**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to provide Physician notification on status changes for three Residents (#18, #6 and #8) out of a total sample of 13 residents. Specifically, 1. For Resident #18, the facility staff failed to notify the Physician of an abnormal high finger stick blood sugar level (FSBS: a measurement of sugar in the blood) result. 2. For Resident #6, the facility staff failed to notify the Physician that one dose of Heparin (blood thinning medication used to prevent blood clots) was not administered as ordered. 3. For Resident #8, the facility staff failed to report the presence of pressure ulcers noted on admission to the Physician, delaying care and treatment. Findings include: 1. Resident #18 was admitted to the facility in September 2022 with a diagnosis of Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of the American Diabetes Association Blood Glucose Testing and Monitoring guidelines, copyright 1995-2023 indicated target ranges for blood glucose levels to be 80-130 mg/dl. Review of the current Physician's orders, last renewed 3/30/2023, indicated an order for monitoring FSBS (Finger Stick Blood Sugar) BID (two times daily) at 7:30 A.M. and 4:30 P.M. No result parameters were included in the Physician's order for FSBS monitoring prior to the surveyor interview with the Director of Nurses (DON). Review of the April 2023 Medication Administration Record (MAR) for Resident #18 indicated a FSBS level of 509 mg/dl documented for 4/17/23 at 4:30 PM. Review of the progress notes for April 2023 showed no evidence that the Physician was notified of Resident #18's FSBS result of 509 mg/dl. During an interview on 4/18/23 at 3:18 P.M., with Nurse #1 and the DON, Nurse #1 said she did not notify the Physician of the Resident's FSBS level of 509 mg/dl on 4/17/23 because there were no parameters included with the FSBS monitoring order. The DON said that when the Physician writes an order for FSBS monitoring the order usually contains parameters for when the Physician should be notified. She said that Resident #18 did not have a FSBS monitoring order that included parameters for when to notify the Physician but that the Physician should still be notified if an FSBS result is abnormal. She also said a FSBS level of 509 mg/dl was an abnormally high result and the Physician should have been notified but that was not done. 2. Resident #6 was admitted to the facility in April 2021 with a diagnosis of unilateral (one sided) primary Osteoarthritis (condition where flexible tissue at the ends of bones gradually wears down and worsens over time) of the left hip. Review of the facility's Medication Policy, titled Preparation and General Guidelines, dated 2017, indicated: - Medications are administered in accordance with written orders of the Prescriber. - If a vital medication is not available, the Physician is notified and Nursing documents the Physician's response. Review of Resident #6's clinical record indicated the Resident was hospitalized after falling at the facility on 4/5/23 where he/she sustained a left hip fracture and required hospitalization to repair the hip. Further review of the clinical record indicated the Resident returned to the facility on 4/9/23. Review of the Hospital Discharge summary, dated [DATE], indicated the following: - The Resident had a diagnosis of Atrial Fibrillation (A-fib: irregular, often rapid heart rate that causes poor blood flow and a potential for blood clots). - The Resident received one dose of Heparin 5,000 units, subcutaneously (injected in the fatty tissue, just under the skin) at 8:38 A.M., on 4/9/23. Review of a Nurse's note, dated 4/9/23 and completed at 3:31 P.M., indicated Resident #6 returned to the facility from the hospital and all medication orders were reviewed with the Physician. Further review of the note indicated to add Heparin 5,000 units every 12 hours. Review of a Physician's order, dated 4/9/23, indicated: Heparin (porcine) 5,000 unit/milliliter (ml) injection solution, inject one ml (5,000 unit) by subcutaneous (inject in the fatty tissue, just under the skin) route every 12 hours, every day at 8:00 A.M. and 8:00 P.M. Review of the April 2023 Medication Administration Record (MAR) indicated the ordered 8:00 P.M. dose of Heparin was not administered to Resident #6 on 4/9/23. Further review of the MAR indicated the medication was not available. Review of the clinical record indicated no evidence that facility staff notified the Physician that the 8:00 P.M. dose of Heparin had not been administered to Resident #6 as ordered on 4/9/23. During an interview on 4/19/23 at 10:42 A.M., Nurse #5 said Heparin was ordered for Resident #6 as a blood thinner to prevent blood clots. Nurse #5 said Resident #6 did not receive the evening dose of Heparin on 4/9/23 as ordered because it was not available in the facility. Nurse #5 also said he could not recall whether the Physician was notified that the scheduled 8:00 P.M. dose of Heparin was not administered as ordered to the Resident on 4/9/23. During an interview on 4/19/23 at 10:59 A.M., the Director of Nursing (DON) said if a Physician ordered vital medication was not available for administration, staff were required to notify the Physician that the medication could not be administered as ordered and to obtain alternate care instructions. The DON said Heparin was considered a vital medication. The DON said Heparin was not stocked in the facility's emergency medication supply and if it was unavailable to be administered, the Nurse would be required to notify the Physician. The DON then said the Unit Manager (UM) was the Nurse that verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23, so she would be able to speak to accessibility of Heparin for Resident #6 when he/she returned from the hospital. During an interview on 4/19/23 at 11:01 A.M., the UM said she verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23. The UM said that since the Resident had already been at the facility, all of his/her medications were available and there were no ordered medications that would not have been available for administration to Resident #6. The UM then said the only medication that may not have been available was Heparin, but this was stocked in the facility's emergency medication supply, so the Resident would not have missed his/her 8:00 P.M. dose on 4/9/23 while awaiting the Pharmacy delivery of the medication. The UM then reviewed the list of medications stored in the emergency medication supply and said Heparin was not a medication that was stored in the facility's emergency medication supply, so it was not available for Resident #6 at 8:00 P.M. on 4/9/23. The UM said she did not notify the Physician that Heparin was not available for Resident #6 because she thought it was stored in the emergency medication supply. The UM further said the Nurse who identified that Heparin was not available for administration to Resident #6 should have notified the Physician, as required, and documented the Physician's response in the clinical record. Please Refer to F760.3. Resident #8 was admitted to the facility in December 2022 with diagnoses including Arthritis and mild cognitive impairment. Review of the facility policy, titled Skin at Risk Treatment Protocol, revised 10/8/2015, indicated that residents at risk for breakdown will be identified on admission, and the Physician must be notified to initiate a specific treatment plan. Review of the Nursing admission assessment dated [DATE] indicated the Resident had Stage II (partial thickness skin loss) open areas of the coccyx (base of the spine, also known as the tailbone) - no measurement given, excoriated (scraped and abraded) skin on the groins and a Deep Tissue Injury (DTI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from injuries and shear) 3.4 x 1.4 centimeters on the left foot. Review of the admission History and Physical, dated 12/30/2022, indicated the exam was a telehealth visit conducted and the skin assessment indicated edema (swelling) of the lower extremities, no lesions, no rash. Review of the December 2022 Physician's orders indicated no evidence of treatments ordered for the impacted skin areas identified on admission. Review of the December 2022 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) indicated no documented treatments administered to the left and right buttocks and to the left foot. Review of the Nursing Progress Note, dated 1/3/2023 at 12:45 P.M., indicated the Resident was seen by the Wound Nurse, and that the Physician was notified of the Stage II pressure areas on the right (1 x 1 x 0.1 centimeters) and left (1 x 4 x 0.1 centimeters) buttocks, and an open area on the left foot (2 x 3 x 0.1 centimeters). Review of the January 2023 Treatment Administration Record (TAR) indicated no documented evidence that treatments were administered to the left and right buttocks and the left foot until 1/3/23 when the following treatments were provided: -Apply Calmoseptine (an ointment used to protect and heal skin irritations) to right and left buttocks area twice a day until healed, start date 1/3/23. -Wash open area on top of left foot with normal saline, pat dry, apply Bacitracin and dressing daily until healed, start date 1/3/23. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was at risk for the development of pressure ulcers, and had an unhealed Stage II pressure ulcer, one unstageable (depth unable to be determined due to dead skin cells and or drainage) Deep Tissue Injury and Moisture Associated Skin Damage (MASD), used a pressure reducing device for the bed and chair, and received pressure ulcer care. During an interview on 4/18/23 at 3:18 P.M., with the Assistant Director of Nursing (ADON), the ADON said when a resident was admitted , a full assessment was completed and if there were any skin issues of concern, a call would be placed to the Physician and orders obtained for the care and services of those areas. The ADON said the progress note dated 1/3/23 indicated that the Physician was updated regarding the wounds present and treatments were ordered. The ADON further said, that based on her preliminary review of the record, there was no documented evidence that the Physician was notified, and that treatment was initiated upon the resident's admission. During a subsequent interview on 4/18/23 at 4:23 P.M., the ADON said, after further review of the clinical record, that no additional documentation was found regarding Physician notification or wound treatments ordered for the pressure areas present upon admission until 1/3/2023.

Based on observation, interview, and record review, the facility failed to provide assistive devices for one Resident (#17) out of a total sample of 13 total residents, to aid in preventing an injury/accident. Specifically, the facility failed to ensure its staff provided leg rests on a wheelchair to support the Resident's legs during transport, resulting in the Resident's right foot getting caught under the wheelchair while the chair was being pushed by staff. Findings include: Resident #17 was admitted to the facility in April 2019 with a diagnosis of Dementia. Review of Resident #17's Activities of Daily Living (ADLs) and Mobility Care Plan, dated 11/8/22 and reviewed 1/31/23, included the following: - The Resident was able to self propel short distances in his/her wheelchair with staff cueing and direction. - Do not use foot pedals on chair, it prevents self-ambulation in the wheelchair. Review of the Resident's Cognitive Deficit Care Plan, dated 1/26/23, indicated the following: - Gain the Resident's attention prior to hands-on care. - Explain in simple terms what to expect, give the Resident time to process. On 4/14/23 at 10:34 A.M., the surveyor observed Resident #17 seated in an alcove by a resident room, facing the hallway. Resident #17 was seated in a wheelchair with his/her feet resting on the floor. At this time, CNA #2 walked in front of the Resident, around his/her wheelchair, then behind the wheelchair and grasped the wheelchair handle. CNA #2 then told the Resident she was going to assist the Resident to his/her room as she began to push the wheelchair forward and turn right into the hallway. As the CNA was pushing the wheelchair, Resident #17's right foot caught on the rug, his/her knee flexed, and the lower part of his/her leg and foot got caught under the wheelchair. Resident #17 gasped, the CNA stopped pushing the wheelchair and told the Resident to pick his/her feet up. During an interview on 4/14/23 at 11:15 A.M., CNA #2 said some residents did not use leg rests on their wheelchairs because they self-propelled. CNA #2 said if staff needed to assist these residents with transport in their wheelchairs, they would instruct them to pick up their feet, and if they were unable, then an additional staff member would assist them to hold their feet up during transport. CNA #2 said Resident #17 did not use leg rests because he/she self-propelled the wheelchair throughout the Unit. CNA #2 said she had assisted Resident #17 to his/her room earlier to provide personal care and the Resident's right leg got caught under the wheelchair because he/she did not lift his/her feet when the CNA began to assist with transport. During an interview on 4/14/23 at 2:06 P.M., the Director of Nursing (DON) said all residents who had wheelchairs were provided with leg rests for transport. The DON said residents who self-propelled their wheelchairs would not use the leg rests when mobilizing on their own, but if staff assisted with transport, the staff were required to put the leg rests on the residents' wheelchairs. The DON also said Resident #17 self-propelled his/her wheelchair on the unit and that if staff approached him/her and gave him/her their hand, he/she would usually self-propel with their direction. The DON said since staff transported the Resident to his/her room that morning, they should have put the leg rests on the chair prior to transport, as required, to avoid a potential accident/injury. The DON then said the Resident had leg rests provided for him/her for this purpose and asked the Unit Manager (UM) to show the surveyor where the leg rests were kept. During an observation and interview on 4/14/23 at 2:11 P.M., the UM said all residents on the Unit who required wheelchairs were provided with leg rests. She said staff were required to put leg rests on residents' chairs when they assisted residents with transport. The UM said Resident #17 self-propelled in the wheelchair, but he/she had leg rests provided when staff needed to transport him/her in the wheelchair and that the leg rests were stored in the Resident's closet. The UM also said she witnessed the Resident's right leg get caught under his/her wheelchair during transport in the morning and that staff should have provided the Resident with leg rests to prevent that from happening. At this time, the UM opened the Resident's closet and located one right-sided leg rest, but was unable to locate the left- sided leg rest. The UM then said she did not know where the left-sided leg rest was but that it should have been in the Resident's closet and that she would need to locate the left-sided leg rest.

Based on observation, interview, record review, and policy review, the facility failed to ensure its staff provided timely pain management interventions for one Resident (#6) out of a total sample of 13 Residents. Specifically, the facility staff failed to respond to the Resident calls for assistance and provide Physician ordered scheduled pain medication in a timely manner. Findings include: Review of the facility's policy, titled Preparation and General guidelines: Equipment and Supplies for Administering Medications, dated 2017, indicated that medications were to be administered within 60 minutes of scheduled time . Resident #6 was admitted to the facility in April 2021 with a diagnosis of unilateral (one sided) primary Osteoarthritis (condition where flexible tissue at the ends of bones gradually wears down and worsens over time) of the left hip. Review of the clinical record indicated Resident #6 was hospitalized after falling at the facility on 4/5/23 where he/she sustained a left hip fracture and required hospitalization to repair the hip. Further review of the clinical record indicated the Resident returned to the facility on 4/9/23. Review of the active Physician's orders indicated the following: -Acetaminophen 500 milligrams (mg) tablet, give two tablets (1000 mg) by oral route three times per day, every day at 8:00 A.M. -Tramadol (narcotic medication used to treatmoderate to severe pain) 50 mg tablet, give one tablet by oral route every eight hours as needed, dated 3/30/23 -Tramadol 50mg tablet, give one tablet by oral route daily, every day at 8:00 A.M., dated 4/12/23 On 4/14/23, between 9:07 A.M. and 9:12 A.M., the surveyor observed Resident #6 in bed in his/her room. The Resident called out, Help me, it hurts repetitively while the surveyor was in the hallway outside the Resident's room. The surveyor observed staff members in the area outside of the Resident's room, walking through the hallway, and no staff members responded to the Resident's call for help. On 4/14/23 at 9:12 A.M., the surveyor observed Rehabilitation Staff #1 enter the Resident's room and close the door. On 4/14/23 at 9:18 A.M., Rehabilitation Staff #1 exited Resident #6's room. During an interview on 4/14/23 at 9:18 A.M., Rehabilitation Staff #1 said he/she entered Resident #6's room that morning to notify him/her of the day's therapy schedule. Rehabilitation Staff #1 said the Resident was in pain, so she helped the Resident reposition in bed, but the Resident was still having pain. Rehabilitation Staff #1 then said she was going to alert the Nurse that the Resident was in pain. On 4/14/23 at 9:26 A.M., the surveyor observed Nurse #3 enter Resident #6's room with a medicine cup in her hand. During an interview on 4/14/23 at 9:33 A.M., Nurse #3 said medications were required to be administered to residents within one hour before and one hour after the scheduled administration time. Nurse #3 said Resident #6 had slept through the night and did not request any pain medication, so she expected the Resident would be uncomfortable that morning. Nurse #3 said Resident #6's pain level was nine out of 10 on the numeric pain scale when she administered his/her pain medication at 9:26 A.M. and that she had given the Resident scheduled extra strength Tylenol (Acetaminophen) and a PRN (as needed) Tramadol at that time. The surveyor then reviewed Resident #6's medication orders with Nurse #3. Nurse #3 said she was not aware Resident #3 had a scheduled order for Tramadol to be administered at 8:00 A.M. and she was out of compliance with providing the Resident's scheduled 8:00 A.M. pain medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility and its staff failed to ensure that the medication pass had an error rate of less than 5%. Two out of two nurses observed failed to administer medications as ordered, for two out of seven Residents (#22 and #15) observed. The medication error rate was calculated at 10.34 % with 29 opportunities for error. Findings include: 1. On [DATE] at 4:09 P.M., the surveyor observed Nurse #1 prepare the following medication (along with other prescribed medications) for Resident #22: -Celecoxib (antidepressant) 100 milligrams (mg), the expiration date observed on the medication card was [DATE]. During an interview on [DATE] at 4:14 P.M., the surveyor intervened prior to Nurse #1 administering the medication. The surveyor asked Nurse #1 what her process was for medication administration. Nurse #1 said she checked the Resident for identification, then checked the Physician order against the medication card, and checked the expiration date. When Nurse #1 checked the medication card for a second time, she said the medication had expired in [DATE]. Nurse #1 then removed the Celecoxib capsule from the cup of medications and disposed of it. 2. On [DATE] at 7:50 A.M., the surveyor observed Nurse #2 administer the following medications (along with other prescribed medications) to Resident #15. -Miralax (laxative) 17 grams (gm) powder in 4 ounces of water -Prednisolone Acetate 1% eye drop, suspension, one drop to the right eye. Nurse #2 did not shake the vial prior to administering the medication. Review of the label on the vial of Prednisolone Acetate 1% eye drop suspension, indicated to shake well prior to administration. Review of the [DATE] Physician's orders indicated the following: -Miralax 17 gm powder in 8 ounces of water, juice, soda, coffee or tea by oral route once daily. During an interview on [DATE] at 8:05 A.M., Nurse #2 said she thought the vial of eye drops shook as she walked holding the medications into the Resident's room. During an interview on [DATE] at 8:45 A.M., Nurse #2 said that she filled the cup of water with the Miralax as high as it could go. When the surveyor asked how big the cup was, Nurse #2 said it was a 4 ounce cup. Nurse #2 and the surveyor reviewed the Physician's orders for Resident #15 and Nurse #2 said she should have mixed 8 ounces of water or juice and not 4 ounces, when she prepared the Miralax.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one Resident (#6) out of a total sample of 13 residents was free of a significant medication error. Specifically, facility staff failed to implement necessary action when Heparin (blood thinning medication used to prevent the development of blood clots) that was ordered by the Physician to be administered every 12 hours, was omitted from the Resident's medication administration, resulting in a missed dose and increasing the risk for development of blood clots. Findings include: Review of facility's Medication Policy titled Preparation and General Guidelines, dated 2017, indicated: - Medications are administered in accordance with written guidelines of the Prescriber. - The Charge Nurse reports equipment and supply deficiencies to the Director of Nursing (DON). - If a medication is withheld, refused, or not available, the Physician is notified. - Nursing documents the notification and Physician's response. Resident #6 was admitted to the facility in April 2021 with a diagnosis of unilateral (one sided) primary Osteoarthritis (condition where flexible tissue at the ends of bones gradually wears down and worsens over time) of the left hip. Review of the clinical record indicated the Resident was hospitalized following a fall at the facility on 4/5/23 where he/she sustained a left hip fracture and required hospitalization to repair the hip. Further review of the clinical record indicated the Resident returned to the facility on 4/9/23. Review of the Hospital Discharge summary, dated [DATE], indicated the following: - The Resident had a diagnosis of Atrial Fibrillation (A-fib: irregular, often rapid heart rate that causes poor blood flow and a potential for blood clots). - The Resident received one dose of Heparin 5,000 units, subcutaneously (injected in the fatty tissue, just under the skin) at 8:38 A.M. on 4/9/23. Review of a Nurse's Note, dated 4/9/23 and completed at 3:31 P.M., indicated Resident #6 returned to the facility from the hospital and all medication orders were reviewed with the Physician. Further review of the Note indicated to add Heparin 5,000 units every 12 hours. Review of the Physician's order, dated 4/9/23, indicated: Heparin (porcine) 5,000 unit/ml (milliliters) injection solution, inject one ml (5,000 unit) by subcutaneous (inject in the fatty tissue, just under the skin) route every 12 hours, every day at 8:00 A.M. and 8:00 P.M. Review of the April 2023 Medication Administration Record (MAR) indicated the ordered 8:00 P.M. dose of Heparin was not administered to Resident #6 on 4/9/23 because it was not available to be administered. Further review of the MAR indicated the Resident did not receive Heparin until the next scheduled 8:00 A.M. dose was administered on 4/10/23. Review of the clinical record indicated no evidence the Physician had been contacted relative to Heparin not being available for administration to Resident #6 or for alternate care instructions when Heparin was identified as unavailable to be administered. During an interview on 4/19/23 at 10:42 A.M., Nurse #5 said Heparin was ordered for Resident #6 as a blood thinner to prevent blood clots, and the ordered 8:00 P.M. dose of Heparin was not administered to the Resident on 4/9/23 because it was not available. Nurse #5 said the Heparin had been ordered through the Pharmacy, but it had not been delivered to the facility in time to be administered to Resident #6 for the scheduled 8:00 P.M. dose. Nurse #5 then said the Heparin was delivered to the facility somewhere around 4:00 A.M. to 5:00 A.M. the next morning (4/10/23). Nurse #5 said he could not recall whether the Physician was contacted for alternate care instructions when it was identified that the Heparin was not available. During an interview on 4/19/23 at 10:59 A.M., the Director of Nursing (DON) said if an ordered medication was not available for a resident, facility staff were expected to contact the Pharmacy and check the facility's emergency medicine supply, and if a vital medication was not available, staff were also required to notify the Physician that the medication could not be administered as ordered and to obtain alternate care instructions. The DON said Heparin was considered a vital medication and was not stocked in the facility's emergency medication supply. When asked whether the DON was made aware that no Heparin was available for Resident #6's scheduled 8:00 P.M. dose on 4/9/23, she said staff do not call her every time something like this occurs. The DON then said the Unit Manager (UM) was the Nurse that verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23, so she would be able to speak to accessibility of Heparin for Resident #6 when he/she returned from the hospital. During an interview on 4/19/23 at 11:01 A.M., the UM said she verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23. The UM said that since the Resident had already been at the facility, all of his/her medications were available for administration. The UM then said the only medication that may not have been available would have been Heparin, but this was stocked in the facility's emergency medication supply, so the Resident would not have missed his/her 8:00 P.M. dose on 4/9/23 while awaiting the Pharmacy delivery of the medication. The UM then reviewed the list of medications stored in the emergency medicine supply and said Heparin was not a medication that was stored in the facility's emergency medication supply, so it would not have been available for Resident #6 at 8:00 P.M. on 4/9/23. The UM said staff who worked the evening shift on 4/9/23 would have been required to call the Physician when they noticed the Heparin was not available to be administered and obtain alternate care instructions. She also said staff would have been required to document their contact with the Physician and whether new orders were obtained for alternate care instructions.

Based on policy review, observation, and interview, the facility failed to ensure medications were appropriately stored in two out of two medication carts. Specifically, the facility staff failed to store topical medications separately from oral medications. Findings include: Review of the facility's policy, titled Medication Storage in the Facility, dated 2017, indicated the following: -Procedure: Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, etc. 1. During an observation of the East Medication Cart, on 4/14/23 at 8:45 A.M., with Nurse #2, the surveyor observed a small basket in the top drawer of the cart that had multiple individual packets of Hydrocortisone cream (steroid for external use), several packets of lubricant (used to insert suppositories), and several packets of thickener (oral agent used to thicken liquids). All of these items were stored together in the same basket. Nurse #2 said she did not know the items could not be stored together. 2. During an observation of the [NAME] Medication Cart, on 4/14/23 at 10:43 A.M., with Nurse #3, the surveyor observed the following items, stored together in the bottom drawer of the medication cart: one open tube of Dicflonec gel (external gel used for arthritis), one open tube of Silvadene cream 1% (external cream used to prevent wound infections), packets of skin preparation (used to create a barrier on the skin to prevent irritation), one open bottle of sodium chloride tablets (oral use), and one open bottle of Ocuvite (vitamin) tablets. Nurse #3 said all of the creams and gels should be stored in the treatment cart, not the medication cart, and they should not have been stored together.