescribing errors may occur when a patient is admitted to the hospital or transferred across the continuum of care to the skilled nursing center; these errors may result in adverse drug events.-Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient's current medication (including name, dosage, frequency, and route) and comparing the incoming admission, transfer and or discharge medication orders to that list. Discrepancies are brought to the attention of the prescriber and, if appropriate, changes are made to the orders.Review of the website, accessdata.fda.gov, approved by the U.S. Food and Drug Administration (FDA) indicated the following:-The recommended frequency to administer Methotrexate for both the treatment of psoriasis and rheumatoid arthritis, is weekly.-Methotrexate has a black box warning (the most serious warning the FDA uses to alert consumers and providers of possible risks associated with the use of this medication).-Taking more Methotrexate than prescribed or taking Methotrexate more often than prescribed, can lead to severe side effects and cause death.-If too much Methotrexate is consumed, immediate medical care is required to help reduce side effects that could be severe and could cause death.Resident #1 was admitted to the facility in July 2025, diagnoses included Antiphospholipid Syndrome (an autoimmune, hypercoagulable state which can lead to blood clots in both arteries and veins, and other symptoms like low platelets) and CREST syndrome (also known as the limited cutaneous (skin) form of systemic sclerosis which causes the body to destroy healthy tissue).Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated he/she was to receive Methotrexate 2.5 milligram (mg) tablets, take 10 tablets [25 mg] by mouth [once] every 7 days (5 tablets [12.5 mg] in the morning and 5 tablets in the evening).Review of Resident #1's Medication Administration Record (MAR) for the month of July 2025, indicated he/she a physician's order to administer Methotrexate 2.5 mg, give 5 tablets by mouth two times a day (9:00 A.M. and 5:00 P.M.) for RA (Rheumatoid Arthritis). The order also included the following warning: hazardous drug, wear gloves and wash hands thoroughly after handling. Pregnant women should avoid contact with this medication. Review of Resident #1's Medication Administration Record (MAR) for the month of July 2025 indicated for the Methotrexate he/she received 25 mg total on the following:-07/23/25 to 07/25/25, 25 mg daily-07/26/25, 12.5 mg daily-07/27/25 to 07/30/25, 25 mg daily-07/31/25, 12.5 mg dailyDuring an interview on 09/03/25 at 1:04 P.M., Nurse #1 said he entered the physician's orders in Resident #1's Electronic Medical Record (EMR) upon his/her admission to the facility. Nurse #1 said that Physician #1 had previously reviewed and approved Resident #1's medications which were listed on his/her Hospital Discharge Summary.Nurse #1 said he made an error when he entered the medication in Resident #1's EMR and instead of entering the Methotrexate to be given in the morning and at night once per week, he entered for it to be given in the morning and at night, every day.Nurse #1 said he was unfamiliar with the intended use and usual dosing for Methotrexate prior to this incident.During a telephone interview on 09/04/25 at 9:02 A.M., Physician #1 said he was in the facility when Resident #1 was admitted . Physician #1 said he had reviewed his/her Hospital Discharge Summary and that all the medications listed on the Summary were to be continued at the facility. Physician #1 said he was very familiar with Methotrexate and that it was to be administered weekly.Review of Resident #1's Nursing Progress Notes, indicated Nurse Practitioner (NP) #1 visited Resident #1 at the facility on 07/23/25 and 07/28/25.Review of Resident #1's NP Progress Notes indicated that on 07/23/25 and 07/28/25, NP #1 documented that Resident #1's Methotrexate order was as follows:-Methotrexate 2.5 milligrams- take 5 [tablets] by mouth everyday two times per day.During a telephone interview on 09/04/25 at 8:35 A.M., Nurse Practitioner #1 said that although he listed all of Resident #1's medications in his Progress Notes, he reviewed only the medications that were pertinent to his visits. NP #1 said that Methotrexate was managed by specialists, and he was not familiar enough with the recommended administration frequency to have questioned the directions as they were listed on Resident #1's physician's orders.Review of Resident #1's Nursing Progress Note, dated 07/31/25, indicated he/she had acute respiratory distress, increased congestion, decreased blood oxygen level despite the use of oxygen, loose bowel movements, and decreased food/fluid intake. The Note indicated he/she was transferred to the Hospital Emergency Department (ED) for an evaluation.Review of Resident #1's Hospital Progress Note, dated 08/01/25, indicated his/her Methotrexate was restarted in June 2025 after being on hold due to thrombocytopenia (a condition caused by low platelets, which can lead to easy bruising and bleeding).Review of Resident #1's Hospital Progress Note, dated 08/03/25, indicated he/she had pancytopenia (low red blood cells-carry oxygen; low white blood cells- fight infection, and low platelets- for blood clotting) likely due to chronic methotrexate toxicity. The Note indicated pancytopenia occurred acutely within the span of 10 days (7/21/25 through 07/31/25); and his/her Methotrexate level that day was 0.29 (levels greater than 0.10 after 24 hours of administration of the medication would be considered toxic) which is more consistent with chronic toxicity per Poison Control.Further review of the Note indicated that Poison Control recommended to continue to administer leucovorin (form of folic acid to help prevent side effects of certain medications) 25 milligrams every six hours and obtain daily methotrexate levels until the level was <0.01.During a telephone interview on 09/04/25 at 9:55 A.M., the Medical Director said he was disappointed that many of the systems in place to avoid medication errors such as this failed. The Medical Director said the medication orders listed on Resident #1's Hospital Discharge Summary should have been implemented and transcribed accurately.During an interview on 09/03/25 at 3:24 P.M., the Director of Nurses (DON) said Resident #1's Methotrexate order was not accurately transcribed in his/her medical record upon admission to the Facility. The DON said the manner in which the nursing staff performed their medication reconciliations was not in accordance with facility protocol.The DON said he expected the nursing staff to carefully and accurately transcribe orders and to be familiar with the medications they are administering.On 09/03/25, the Facility was found to be in Past Non-Compliance, with an effective date of 08/30/25, and presented the Surveyor with a plan of correction which addresses the areas of concern as evidenced by:A) On 08/04/25 through 08/20/25, the Staff Educator educated the nursing staff on accurately transcribing medication orders for new admissions and readmissions to the facility, and the new system/process regarding Que orders.B) On 08/04/25, the Facility implemented a new system, the admitting nurse will Que the orders in the Electronic Medical Record, a second nurse will verify with the discharge summary and activate the orders.C) On 08/04/25 an audit was initiated for all current new admissions and readmissions for the previous 30 days for admissions medication transcription accuracy.D) A weekly monitoring audit on new admissions and re-admissions was completed on 08/20/25 by the Director of Nurses and will continue monthly for two months to ensure compliance.E) On 08/04/25 through 08/30/25, the Director of Nurses and Staff Educators educated all staff nurses, unit managers, supervisors, and department heads on the Facility policy for medication verification and reconciliation for all new admissions and re-admissions.F) On 08/04/25, the unit managers or designee will review the medication reconciliation forms within 24 hours of admission or readmission to ensure they are complete, accurate, and all areas of conflict were addressed with the MD or provider.G) On 08/04/25 through 08/30/25, the licensed staff will review resident admitted in the last 30 days to ensure the medication reconciliation is completed and any potential conflicts are reported and resolved.H) The Director of Nurses reviews the medication reconciliation forms during morning clinical meeting to ensure completion.I) On 08/15/25, audits to ensure the medical reconciliation was completed were initiated and are on-going by the Director of Nurses or designee.J) Audits to be reviewed at the quarterly QAPI meetings by the QAPI committee.K) The Director of Nurses and/or Designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents, (Resident #1) who had an allergy to shellfish, the facility failed to ensure his/her environment was free of hazards, when on 09/12/24, Resident #1 was served a meal that consisted of seafood (which included shrimp), Resident #1 consumed the meal, developed signs and symptoms of an allergic reaction, including shortness of breath (SOB), puffy watery eyes and flushed appearance, he/she developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called, and Resident #1 was transported to the Hospital Emergency Department (ED) for evaluation of anaphylaxis (a severe, potentially life-threatening allergic reaction) where he/she was admitted for further treatment. Findings Include: Review of the Facility's Policy tilted Food Allergies and Intolerances, dated as revised August 2017, indicated the following: -residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional values; steps are taken to prevent resident exposure to the allergen(s) -food allergies are immune system responses to allergens (foods) -severe food allergies are noted on the face of the chart indicating severe food allergy: (name of food) and communicated in writing directly to the dietician and the director of food and nutrition services -meals for residents with severe food allergies are specially prepared so that cross-contamination with allergens does not occur -residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat -nursing staff and food service employees are trained in the signs and symptoms of allergic reactions to foods and basic first aid measures in the event of a food allergy emergency -the attending physician will be notified of the resident's food allergies and orders for emergency medications (e.g., epinephrine, antihistamines) and emergency interventions will be documented Review of the Facility's Policy tilted Tray Identification, dated as revised April 2007, indicated the following: -appropriate identification/coding shall be used to identify various diets -to assist in setting up and serving the correct food trays/diets to resident, the Food Services Department will use appropriate identification (e.g., color coded or computer generated diet cards) to identify the various diets -the Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas -nursing staff shall check each food tray for the correct diet before serving the residents -if there is an error, the Nurse Supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served Resident #1 was admitted to the Facility in September 2024, diagnoses included hyperlipidemia (high cholesterol), depression, hypertension, mild intermittent asthma, and cardiac murmur (whooshing or rasping sound during a heartbeat). Review of Resident #1's Allergy Report, dated 09/06/24, indicated he/she had the following allergies: shellfish (e.g., shrimp, crabs, lobster, oysters, scallops, and snails), Zoloft (antidepressant) cat/dog dander, iodine and pollen extract. Review of Resident #1's admission Assessment for Mental Status, dated 09/09/24, indicated that he/she was alert, oriented and able to make his/her own health care decisions. Review of Resident #1's Nutrition Evaluation, dated 09/10/24, indicated that he/she had the following allergies: shell fish, iodine, Zoloft, cat/dog dander and pollen extract. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/14/24, indicated that on 09/12/24, Resident #1 suffered an allergic reaction when he/she ingested shrimp for dinner. The Report indicated that Resident #1 reported shortness of breath (SOB), puffy eyes, his/her Physician was notified and ordered to administer an Epinephrine (Adrenaline, hormone, medication used for emergency treatment of severe life threatening allergic reactions) injection, Prednisone (corticosteroid), and Benadryl (antihistamine) stat (immediately) (which was administered by the Nursing Supervisor) and to monitor Resident #1. The Report indicated that Resident #1 developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called and he/she was transported to the Hospital Emergency Department for evaluation. The Report further indicated that Resident #1 had an allergy to shellfish, and he/she was served seafood that he/she was allergic to. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented (on 9/12/24) with anaphylaxis (severe, potentially life threatening allergic reaction) due to shrimp exposure (shellfish allergy) and he/she received an EpiPen (epinephrine) injection, Prednisone 60 milligrams (mg) and Benadryl 50 mg in the field. The Summary indicated upon his/her arrival to the emergency room, he/she was tachycardic (fast heart rate over 100 beats a minute) requiring 6 Liters (L) of oxygen, and he/she was treated with additional Epinephrine 0.3 mg, Pepcid 20 mg, and Solumedrol (corticosteroid) 80 mg. The Summary further indicated Resident #1 reported that he/she was eating dinner which included shrimp, causing him/her to have a sudden, severe onset of difficulty breathing and he/she experienced a tightening sensation in his/her throat. During an interview on 10/09/24 at 12:36 P.M., Resident #1 said at dinner time (exact date unknown) someone had given him/her food that had shrimp on it and said he/she ate the shrimp because that is what he/she was given. Resident #1 said shortly after eating the shrimp, he/she could not breathe and was gasping for air. Resident #1 said he/she put his/her call light on, one of the Certified Nurse Aides (CNA's) came to his/her room, he/she told her that he/she did not feel good and was having trouble breathing. Resident #1 said it was because he/she was having an allergic reaction to the shrimp. Resident #1 said it was awful and said he/she only remembered hearing someone say we are going to use an EpiPen on you. Review of the Facility's Dietary Menu, dated 09/12/24, indicated the following two meals were on the menu to be served for dinner: -Pasta and Krab Salad Plate and Chefs Breadbasket -Italian Sub Sandwich with Pasta Salad However, further review of the Facility's Dietary Substitution List, indicated that on 09/12/24, Seafood [NAME] was substituted for the Krab and Pasta Salad dinner meal. During an interview on 10/09/24 at 1:44 P.M., the Assistant Food Service Director (AFSD) said on 09/12/24 Seafood [NAME] was substituted for the pasta and Krab salad dinner meal. The AFSD said Seafood [NAME] consisted of crab, shrimp, and fish in a white cream sauce over pasta. Review of Resident #1's Nurse Progress Note, dated 09/12/24, (written by Nursing Supervisor), indicated that Resident #1 presented with acute shortness of breath (SOB), puffy watery eyes and he/she was flushed appearing with acute hypoxia (low level of oxygen in the blood). The Note indicated there was a suspicion Resident #1 had an allergy to shrimp (per him/her) and he/she was given an EpiPen injection, along with 60 mg of Prednisone and Benadryl. The Note indicated Resident #1 was observed having stridor with deteriorating breathing, 911 was called, and he/she was transferred to the Hospital Emergency Department (ED). During an interview on 10/10/24 at 12:18 P.M., (which included review of her written witness statement), Certified Nurse Aide (CNA) #1 said on 09/12/24 at dinner time Nurse #1 checked Resident #1's meal tray to make sure the food was appropriate and handed it to her. CNA #1 said she brought Resident #1's meal tray to him/her, set up his/her meal and left the room. CNA #1 said Resident #1's meal was pasta with white sauce, but said she did not know and could remember if there was seafood (shrimp) on top of the pasta. CNA #1 said about 45 minutes later Resident #1 put his/her call light on, she went to answer it and Resident #1 told her he/she did not feel good and to call the nurse please. CNA #1 said she told Nurse #1 right away that Resident #1 was not feeling good. During an interview on 10/10/24 at 11:27 A.M., (which included review of her written witness statement), Nurse #1 said the nurses check all resident's meal trays for correct diet order and any allergies before they are given to a resident. Nurse #1 said when she checked Resident #1's meal tray there was pasta with a white gravy sauce. Nurse #1 said she did not remember what other food was on the pasta, said it was not meat (beef) and that she could not recall seeing any seafood. Nurse #1 said after checking Resident #1's meal tray she put his/her tray back into the food truck. Nurse #1 said about 45 minutes later CNA #1 told her that Resident #1 was having trouble breathing and she immediately went to his/her room. Nurse #1 said Resident #1 was SOB, was having trouble breathing and she informed the Nursing Supervisor. Nurse #1 said she was not aware that Resident #1 had a shellfish allergy because when she checked his/her meal tray, that she had not looked at his/her diet slip for allergies, but said she should have. Review of Resident #1's Dinner meal diet slip, dated 09/12/24, indicated that he/she had an allergy to shellfish. During an interview on 10/09/24 at 2:10 P.M., the Nursing Supervisor said Nurse #1 informed him that Resident #1 complained of being SOB and he immediately went to Resident #1's room. The Supervisor said Resident #1's face looked puffy, flushed and his/her eyes were watery and that it looked like he/she was having an allergic reaction to something. The Supervisor said he asked Resident #1 if he/she was allergic to anything and said Resident #1 told him that he/she was allergic to shrimp and might have eaten some. The Supervisor said he notified Resident #1's Physician and received orders to administer an EpiPen injection, Prednisone, and Benadryl STAT and continue to monitor Resident #1 for stridor. The Supervisor said after administering the medications, Resident #1 continued to be monitored, his/her breathing becoming worse, and that he/she developed stridor. The Supervisor said 911 was called and Resident #1 was transferred to the Hospital ED for evaluation. During a telephone interview on 10/15/24 at 12:34 P.M., the Director of Nursing (DON) said upon admission to the Facility, they were aware that Resident #1 had an allergy to shellfish. The DON said she was notified on 09/12/24 that Resident #1 was sent to the Hospital due to possibly being exposed to seafood. The DON said she did an investigation and said Resident #1 had been exposed to shellfish, that she was not sure how it happened, but added that the kitchen must have sent the wrong meal tray. The DON said she expected all nurses to check residents' meal trays, compare it with the resident's diet order slip and allergies listed on a resident meal slip to ensure that residents are receiving the correct meal, prior to receiving their tray. The DON said if a resident's diet slip does not match what is on the meal tray, the tray should be removed immediately from the food truck and the nurse should call the kitchen to request a meal tray with an appropriate meal for the resident. On 09/16/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 09/16/24, Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary). B. On 09/16/24, the Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl. C. On 09/12/24 and 09/13/24, the Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physicians' and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present. D. On 09/13/24 and 09/16/24, the Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy. E. All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine. F. The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed. G. The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month. H. The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved. I. The Director of Nurses and/or designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had an allergy to shellfish, the Facility failed to ensure meals prepared and served to him/her accommodated his/her food allergy, when on 09/12/24, dietary staff preparing his/her dinner time meal tray put a meal that included shellfish (shrimp) on it, Resident #1 complained of not feeling well, said he/she had difficulty breathing, 911 was called and he/she was transported to the Hospital Emergency Department (ED), for evaluation and treatment of anaphylaxis (a severe, potentially life-threatening allergic reaction) and he/she was admitted . Findings Include: Review of the Facility's Policy tilted Food and Nutrition Services, dated as revised October 2017, indicated the following: -each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs -food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident -if an incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that a new food tray can be issued Review of the Facility's Policy tilted Tray Identification, dated as revised April 2007, indicated the following: -appropriate identification/coding shall be used to identify various diets -to assist in setting up and serving the correct food trays/diets to resident, the Food Services Department will use appropriate identification (e.g., color coded or computer generated diet cards) to identify the various diets -the Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas -nursing staff shall check each food tray for the correct diet before serving the residents -if there is an error, the Nurse Supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served Resident #1 was admitted to the Facility in September 2024, diagnoses included hyperlipidemia (high cholesterol), depression, hypertension, mild intermittent asthma, and cardiac murmur (whooshing or rasping sound during a heartbeat). Review of Resident #1's Allergy Report, dated 09/06/24, indicated he/she had the following allergies: shellfish (e.g., shrimp, crabs, lobster, oysters, scallops, and snails), Zoloft (antidepressant), cat/dog dander, iodine, and pollen extract. Review of Resident #1's Nutrition Evaluation, dated 09/10/24, indicated that he/she had the following allergies: shell fish, iodine, Zoloft, cat/dog dander and pollen extract. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 09/14/24, indicated that on 09/12/24, Resident #1 suffered an allergic reaction when he/she ingested shrimp for dinner. The Report indicated that Resident #1 reported shortness of breath (SOB), puffy eyes, his/her Physician was notified and ordered to administer an Epinephrine (hormone, treats severe life threatening allergic reactions) injection, Prednisone (corticosteroid), and Benadryl (antihistamine) stat (immediately) (which was administered by the Nursing Supervisor) and to monitor Resident #1. The Report indicated that Resident #1 developed stridor (abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway), 911 was called and he/she was transported to the Hospital Emergency Department for evaluation. During an interview on 10/09/24 at 12:36 P.M., Resident #1 said at dinner time someone had given him/her food that had shrimp on it (exact date unknown) and said he/she ate the shrimp because that is what he/she was given. Resident #1 said shortly after eating the shrimp, he/she could not breathe and was gasping for air. Resident #1 said he/she put his/her call light on, one of the CNA's came to his/her room, he/she told her that he/she did not feel good and was having trouble breathing. Resident #1 said that was because he/she was having an allergic reaction to the shrimp. Resident #1 said it was awful and said he/she only remembered was hearing someone say, we are going to use an EpiPen on you. Review of the Facility's Dietary Menu, dated 09/12/24, indicated the following two meals were on the menu to be served for dinner: -Pasta and Krab Salad Plate and Chefs Breadbasket -Italian Sub Sandwich with Pasta Salad However, further review of the Facility's Dietary Substitution List, indicated that on 09/12/24, Seafood [NAME] was substituted for the Krab and Pasta Salad dinner meal. During an interview on 10/09/24 at 1:44 P.M., the Assistant Food Service Director (AFSD) said on 09/12/24 Seafood [NAME] was substituted for the Pasta and Krab salad dinner meal. The AFSD said Seafood [NAME] consisted of crab, shrimp, and fish in a white cream sauce over pasta. Review of Resident #1's Dinner meal diet slip, dated 09/12/24, indicated that he/she had an allergy to shellfish. During an interview on 10/10/24 at 10:07 A.M., Dietary Aide #2 said he worked 4:00 P.M. to 8:00 P.M. on 09/12/24 and called out all residents dinner diet orders to the Cook. Dietary Aide #2 said when he does the calling out in the tray line, he reads the residents diet order and any allergies off to the [NAME] and said the [NAME] then puts the food on the plate, the plate is then placed on the resident's tray and put into the food truck. Dietary Aide #2 said he could not remember anything about a resident receiving the wrong meal that day. During an interview on 10/10/24 at 1:51 P.M., the [NAME] said there is a tray line and one of the Dietary Aides is the caller. The [NAME] said the caller reads the diet slip (which includes the resident's diet and any allergies) to the cook who then puts the meal on the plate, the caller then takes the plate, places it on the resident's tray and into the food truck. The [NAME] said the dinner menu on 09/12/24 was Pasta and Krab Salad but it was substituted with Seafood [NAME] which comes pre-made with crabmeat, shrimp, and scallops in a white cream sauce, that was then put on top of the pasta. The [NAME] said that he did not put any fish in the [NAME] that night. The [NAME] said Dietary Aide #2 called out the resident's dinner diet slips to him on 09/12/24. The [NAME] said he really did not know how Resident #1 received the wrong meal, but it happened and said that most likely the caller (Dietary Aide #2) did not call out his/her allergies to him (the Cook) that night. The [NAME] said he relies on the Dietary Aide that is calling out the resident's diet slips because he cannot see what is on the diet slips when he is preparing the meal. During an interview on 10/09/24 at 11:52 A.M., the Food Service Director (FSD) said all diet slips indicate a resident's diet order, allergies, and dislikes. The FSD said a Dietary Aide calls out the resident's diet and any allergies to the Cook, the [NAME] prepares the meal plate, and the plate is handed to the caller (Dietary Aide) who is then supposed to verify the resident's diet, cover the meal and it is placed on the food truck. The FSD said he expects all dietary staff to follow proper procedure for calling and preparing the correct meal tray (according to dietary orders and allergies) for all residents before the plated meal is placed on their trays and into the food truck. During an interview on 10/10/24 at 11:27 A.M., (which included review of her written witness statement), Nurse #1 said nurses check all resident's meal trays for correct diet order and any allergies before they are given to a resident. Nurse #1 said when she checked Resident #1's meal tray there was pasta with a white gravy sauce. Nurse #1 she did not remember what other food was on the pasta, but said it was not meat (beef) and that she could not recall seeing any seafood. Nurse #1 said after checking Resident #1's meal tray she put his/her tray back into the food truck. Nurse #1 said about 45 minutes later CNA #1 told her that Resident #1 was having trouble breathing and she immediately went to his/her room. Nurse #1 said Resident #1 was SOB, was having trouble breathing and she informed the Nursing Supervisor. Nurse #1 said she was not aware that Resident #1 had a shellfish allergy because when she checked his/her meal tray she had not looked at his/her diet slip for allergies, but said she should have. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that (on 9/12/24) Resident #1 presented with anaphylaxis (a severe, potentially life-threatening allergic reaction) due to shrimp exposure (shellfish allergy) and he/she received EpiPen injection, Prednisone 60 milligrams (mg) and Benadryl 50 mg, in the field. The Summary indicated upon his/her arrival to the emergency room, Resident #1 was tachycardic requiring 6 Liters (L) of oxygen, and he/she was treated with additional Epinephrine 0.3 mg, Pepcid 20 mg, and Solumedrol (corticosteroid) 80 mg. The Summary further indicated Resident #1 reported that he/she was eating dinner which included shrimp, causing him/her to have a sudden, severe onset of difficulty breathing and he/she experienced a tightening sensation in his/her throat. During a telephone interview on 10/15/24 at 12:34 P.M., the Director of Nursing (DON) said Resident #1 had an allergy to shellfish and she was notified on 09/12/24 that Resident #1 was sent to the Hospital due to possibly being exposed to seafood. The DON said she did an investigation and said Resident #1 had been exposed to shellfish, was not sure how it happened, but that the kitchen must have sent the wrong meal tray. On 09/16/24, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 09/16/24, Resident #1 returned to the Facility with a new order for epinephrine PRN (as necessary). B. On 09/16/24, the Assistant Director of Nursing conducted a house wide audit on all residents with food allergies, resident's allergies were compared with dietary tray cards, Physician orders were reviewed for residents with food allergies and for PRN orders for EpiPen and Benadryl. C. On 09/12/24 and 09/13/24, the Director of Nursing and Nursing Supervisor provided education to all Licensed Nursing Staff on checking meal trays prior to passing which included: to check meal tray and meal ticket to ensure it matches Physician and diet orders in point Click Care (PCC), to check allergies on the meal tickets to ensure that resident is receiving the right tray, and CNA's are not to open the meal truck unless a nurse is present. D. On 09/13/24 and 09/16/24, the Assistant Food Service Director provided education to all Dietary Staff on allergy awareness, meal ticket reading, residents allergies and tray ticket accuracy. E. All new resident admissions and re-admissions done by the admitting Nurse, the Nurse will review resident's food allergies and ensure residents have a Physician order for PRN Epinephrine. F. The Unit Managers will review and update all resident's allergies during quarterly care plan meetings and as needed. G. The Director of Nurses and/or designee and Assistant Food Service Director will conduct random audits to ensure residents with food allergies receive the correct diet meal two times weekly for four weeks, then weekly for four weeks and then monthly for one month. H. The Director of Nursing and/or designee are responsible for audit results and the findings of the audits will be reviewed at the monthly QAPI meeting until compliance is achieved. I. The Director of Nurses and/or designee are responsible for overall compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to 1. provide adequate supervision and interventions related to falls resulting in falls with injury for two Residents (#60 and #76) and 2. failed to develop and implement an elopement care plan resulting in elopement for one Resident (#103) out of a total of sample of 33 residents. Findings include: 1. For Resident #60, the facility failed to provide adequate supervision during ambulation. Resident #60 fell while ambulating independently and sustained a hip fracture requiring surgery and head laceration requiring sutures. Resident #60 was admitted to the facility in January 2023 with diagnoses including chronic obstructive pulmonary disease, repeated falls and schizoaffective disorder. Review of the most recent Minimum Data Set assessment, dated 4/22/23, indicated Resident #60 is severely cognitively impaired and requires assistance with bathing, dressing and ambulation. Review of Resident #60's clinical record indicated he/she resided on the [NAME] unit from January 2023 through April 2023. Review of Resident #60's fall risk assessment, dated 2/10/23, indicated Resident #60 was at high risk of falls and had 3 or more falls in the past 3 months. Review of Resident #60's care plans indicated the following: Focus: Activities of Daily Living, 2/8/23 Interventions: Ambulate continual supervision to assist of 1-2. Transfers, continual supervision to assist. Focus: At risk for falls due to history of falls, unsteady gait, 2/8/23 Interventions: Provide assistance to transfer and ambulate as needed. Encourage to transfer and change positions slowly. Bed alarm. Chair alarm. Review of the Physical Therapy Discharge Summary for dates of service 4/4/23 - 4/6/23 indicated that Resident #60 utilized a four-prong cane inappropriately and required continual supervision or touching assistance for ambulation. Review of Resident #60's fall investigation indicated that on 4/10/23 at 12:04 P.M., Resident #60 had an unwitnessed fall in the hallway. The incident report included written statements which indicated Resident #60 had been seen by staff ambulating in the hallway independently and dragging his/her cane behind him/her prior to the fall. Resident #60 was sent to the hospital where he/she was diagnosed with a hip fracture requiring surgical intervention and a laceration to his/her forehead requiring sutures. The incident report failed to indicate whether Resident #60's care planned alarms were in use at that time of the fall or sounding. During an interview with Nurse #3 on 6/1/23 at 1:51 P.M., she said that she had seen Resident #60 walking alone down the hallway of the nursing unit before he/she fell. Nurse #3 said that Resident #60 was independent with ambulation when he/she resided on the [NAME] unit (which contradicted his/her care plan). During an interview with the Director of Nursing (DON) and the Administrator on 6/1/23 at 12:25 P.M., the DON said that when Resident #60 resided on the [NAME] Unit, he/she would ambulate independently on the unit. The Administrator and the DON agreed that Resident #60's care plans indicated he/she required supervision during ambulation, transfers and also alarms to alert staff if Resident #60 was getting up out of bed or his/her chair. 2. For Resident #76, the facility failed to implement effective interventions related to falls resulting in a fall with injury. Review of the facility's policy titled Assessing Falls and their Causes, dated March 2018, indicated: * When a resident falls, the following information should be recorded: Appropriate interventions taken to prevent future falls. Resident #76 was admitted in April 2023 with diagnoses including Alzheimer's disease and dysphagia. Review of Resident #76's most recent Minimum Data Set assessment, dated 4/8/23, indicated Resident #76 is severely cognitively impaired and requires assistance with bathing, dressing and ambulation. During an observation on 5/30/23 at 11:38 A.M., the surveyor observed Resident #76 self-propelling in his/her wheelchair with a chair alarm in place. Review of Resident #76's clinical record indicated his/her health care proxy was activated by the physician on 4/12/23, indicating he/she was not his/her own decision maker. Review of Resident #76's care plans indicated the following: Focus: Cognitive Loss, initiated 4/2/23 Interventions: Provide cuing and prompting for such things as activities person care or room location. Focus: At risk for falls due to impaired balance/poor coordination, unsteady gait, weakness, sensory deficits, decreased safety awareness. Interventions: Encourage to transfer/change positions slowly (4/11/23). Provide assistance to transfer and ambulate as needed. Have commonly used articles within easy reach. Maintain bed in low position. (4/2/23) Review of Resident #76's fall incident report, dated 4/18/23, indicated he/she was found by staff on the floor of the hallway at 4:45 P.M. In response to the fall the intervention implemented was to reinforce the need to call for assistance; an intervention that would not be effective due to Resident #76's cognitive deficits. Review of Resident #76's fall incident report, dated 4/27/23, indicated that at 4:10 P.M., Resident #76 was heard calling for help and found on the floor of his/her room. Resident #76 was sent to the hospital and required staples for a head laceration. During an interview with the Director of Nursing (DON) and the Administrator, the DON said that after a resident falls the expectation is for staff to investigate the cause of the fall and update the Resident care plan with appropriate intervention(s). The DON said that after Resident #76's initial fall on 4/18/23, the facility wanted to utilize alarms as an intervention, but Resident #76's family declined. The DON said that because of their declination, the facility implemented the use of reinforcement to call for help, despite Resident #76's impaired cognitive status. 3. For Resident #103, the facility failed to develop and implement an elopement risk care plan after Resident #103 was identified as being at risk for elopement. On 5/30/23, Resident #103 eloped from the facility and was found at a senior center 2.5 miles away from the facility. Review of facility's policy titled Wandering and Elopement, dated March 2019, indicated: * If identified at risk for wandering, elopement or other safety issues, the Resident's care plan will include strategies and interventions to maintain the resident's safety. Resident #103 was admitted to the facility in April 2023 with diagnosis including schizophrenia, encephalopathy and dementia. Review of Resident #103's most recent Minimum Data Set assessment, dated 4/17/23, indicated Resident #103 scored 13 out of a possible 15 on the Brief Interview for Mental Status exam, indicating he/she is cognitively intact and requires physical assistance for ambulation and transfers. Review of the clinical record indicated Resident #103 had a court appointed Guardian for decision making due to incapacity, effective July 2020. Review of Resident #103's elopement risk evaluation, dated 4/20/23, indicated Resident #103 was at risk for elopement and walks around unit asking for the exit door. The evaluation also indicated that Resident #103's care plan would be updated and revised based on the evaluation. Review of Resident #103's care plans failed to indicate any elopement risk care plan or interventions, methods or means for staff to monitor his/her whereabouts after having been identified as being at risk for elopement. Review of Resident #103's incident report dated 5/30/23 indicated that Resident #103 was asking to speak with someone about being discharged home and staff placed a call to the case-manager to speak with him/her at 9:41 A.M. A written statement by the case-manager indicated that she had spoken with Resident #103 on 5/25/23 because Resident #103 was asking to be discharged to a shelter. The report indicated that Resident #103 then told staff he/she was going outside for fresh air. Witness statements from staff indicated that Resident #103 was observed seated on the front patio with his/her walker at approximately 9:45 A.M., and 10:30 A.M The report indicated that Resident #103 was noted to be missing from the building at approximately 11:00 A.M The report indicated that the police were notified at 11:15 A.M. and at approximately 12:50 P.M., the facility received a call from the Senior Center that Resident #103 was there; approximately 2.5 miles away. During an interview with the Administrator and the Director of Nursing on 6/1/23 at 12:25 P.M., they said that Resident #103 had been identified as a high risk for elopement but no care plan was developed to prevent his/her elopement. They said that Resident #103 was granted access to sitting outside unsupervised despite being an identified elopement risk and then eloped from the facility.