**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician reviewed medication orders for accuracy for one Resident (#3) of three residents reviewed for physician visits. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine once a day. Upon admission to [Nursing Home Facility], the medication frequencies were transposed which resulted in R3 receiving the incorrect dosage of both Carbidopa/Levodopa and Levothyroxine. When R3 arrived at the nursing home they were ambulatory, able to function, able to make themselves lunch and care for self. When R3 was discharged , R3 was unable to ambulate, appeared confused, and could not have a conversation. Review of complaint intake number MI00153196 to the SA, dated [DATE], revealed R3 was admitted to (skilled nursing facility name) on [DATE]. On [DATE], the facility reversed the order for thyroid medicine and Carbidopa/Levodopa medications which resulted in R3 receiving five times the dose of the Levothyroxine for five consecutive days ([DATE] through [DATE]). Further review of the intake indicated R3 expired at home the next day days after discharge from the facility. Review of R3's progress note, dated [DATE] at 1:00 PM, read in part, Resident admitted .for 5-day respite care by wife in personal vehicle. A & O x 3 (alert and oriented to person, place and situation) ambulated to room with walker. Lungs CTA (clear to auscultation) . Review of R3's progress note generated by the electronic medical record, dated [DATE] at 3:14 PM, read in part, This order is outside the recommended dose or frequency. (Levothyroxine) oral tablet 200 mcg, give 2 tablets by mouth on time a day for thyroid and give 2 tablets by mouth one time a day for Parkinson's and give 1 tablet by mouth one time a day for Parkinson's .exceeds the usual dosing regimen .daily .exceeds the usual frequency of daily . Review of R3's progress note created by Physician Assistant (PA) P, dated [DATE] at 6:39 PM, read in part, Patient is a new admission to the facility. Patient medications were reviewed/verified against discharge summary which nursing had supplied. Pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing . On [DATE] at 9:35 AM, an interview was conducted with Family Member (FM) J' who was asked about R3 respite stay at the facility and replied, On [DATE], I received a phone call from the NP (Nurse Practitioner) at the facility and was told (R3's) condition had changed and developed a fever, increased heart rate, receiving fluids, was on oxygen, and had taken a turn for the worst. The facility told me that (R3) had gotten a couple extra doses of Levothyroxine. Several extra doses of Levothyroxine. When I asked why (R3) got extra doses the facility would not answer me. The facility said that (R3) could not go home as scheduled and that they were keeping (R3) for an extra night, maybe two. Then finally the facility told me what happened that they switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. More than one nurse gave (R3) the incorrect medication scheduling. (R3's) condition change was related to the medication errors. The nurse transcribed the medications wrong, and the doctor signed off and sent a note to nursing and then nursing never changed the orders. (R3) walked into the facility and when I went to go get (R3) they had to be taken out of the facility via wheelchair and two-person assistance. (R3) was so mentally out of it he could not walk. (R3) was rambling on from the time I picked him up and continued all through the remainder of the day until (R3) finally fell asleep. (R3) was hallucinating and talking to our dog like it was (R3's) sister-in-law calling the dog by her name. (R3) was disoriented totally. (R3) was mentally and physically not normal and could not stand on his own. (R3) fell in the middle of the night, Hospice had to come out, he was incontinent, and the Hospice doctor recommended comfort care. (R3) passed away around 5:30 AM the next day on [DATE]. After (R3) passed the Hospice nurse and the medical examiner came out. (R3's) body was sent down state to a hospital for an autopsy and then was sent back to a local funeral home for cremation. On [DATE] at 10:40 AM, an interview was conducted with Medical Examiner (ME) G who was asked if they recalled R3's respite care at the facility and replied, I didn't know about (R3) until I was called to his house after he passed. I know that his wife took him in on [DATE] for respite care to the facility. (R3's) wife told me that 2 to 3 days into the stay that (R3) was acting strange and not making much sense. After 4 or 5 days (R3's) wife was like, 'What's going on with (R3)?' and apparently the facility nurse transcribed the wrong medications. The facility switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. (R3) was incoherent and talked to the dog as if it was his sister-in-law. (R3) received a God-awful amount of Levothyroxine in a short amount of time. (R3) had elevated temperature and was shaky. The facility admitted to wrongdoing. Review of R3's Hospice plan of care and admission medication list, dated [DATE], revealed the following orders: 1.) Carbidopa 25 mg (milligram) /Levodopa 100 mg, disintegrating tablet, oral, one tablet three times daily, morning one pill, at noon two pills, and one pill in the evening, 2.) Levothyroxine 200 mcg, one tablet one time daily. Review of facility physician orders, dated [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. Review of R3's medication administration record (MAR), dated [DATE] through [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. R3 received two extra doses of Levothyroxine on [DATE], four extra doses on [DATE], four extra doses on [DATE], and four extra doses on [DATE], equating a total of 2800 mcg within a 96-hour time period. Review of R3's originally transcribed medication orders for Levothyroxine and Carbidopa /Levodopa, dated [DATE] at 3:14 PM, revealed orders to be transcribed/created by RN / Unit Manager B and confirmed by RN B. On [DATE] at 10:40 AM, an interview was conducted with the Medical Director (MD) E who was asked what the normal dose was for Levothyroxine and replied, Dose varies with lab work. If the dose is more than 200 mcg then I normally refer the patient to an endocrinologist. However, 200 mcg is the cut off. MD E was asked what the signs and symptoms are of a thyroid storm and replied, Tachycardia (increased heart rate), muscle aches, elevated temperature, difficulty sleeping, feeling hot, palpitations and weight loss. MD E was asked about the transcription error for R3 and their Levothyroxine and Carbidopa /Levodopa and replied, The physician assistant should have discontinued the order and made a new order to reflect the correct instructions and not left it as pending. The pharmacist should have caught the errors. I would expect nursing to know better because you only give Levothyroxine once a day in the morning before breakfast. It is basic nursing 101. On [DATE] at 2:40 PM, an interview was conducted with the Director of Nursing (DON) who was asked about the progress note in R3's medical record dated [DATE] created by Physician Assistant (PA) P stating pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing and who was responsible for how the confirmation was made and replied, PA P should have discontinued or changed the medication orders with verification of R3 medication list. Thyroid storm is a rare life-threatening condition of the thyroid gland. It develops in cases of untreated hyperthyroidism, or overactive thyroid (thyrotoxicosis) [or overdosing of a synthetic medication designed to act to supplement the decreased activity of the thyroid gland in the case of synthroid/levothyroxine use]. Retreived from: https://medlineplus.gov/ency/article/000400.htm Review of Levothyroxine, retrieved from website: http://www.synthroid.com/starting/taking-synthroid-the-right-way?cid=ppc_ppd_MSFT_Synthroid_Branded_when_is_best_time_of_day_to_take_synthroid_Phrase_USSYNT210334&gclid=9df9ab0c7de2146322dec3334cfd7502, date retrieved [DATE], read in part, Taking [Levothyroxine] the right way: In order for Synthroid to be effective, it should always be taken the same way every day. This is important because the amount of medicine you need is very precise. And even the way you take Synthroid can affect how much medicine your body is getting. It's important to always take your medication exactly as your doctor prescribed. The right way, every day. Take [Levothyroxine] once a day, every day at the same time before breakfast. Take [Levothyroxine] with only water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water .Use and Important Safety Information .Taking too much levothyroxine may affect your heart, especially if you are elderly or have heart disease. Tell your doctor immediately if you have any signs of increased heart rate, chest pain, or an irregular heartbeat .Tell your doctor if you start experiencing any of the following symptoms: rapid or abnormal heartbeat, chest pain, difficulty catching your breath, leg cramps, headache, nervousness, irritability, sleeplessness, shaking, change in appetite, weight gain or loss, vomiting, diarrhea, increased sweating, difficulty tolerating heat, fever, changes in menstrual periods, swollen red bumps on the skin (hives) or skin rash, or any other unusual medical event .Use SYNTHROID only as ordered by your doctor. Take SYNTHROID as a single dose, preferably on an empty stomach, one-half to one hour before breakfast .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe and double check admission medications per standards of practice for one Resident (#3) of three residents reviewed for new admissions. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine once a day. Upon admission to [Nursing Home Facility], the medication frequencies were transposed which resulted in R3 receiving the incorrect dosage of both Carbidopa/Levodopa and Levothyroxine. R3 was supposed to receive Carbidopa/Levodopa five times a day, and Levothyroxine once a day 200 mcg (micrograms). The nursing home flipped R3's medications. R3 was provided Levothyroxine five times a day, and Carbidopa/Levodopa once a day. When R3 arrived at the nursing home they were ambulatory, able to function, able to make themselves lunch and care for self. When R3 was discharged , R3 was unable to ambulate, appeared confused, and could not have a conversation Review of complaint intake number MI00153196 to the SA, dated [DATE], revealed R3 was admitted to (skilled nursing facility name) on [DATE]. On [DATE], the facility reversed the order for thyroid medicine and Carbidopa/Levodopa medications which resulted in R3 receiving five times the dose of the Levothyroxine for five consecutive days ([DATE] through [DATE]). Further review of the indicated R3 expired at home the next day after discharge from the facility. Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). Review of R3's progress note, dated [DATE] at 1:00 PM, read in part, Resident admitted .for 5-day respite care by wife in personal vehicle. A & O x 3 (alert and oriented to person, place and situation) ambulated to room with walker. Lungs CTA (clear to auscultation) . Review of R3's progress note, dated [DATE] at 3:14 PM, read in part, This order is outside the recommended dose or frequency. (Levothyroxine) oral tablet 200 mcg, give 2 tablets by mouth on time a day for thyroid and give 2 tablets by mouth one time a day for Parkinson's and give 1 tablet by mouth one time a day for Parkinson's .exceeds the usual dosing regimen .daily .exceeds the usual frequency of daily . Review of R3's progress note, dated [DATE] at 6:39 PM, read in part, Patient is a new admission to the facility. Patient medications were reviewed/verified against discharge summary which nursing had supplied. Pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing . Review of R3's Hospice visit note, dated [DATE], read in part, Vital signs: Blood pressure 160/84, pulse 78, respiratory rate 24, temperature 98.2, pain 3/10, and oxygen saturation 95%. Patient (R3) arrived at the facility 1:15 PM. (R3) is in his room, resting on his bed. He stated the transport went well. Patient said he is good with his room .Went over meds (medications) with nurse . On [DATE] at 9:00 AM, an interview was conducted with the Hospice Licensed Practical Nurse (LPN) O who was asked to verify their visit note when R3 was admitted on [DATE]. LPN O replied, Yes, I went over the medication list with the unit manager (Registered Nurse [RN] B), but I was not with them when the medication orders were transcribed. LPN O was asked if R3 at the time of admission was at their baseline and replied, Yes, (R3) walked into the facility with their walker and no assistance. (R3) was fine then. (R3's) lungs were clear and showed no signs or symptoms of a urinary tract infection of any other infection. The facility screwed up their medications and instead gave them one Carbidopa/Levodopa once a day and Levothyroxine three times a day with a total of five tabs. I was surprised the facility had released (R3). I thought the facility would have kept (R3) until returning to their baseline. I feel like (R3) was discharged too soon. I would have done things differently and made the medication error right. LPN O was asked if they were present at the time R3 was discharged and replied, Not at the facility, but I did go to see (R3) at home later. (R3) was not quite up to their normal self. I was surprised and sad to hear that (R3) had passed away. I did not expect that. LPN O was asked if they recalled how R3 was when they came to visit R3 on [DATE] and replied, (R3) had increased fever, and their vital signs were all messed up. (R3) was not normal. (R3's) temperature changed because they were getting too much Levothyroxine. Review of R3's vital signs, dated [DATE] at 12:53 PM, revealed the following: Blood pressure 127/71, pulse 91, respiratory rate 16, temperature 98.6, and oxygen saturation 93%. Weight 228.6 pounds obtained on [DATE] at 4:05 PM. Review of R3's progress note, dated [DATE] at 5:50 AM, read in part, At 0510 (5:10 AM) CNA (Certified Nurse Aide) reported resident to be confused and shaking. VSS (vital signs) were taken and BP (blood pressure) 180/84 T (temperature) 101.6 P (pulse) 116 R (respirations) 22 BS (blood sugar) 165 O2 (oxygen) 93%-86% (acetaminophen) administered at 0524 (5:24 AM) (lorazepam) at 0516 (5:16 AM). Cold wash cloths applied to neck and O2 applied at 2 L (liters) nc (nasal cannula) . Review of R3's progress note, dated [DATE] at 1:04 PM, read in part, Resident noted to have increased confusion, abnormal vitals (sic) signs. N.O. (new order) from .NP (nurse practitioner) for NS (normal saline) IV at 125 ml/hr (milliliters/hour) for 24 hours, vitals (sic) signs every 4 hours for 24 hrs (hours), Labs ordered . Review of R3's progress note, dated [DATE] at 3:34 PM, read in part, Patient being seen today as he is febrile, tachycardic, and increase confusion .overnight he became febrile, tachycardic and lethargic with need for oxygen .It was also noted he was receiving more than double of dose of his levothyroxine as well .Due to the unsureness of cause of symptoms will order labs as well as give a liter of IV Normal Saline and continue to monitor vitals .not been drinking very much the last couple days .patient was supposed to be discharged home today .would like to keep him overnight to be monitored and possibly discharge home tomorrow . On [DATE] at 9:20 AM, an interview was conducted with Hospice RN I who was asked if she recalled R3 being at the facility for respite care and replied, Yes. I found out on [DATE] of the medication errors. (R3) was getting Levothyroxine the same as they would with their Carbidopa/Levodopa. So (R3) was getting one Carbidopa/Levodopa once a day and Levothyroxine three times a day with a total of five tabs (two in the morning, one in the afternoon and two in the evening). On [DATE] at 9:27 AM, an interview was conducted with Hospice Case Manager K who was asked if they recalled R3 being at the facility for respite care and replied, Yes. (R3) was supposed to be at the facility for respite care including five nights and six days, but (R3) was discharged on [DATE] on the seventh day. The facility notified her (Case Manager K) of the medication error and R3 needing to stay an extra day because of requiring IV fluids. The medication error was between two medications that were transcribed incorrectly by the facility staff. R3 was getting one Carbidopa/Levodopa once a day and Levothyroxine three times a day with a total of five tabs (two in the morning, one in the afternoon and two in the evening). The facility Nurse Practitioner (NP) assessed and ordered the normal saline fluids, monitoring, and labs to be drawn. Labs ordered were a comprehensive metabolic (CMP), thyroid stimulating hormone (TSH), triiodothyronine (T3), and a thyroxine (T4). The facility has the results. I notified my supervisor regarding the medication errors and interventions. On [DATE] at 9:35 AM, an interview was conducted with Family Member (FM) J' who was asked about R3 respite stay at the facility and replied, On [DATE], I received a phone call from the NP (Nurse Practitioner) at the facility and was told (R3's) condition had changed and developed a fever, increased heart rate, receiving fluids, was on oxygen, and had taken a turn for the worst. The facility told me that (R3) had gotten a couple extra doses of Levothyroxine. Several extra doses of Levothyroxine. When I asked why (R3) got extra doses the facility would not answer me. The facility said that (R3) could not go home as scheduled and that they were keeping (R3) for an extra night, maybe two. Then finally the facility told me what happened that the switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. More than one nurse gave (R3) the incorrect medication scheduling. (R3's) condition change was related to the medication errors. The nurse transcribed the medications wrong, and the doctor signed off and sent a note to nursing and then nursing never changed the orders. (R3) walked into the facility and when I went to go get (R3) they had to be taken out of the facility via wheelchair and two-person assistance. (R3) was so mentally out of it he could not walk. (R3) was rambling on from the time I picked him up and continued all through the remainder of the day until (R3) finally fell asleep. (R3) was hallucinating and talking to our dog like it was (R3's) sister-in-law calling the dog by her name. (R3) was disoriented totally. (R3) was mentally and physically not normal and could not stand on his own. (R3) fell in the middle of the night, Hospice had to come out, he was incontinent, and the Hospice doctor recommended comfort care. (R3) passed away around 5:30 AM the next day on [DATE]. After (R3) passed the Hospice nurse and the medical examiner came out. (R3's) body was sent down state to a hospital for an autopsy and then was sent back to a local funeral home for cremation. On [DATE] at 10:40 AM, an interview was conducted with Medical Examiner (ME) G who was asked if they recalled R3's respite care at the facility and replied, I didn't know about (R3) until I was called to his house after he passed. I know that his wife took him in on [DATE] for respite care to the facility. (R3's) wife told me that 2 to 3 days into the stay that (R3) was acting strange and not making much sense. After 4 or 5 days (R3's) wife was like, 'What's going on with (R3)?' and apparently the facility nurse transcribed the wrong medications. The facility switched the scheduling of the Levothyroxine with the Carbidopa/Levodopa and put (R3) in a thyroid storm. (R3) was incoherent and talked to the dog as if it was his sister-in-law. (R3) received a God-awful amount of Levothyroxine in a short amount of time. (R3) had elevated temperature and was shaky. The facility admitted to wrongdoing. On [DATE] at 9:10 AM, an interview was conducted with LPN L who was asked what the process was for adding new admission orders in for medications and replied, The unit managers normally add them in and then they are checked by a second manager. If it is the weekend or the managers are gone then the floor nurses must do it but there should always be a second check. Review of R3's Hospice plan of care and admission medication list, dated [DATE], revealed the following orders: 1.) Carbidopa 25 mg (milligram) /Levodopa 100 mg, disintegrating tablet, oral, one tablet three times daily, morning one pill, at noon two pills, and one pill in the evening, 2.) Levothyroxine 200 mcg, one tablet one time daily. Review of facility physician orders, dated [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. Review of R3's medication administration record (MAR), dated [DATE] through [DATE], revealed the following: 1.) Carbidopa /Levodopa 25 mg/100 mg, disintegrating tablet, give 1 tablet by mouth one time a day for Parkinson's, 2.) Levothyroxine 200 mcg, give 1 tablet by mouth at dinner for Parkinson's, 3.) Levothyroxine 200 mcg, give 2 tablets by mouth at lunch for Parkinson's, 4.) Levothyroxine 200 mcg, give 2 tablets by mouth upon rising for Parkinson's. R3 received two extra doses of Levothyroxine on [DATE], four extra doses on [DATE], four extra doses on [DATE], and four extra doses on [DATE], equating a total of 2800 mcg within a 96-hour time period. Review of R3's originally transcribed medication orders for Levothyroxine and Carbidopa /Levodopa, dated [DATE] at 3:14 PM, revealed orders to be transcribed/created by RN / Unit Manager B and confirmed by RN B. On [DATE] at 10:40 AM, an interview was conducted with the Medical Director (MD) E who was asked what the normal dose was for Levothyroxine and replied, Dose varies with lab work. If the dose is more than 200 mcg then I normally refer the patient to an endocrinologist. However, 200 mcg is the cut off. MD E was asked what the signs and symptoms are of a thyroid storm and replied, Tachycardia (increased heart rate), muscle aches, elevated temperature, difficulty sleeping, feeling hot, palpitations and weight loss. MD E was asked about the transcription error for R3 and their Levothyroxine and Carbidopa /Levodopa and replied, The physician assistant should have discontinued the order and made a new order to reflect the correct instructions and not left it as pending. The pharmacist should have caught the errors. I would expect nursing to know better because you only give Levothyroxine once a day in the morning before breakfast. It is basic nursing 101. On [DATE] at 11:45 AM, an interview was conducted with RN M who was asked what the normal time and frequency was for Levothyroxine and replied, It is given in the morning and once a day. RN M was asked if they recalled R3 and their Levothyroxine dose, time, and frequency and replied, I didn't think it was strange to give it three times a day because (R3) was on Hospice. RN M was asked why they never checked the electronic medical record for the admission paperwork to double check the Levothyroxine frequency and dosing and replied, I don't know. I just assumed the order was put in correctly. On [DATE] at 12:05 PM, an interview was conducted with Pharmacist F who was asked what their process is for medication regimen reviews for new admissions and replied, I have to run a report for verification of orders on new admissions in the electronic medical records system. I try to get in there Monday through Friday everyday to see who a new admission is or if someone was transferred out. Or pull the report and look to see if they have documentation to verify the orders. Pharmacist F was asked if they were the pharmacist that did the medication regimen review for R3 on [DATE] and replied, Yes. Pharmacist F was asked why they did not address the pending confirmation for R3's Levothyroxine, Carbidopa-Levodopa and Trazodone dosing and replied, I think the orders may have been pending confirmation, so it was not official yet, so it did not show up on the order profile. On [DATE] at 12:45 PM, an interview was conducted with RN C who was asked what pending confirmation meant from a physician who signed off on a medication review for a new admit and replied, The physician should have compared the admit instructions with the transcribed orders and made a change if a change needed to be made. RN C was asked why the nurse practitioner had ordered normal saline for R3 and replied, For fluid resuscitation related to dehydration potential and medication errors. RN C was asked for what medication error for R3 and replied, The Levothyroxine error I think. RN C was asked what the process was for new admission medications and replied, Orders are transcribed by the unit managers and double checked with the original admission paperwork to the orders transcribed by another unit manager or nurse if one is not available. Then after the second check the on-call or house physician verifies the orders. RN C verified that the created by and the confirmed by should be two different nurse signatures. On [DATE] at 1:00 PM, an interview was conducted with RN B who was asked about the process for new admissions and transcribing medication orders and replied, The unit manager normally puts them in if they are at the facility and then the orders are double checked by a second nurse usually another unit manager. RN B was asked if she put the orders in for R3 and replied, Yes. RN B was asked who did the second check on R3's medication orders and replied, RN 'C'. On [DATE] at 1:10 PM, and interview was conducted with RN C who was asked if they recalled double checking the medication orders transcribed by RN B for R3 and replied, I can't recall double checking (R3's) medication orders. There needs to be a better process. RN C was asked if there was a check off list that must be completed for new admissions that certain things were completed and initialed off by staff and replied, No, there is not a check off list. We just use the medication list provided by the receiving hospital or where the resident comes from. RN C confirmed that there was no progress note for R3 that medications transcribed were double checked. On [DATE] at 1:20 PM, an interview was conducted with Nurse Practitioner (NP) D who was asked if they recalled R3 and replied, Yes. (R3) was admitted to the facility for respite care. (R3) became tachycardic, febrile, and lethargic. When it was discovered that (R3) was receiving more Levothyroxine I ordered normal saline and (R3) perked up. I wish nursing would have asked about and questioned the frequency of (R3's) Levothyroxine and they never did. I put a hold on the Levothyroxine for five days. I ordered a TSH, T3, T4, and CMP. NP D was asked if they got all the results back of the lab work for R3 and replied, The TSH result was 0.02, which is low, and I did order a T4, but we never got results. NP D was asked where in the human body Levothyroxine was metabolized and replied, I'm not sure. NP D was asked if poison control was notified of the medication error for direction and replied, No. NP D stated, There should have been better communication with pending confirmation and reviewed the admitting medications and made changes on order entry failures. NP D was asked if R3 had a medical diagnosis of end stage liver failure and replied, Yes, decreased liver function and would not have excreted the Levothyroxine as fast as a normal healthy liver. The medication would have had more of a build up in (R3's) system. My first presentation I did think (R3) was possibly in a thyroid storm because (R3) had increased heart rate, increased fever, lethargy, and confusion. Review of R3's medication audit report, dated [DATE] at 1:54 PM, revealed that RN B queued the Levothyroxine 200 mcg, give 2 tablets by mouth upon rising, give 2 tablets by mouth at lunch, and give 1 tablet by mouth at dinner for Parkinson's order for R3 on [DATE] at 11:23 AM and then created and confirmed the same order on [DATE] at 3:14 PM. On [DATE] at 2:40 PM, an interview was conducted with the Director of Nursing (DON) who was asked about the process for new admissions and transcribing medication orders and replied, We receive a referral and get the discharge summary with a list of medications currently being taken and confirm if the person is coming. The unit manager who receives the referral enters the medication orders in the electronic medical record and a second unit manager double checks the orders entered. The DON was asked if there was anyway to know who did the second check on R3's medication order entry and replied, No, there is no way to know who did the second check in the electronic medical record. The DON was asked about the progress note in R3's medical record dated [DATE] created by Physician Assistant (PA) P stating pending confirmation of Levothyroxine, Carbidopa-Levodopa and Trazodone dosing and who was responsible for how the confirmation was made and replied, PA P should have discontinued or changed the medication orders with verification of R3 medication list. The DON was asked if there is a policy for transcribing medication orders and replied, No policy just a process. I am not sure how the provider or the pharmacist did not catch the errors either. On [DATE] at 2:52 PM, an interview was conducted with LPN N who was asked what the normal time and frequency was for Levothyroxine and replied, It is given in the morning and once a day. LPN N was asked if they recalled R3 and their Levothyroxine dose, time, and frequency and replied, I assumed because (R3) was on Hospice that it was correct. LPN N was asked if they ever checked the electronic medical record for the admission paperwork to double check the Levothyroxine frequency and dosing and replied, I don't think of that. I just assumed the order was put in correctly. Review of R3's laboratory requisition from the facility, dated [DATE] at 10:20 AM, revealed R3's labs were to be drawn for a CMP, CBC (complete blood count), T3, T4, and TSH. Check boxes on the laboratory requisition were marked with a black X. Review of R3's laboratory results dated , [DATE] at 10:20 AM, revealed the lack of a T4 result. On [DATE] at 3:15 PM, a request was sent to the local laboratory for R3's original laboratory blood draw requisition. On [DATE] at 3:25 PM, R3's original laboratory requisition was obtained and revealed the lab for the T4 was never marked by the facility staff to be tested. On [DATE] at 3:45 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked why the laboratory requisition that the facility had on file was different from the original one that the local laboratory had on file and replied, I don't know. That is a good question. I will go ask the DON. On [DATE] at 3:55 PM, an interview was conducted with the DON who was asked why the discrepancy between the local laboratory requisition and the facility requisition and replied, I called the nurse who filled out the laboratory requisition for R3's blood to be drawn and they stated that after the original laboratory requisition was filled out and blood was drawn they noted the error and then later marked it after the laboratory requisition was sent. The DON was asked if the local laboratory was called to add the lab test for the T4 and replied, It was an oversight on the nurse and no malice was intended. Review of facility document titled, Medication Incident Report, dated [DATE] at 12:10 PM, revealed the following: 1.) Two medication transcription errors with Levothyroxine and Carbidopa-Levodopa. 2.) Incorrect dose times were entered incorrectly in eMAR (electronic medication administration record) upon admission. 3.) As noted by PA P and dosage times for Levothyroxine entered for Carbidopa-Levodopa and vice versa. 4.) Physician notified on [DATE] at 9:40 AM. 5.) Order changes: Lab draw. 6.) Corrective action taken: Nurse educated to ensure new admission orders are entered correctly. Follow up with physician verifying orders for any resident corrections. On [DATE] at 4:00 PM, an interview was conducted with the DON who was asked if any other nurses were educated or written up and replied, No, just the one who transcribed the orders incorrectly. Thyroid storm is a rare life-threatening condition of the thyroid gland. It develops in cases of untreated hyperthyroidism, or overactive thyroid (thyrotoxicosis) [or overdosing of a synthetic medication designed to act to supplement the decreased activity of the thyroid gland in the case of synthroid/levothyroxine use]. Retreived from: https://medlineplus.gov/ency/article/000400.htm Review of policy titled, Medication Administration, dated [DATE], read in part, Resident medication are administered in an accurate, safe, timely, and sanitary manner .Procedure .2. Verify the medication label against the medication administration record for resident name, time, drug, dose, and route. a. The nurse is responsible to read and follow precautionary instructions on prescription labels. b. If the label and medication sheet are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. c. Report any discrepancies to the pharmacy. Do not administer the medication until the discrepancy is resolved . Review of Levothyroxine, retrieved from website: http://www.synthroid.com/starting/taking-synthroid-the-right-way?cid=ppc_ppd_MSFT_Synthroid_Branded_when_is_best_time_of_day_to_take_synthroid_Phrase_USSYNT210334&gclid=9df9ab0c7de2146322dec3334cfd7502, date retrieved [DATE], read in part, Taking [Levothyroxine] the right way: In order for Synthroid [Levothyroxine's brand name] to be effective, it should always be taken the same way every day. This is important because the amount of medicine you need is very precise. And even the way you take Synthroid can affect how much medicine your body is getting. It's important to always take your medication exactly as your doctor prescribed. The right way, every day. Take [Levothyroxine] once a day, every day at the same time before breakfast. Take [Levothyroxine] with only water and on an empty stomach. Wait 30 minutes to 1 hour before eating or drinking anything other than water .Use and Important Safety Information .Taking too much levothyroxine may affect your heart, especially if you are elderly or have heart disease. Tell your doctor immediately if you have any signs of increased heart rate, chest pain, or an irregular heartbeat .Tell your doctor if you start experiencing any of the following symptoms: rapid or abnormal heartbeat, chest pain, difficulty catching your breath, leg cramps, headache, nervousness, irritability, sleeplessness, shaking, change in appetite, weight gain or loss, vomiting, diarrhea, increased sweating, difficulty tolerating heat, fever, changes in menstrual periods, swollen red bumps on the skin (hives) or skin rash, or any other unusual medical event .Use SYNTHROID only as ordered by your doctor. Take SYNTHROID as a single dose, preferably on an empty stomach, one-half to one hour before breakfast . Review of Thyroid Storm: Causes, Symptoms, Diagnosis & Treatment, retrieved from website: https://my.clevelandclinic.org/health/diseases/23203-thyroid-storm, date retrieved [DATE], read in part, .Diagnosis and tests. How is thyroid storm diagnosed? A healthcare provider diagnoses thyroid storm if the person has severe and life-threatening symptoms, such as extreme fever and heart issues, and high levels of thyroid hormone and low levels of thyroid-stimulating hormone (TSH) in their blood . Review of Thyroxine Poisoning, retrieved from website: http://www.ncbi.nih.gov/books/NBK279036/, dated retrieved [DATE], read in part, Clinical recognition . Ingested thyroxine, which is itself probably of modest physiologic significance, is rapidly partially converted to triiodothyronine (T3), the active form of thyroid hormone .Both thyroxine and triiodothyronine levels in serum rise within 1-2 hours of ingestion. Rarely, the overdose is discovered immediately, and the patient is brought to the hospital 6-12 hours after the ingestion. At this time, the common clinical signs and symptoms include nervousness, insomnia, mild tremor of hands, tachycardia, mild elevation of body temperature, blood pressure elevation, and loose stools . Cardiac effects aside from tachycardia are seldom seen in young adults but may occur in middle age and older adults, with reported arrhythmias and acute myocardial infarction . One-time ingestion of up to 3 mg thyroxine .As already mentioned serious complications are not common, but they can appear days after ingestion, and therefore the patients should be closely monitored .Diagnosis and differential: Elevated levels of total and free T4 and T3 have been described with suppressed serum TSH levels and otherwise typically a normal biochemical profile. The half-life of serum T4 may be shortened. In one study the half-life of LT4 was 5.7 days which is slightly shorter than the usual half-life of L-thyroxine . n many cases, there is a progressive rise in both serum total T4 and total T3 levels in the first 24 hours following the overdose, caused by continued absorption of the ingested LT4 .Follow-up: Patients should be monitored for several days to be sure that serum T4 and T3 levels are falling . Review of A Study of Thyroid Dysfunction in Cirrhosis of Liver and Correlation with Severity of Liver Disease, retrieved from website: http://pmc.ncbi.nlm.gov/articles/PMC6166553/, date retrieved [DATE], read in part, Introduction: Liver plays an important role in the metabolism of thyroid hormones . Moreover, the liver is involved in thyroid hormone conjugation and excretion .End-stage liver disease can significantly impact the metabolism of levothyroxine, a synthetic thyroid hormone .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intakes MI00150419 and MI00151063. Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 19 residents (#37, #51, #7, #87, #35, #36, #42, #48, #65, #81 and nine confidential residents) reviewed for staffing. This deficient practice resulted in actual harm for Residents #37, #7, #35, #42, and #48 who were forced to lay in their own excrement or urine for extended periods of time or delay a bowel movement due to insufficient staffing, resulting in reported feelings of frustration, helplessness, humiliation, and anger and/or inference of these feelings based on the reasonable person concept. Findings include: Resident #37 (R37) Review of the Minimum Data Set (MDS) assessment, dated 2/10/2025, revealed R37 was admitted to the facility on [DATE]. R37 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for ADLs (activities of daily living), including toileting hygiene, bathing and all mobility. Review of the Brief Interview for Mental Status (BIMS) assessment revealed R37 scored 13/15, indicating the Resident was cognitively intact. On 3/24/2025 at 7:40 a.m., a strong, offensive odor was noted in the hallway outside of R37's room. Upon entering R37's room and approaching the Resident in bed, it was noted the odor was stronger and was coming from the area of R37's bed. When asked when the last time staff had been in to administer care, R37 reported staff were last in during the night because her ostomy bag was leaking. R37 was observed pulling down the blanket and sheet, which was sticking to R37's abdomen and covered with a light brown substance. R37's colostomy bag was observed attached to her mid-abdomen and was three-quarter full of light brown stool and was taut due to gas collection. The outside of the bag was noted to be covered with light brown stool. R37's left side lower abdomen and left upper thigh had dried stool present and stool was observed leaking from the left side of the colostomy, soiling the sheet the resident was lying on. R37 reported staff did not have time to change the ostomy bag when it was found leaking overnight and just patched it. On 3/24/2025 at 8:40 a.m., R37 was observed seated in bed with a strong odor of stool present when standing next to R37's bed. Light brown stool was observed on the exposed white sheet resting on R37's left hip. When asked if staff had been in to assist her with cleaning up and changing the leaking ostomy bag, R37 reported staff brought in her breakfast tray and when R37 asked about getting cleaned up, was told she would have to wait until after staff were finished serving breakfast. When asked if she would prefer to be cleaned up before eating, R37 shrugged and stated, what can I do? During an interview on 3/25/2024 at 2:35 p.m., Certified Wound Care and Registered Nurse (RN) L reported she was asked to change R37's ostomy bag on the morning of 3/24/2025. RN L confirmed R37's colostomy bag was found leaking with the bed and clothing soiled with stool. RN L reported she was unaware R37's bag began leaking on the previous shift and that it was not changed. LPN L stated she was also unaware R37 was served breakfast with the colostomy visibly leaking, soiling the sheets and clothes, and that R37 was told she would need to wait to be cleaned up until after the meal. RN L reported they were short staffed on the previous shift due to a call in. Review of R37's March 2025 Treatment Administration Record (TAR) revealed R37's colostomy appliance and bag were documented as changed on 3/24/2025 at 10:01 a.m. During an interview on 3/25/2025 at 2:45 p.m., a confidential staff member, reported a concern there were not enough staff scheduled on a daily basis to address resident care needs. The confidential staff member reported out of the 36 residents residing on the Maple Unit (200 Hall), 22 were on a two-hour check and change schedule and many of those resident's required two-person assistance. Staff GG reported staff were feeling burned out and defeated with being unable to meet resident needs. Review of R37's care plan report (Kardex) revealed the following: Check q 2 hr [every two hours] and prn [as needed] for incontinence. Resident #51 (R51) Review of the MDS assessment, dated 1/17/2025, revealed R51 was admitted to the facility on [DATE]. R51 required substantial/maximal assistance (helper does more than half the effort) with bed mobility. Review of the BIMS assessment revealed R51 scored 11/15, indicating moderate cognitive impairment. An observation upon entering the Maple Unit on 3/25/2025 at 7:35 a.m. revealed the call light activation indicator above R51's door was illuminated, indicating a call light was activated. R51 was observed lying in bed with the head of the bed at approximately a 70-degree angle. R51 was slouched down in the bed with her head positioned near the bottom of the head of the bed with two pillows above and hanging over her head. R51's right foot was hanging off the right side of the bed and her left foot was touching the foot board. During an interview at the time of the observation, R51 reported she activated the call light for assistance with a boost to be repositioned farther up in the bed. Continuous observation from 7:35 a.m., revealed R51's call light remained unanswered at 7:50 a.m. at which time four staff were observed in the Maple Unit dining room and two nurses were observed working at the nurse's station. At 8:00 a.m., Certified Nursing Assistant (CNA) U was observed delivering R51's breakfast tray to her room, delivered the meal tray and exited with the call light still activated. During an interview at the time of the observation, R51 reported she asked CNA U for assistance repositioning in bed. R51 reported CNA U informed R51 she needed to wait until another staff person was available to assist. R51 was observed to be in the same position in the bed as previously observed at 7:35 a.m. It was noted R51's call light remained activated. At 8:04 a.m., CNA U was observed in Maple Unit dining room assisting two Activity Aides and one CNA with delivering meal trays. During an interview at the time of the observation, CNA U was asked if she was aware R51's call light was activated and that R51 was requesting to be repositioned. CNA U stated she was aware but needed to assist with passing meal trays. CNA U appeared flustered as she then left to seek another staff person to assist R51. R51 received assistance at 8:05 a.m., 30 minutes after the Resident's light was first observed activated. Resident #7 (R7) Review of the MDS assessment, dated 2/6/2025, revealed R7 was admitted to the facility on [DATE]. R7 required supervision or touching assistance (helper provides verbal cues or touching/steadying assistance) with transfers and walking, and partial/moderate assistance (helper does less than half the effort) with toileting hygiene, including adjusting clothes before and after using the toilet. Review of the MDS revealed R7 scored 8/15, indicating moderate cognitive impairment. An observation upon entering the Maple Unit on 3/25/2025 at 1:45 p.m., revealed the call activation indicator above R7's door was illuminated, indicating a call light was activated. Upon entering the room, R7 reported she activated her call light for assistance to go to the bathroom. R7's right hand was observed holding onto her abdomen and while wincing, R7 stated, I have to move my bowels. At the time of the observation, no staff were visible on the Maple Unit, including the halls, dining area or nurse's station. At 1:53 p.m. CNA P was observed walking down the hall from the area of room [ROOM NUMBER]. CNA P was alerted to R7's call light by this Surveyor. CNA P was observed entering room [ROOM NUMBER], where a bathroom call light was observed activated. Upon exiting room [ROOM NUMBER], CNA P entered R7's room, at which time the call light was deactivated. CNA P then exited R7's room. CNA P was interviewed immediately following the observation and reported she had to wait for another staff person to become available to assist in transferring R7 to the bathroom. CNA P reported the nurse assigned to the unit was caring for another resident, two other CNAs were providing care to another resident and one CNA was at lunch. CNA P stated providing cares after lunch was a challenge due to so many of the residents requiring assistance with transfers and toileting. CNA P reported there were no other staff available to cover for staff lunches and the Residents often had to wait for assistance. At 2:05 p.m. CNA V was observed approaching CNA P near the [NAME] Unit dining room asking for assistance with another resident. CNA P was observed walking down the hallway away from R7's room with CNA V. Immediately after CNA P left to assist CNA V, R7 was observed sitting in bed, as previously observed. When asked if she had received assistance, R7 held her right hand over her abdomen and stated she had not received assistance and stated I really need to go. At 2:12 p.m., RN L and CNA Q entered R7's room and R7 was heard stating I really need to move my bowels. A total of 27 minutes elapsed between the time R7's call light was observed activated and the time R7 was assisted to the bathroom. Resident #87 (R87) Review of the MDS assessment, dated 1/30/2025, revealed R87 was admitted to the facility on [DATE] with a diagnosis of right hip fracture. R87 required substantial/maximal assistance with toileting hygiene, partial/moderate assistance with transfers and was dependent on staff for ambulation and wheelchair mobility. Review of the MDS Section H - Bladder and Bowel, revealed R87 was always continent of bladder and bowel. Review of the BIMS assessment revealed a score of 8/15, indicating moderate cognitive impairment. During a telephone interview on 3/24/2025 at 6:54 p.m., R87's Family Member (FM) GG reported R87 was a resident at the facility until she discharged on 2/19/2025. FM GG stated R87 expressed concern with staff assistance at the facility. FM GG reported witnessing staff not responding to call lights in a timely manner with wait times up to 45 minutes for assistance. FM GG reported R87 fell on multiple occasions while attempting to go to the bathroom unassisted. When asked about the falls FM GG stated, R87 told him she had called for assistance, but no one responded and she would not pee the bed. R87 reported his concerns prompted him to take R87 out of the facility and home to follow up with her own physicians. When asked if R87 was available for interview, FM GG reported the Resident expired on 3/9/2025. Review of R87's fall reports, provided by the Director of Nursing (DON) revealed the following: 1/24/2025, 7:55 a.m. resident noted on the floor by passing nurse. Resident stated she was attempting to go to the bathroom. 2/05/2025, 1:26 p.m. opened door and observed resident on the floor . resident stated she was trying to go to the bathroom. 2/07/2025, 12:06 a.m. Resident was attempting to stand and then started sliding out of her [wheelchair] . she said she was going to the bathroom . fell [related to] weakness [and] did not wait for assist. Confidential Group Meeting During a confidential group meeting conducted on 3/24/2025 at 10:30 a.m., nine out of nine residents in attendance reported concerns with staffing levels in the facility and all reported consistent and extensive call light response times. Confidential Resident #9 (CR9) reported waiting on the toilet for more than 30 minutes for assistance after pulling the call light cord. CR9 reported when they expressed concern over how long the wait was, they were told staff had other duties that took priority. CR1 reported he was told he could not attend breakfast in the dining room unless he requested to do so the night before. When asked if he was allowed request to attend breakfast in the dining room the morning of the meal, CR1 reported there were no staff available to assist in cleaning up or transfers before or during mealtime. CR7 reported if they call for assistance to the bathroom close to or during a mealtime, they are consistently informed by staff they must wait for assistance until things die down. CR7 reported waiting 30 minutes or more for assistance after activating the call light only for staff to enter his room to say they will need to wait until staff are free to assist and at times, staff never come back to help. CR2 reported being left on the toilet for an extended period of time after activating the call light and stated my legs went numb. Review of the PBJ (Payroll Based Journal) Staffing Data Report, for FY (Fiscal Year) Quarter 1, 2025 (October 1 - December 31), revealed the facility was flagged for excessively low weekend staffing based upon data submitted by the facility. Review of the Daily Schedule Sheet(s), for October 1, 2024 through December 31, 2024, provided by the DON, revealed the following: Saturday, 10/11/2024 Evening Shift (7:00 p.m. - 7:00 a.m.): three licensed nurses and five CNAs scheduled for a total census of 73. Actual working schedule revealed two CNAs listed as CI (called-in) and three CNAs out of five scheduled worked the shift, for total of six staff for 73 residents. Friday, 10/18/2025 Evening Shift: three licensed nurses and five CNAs scheduled for a total census of 78. Actual working schedule revealed one CNA only worked 7:00 p.m. - 11:00 p.m., leaving staff of three licensed nurses and two CNAs from 11:00 p.m. - 7:00 a.m., for a total of five staff for 78 residents. Saturday, 12/07/2024 Evening Shift: three licensed nurses and five CNAs scheduled for a total census of 83. Actual working schedule revealed one CNA listed as CI, and one CNA worked 7:00 p.m. - 4:00 a.m., leaving staff of three licensed nurses and three CNAs for a total of six staff for 83 residents. During an interview on 3/26/2025 at 8:51 a.m., the DON was queried regarding the facility process for scheduling nursing and direct care staff. The DON reported scheduling was conducted based on the facility census and resident needs. When asked if she thought three CNAs were sufficient to care for 73 residents, the DON reported nursing staff are available to assist the CNAs with care on the evening shift because there are not many meds to pass. The DON was informed of the survey team's observations of long wait times and resident's left soiled for long periods of time, to which she responded staff were not acting usual due to surveyors being in the building. When asked if she felt she had enough staff scheduled to competently care for the residents, the DON did not offer a response. The DON reported nurse managers are included in the daily staffing numbers and generally workday shift, eight-hour days, Monday through Friday. A review of resident required assistance listing, reflecting the current census of 89 residents and provided by the DON, revealed the following: Residents requiring one person assistance with transfers: 41. Residents requiring two persons assistance with transfers: 12. Residents requiring use of the sit-to-stand mechanical lift: 5. Residents requiring use of the total mechanical lift: 15. On 3/23/25 at 10:20 AM, an intense noxious odor was detected from the locked dementia unit. A tour of the locked unit was conducted and the noxious odor increased in intensity. Resident #35 (R35) Review of R35's annual Minimum Data Set (MDS) assessment, dated 12/12/24, revealed R35 required substantial/maximal assistance for toileting, indicating the helper completed more than half the effort and R35 was occasionally incontinent. R35 scored a 00 of 15 on the Brief Interview of Mental Status (BIMS) assessment, reflective of severe cognitive impairment. On 3/23/25 at 11:56 AM, an observation was made of R35 in their room lying in bed. R35 reached out in an attempt for help. Certified Nurse Aide (CNA) H was made aware of R35 needing assistance. CNA H was asked if R35 was incontinent and the last time they were checked on. CNA replied, Yes, I was in here around 8:00 AM this morning. CNA H confirmed that R35 was soiled in urine and needed incontinence care. Resident #36 (R36) Review of R36's quarterly MDS assessment, dated 12/6/24, revealed R36 required substantial/maximum assistance for personal hygiene, indicating the helper completed more than half the effort. R36 scored a 02 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:41 AM, an observation was made of R36 being assisted to the dining room. R36's hair was not brushed, and they had hair sticking up in the back right side of their head. On 3/23/25 at 12:20 PM, an interview was conducted with CNA J who was asked if residents were provided with assistance for brushing hair. CNA J replied, Some residents need assistance and others won't let you. So, it just depends on their mood. Resident #42 (R42) Review of R42's admission MDS assessment, dated 11/15/25, revealed an admission to the facility on [DATE], with active diagnoses that included: hypertension, type two diabetes mellitus, and amputation below the knee of the right leg. R42 scored an 8 of 15 on the BIMS assessment, reflective of moderately impaired cognition. R42's quarterly MDS, dated [DATE], revealed R42 required total assistance for toileting and was frequently incontinent. On 3/23/25 at 10:26 AM, an interview was conducted with Family Member (FM) HH who stated that they wished the staff would get R42 up out of bed more often. FM HH stated R42 had lost weight since being admitted to the facility, and they don't even have a TV they can watch so R42 just lays in bed all day doing nothing. On 3/25/25 at 7:28 AM, an observation was made of R42 in their room lying in bed with the bed sheets half off. R42 was observed to be lying on a soaker pad that was soaked with urine and had a yellow/brown stain on the outer edges of the urine mark and the room had a noxious smell of urine. On 3/25/25 at 7:30 AM, an interview was conducted with CNA F who was asked if they were working on the dementia unit. CNA F replied, I worked last night, and my shift is done at 7:30 AM . CNA F was asked when the last time they had checked and changed R42. CNA F replied, I did a check and change on them at 3:00 AM. On 3/25/25 at 8:30 AM, an observation was made of CNA H who was delivering a breakfast tray to R42 in their room. CNA H was asked if they would provide incontinence care for R42 before they ate breakfast. CNA H replied, Yes, of course. CNA H was asked how they were going to accomplish the task as R42 was a two person assist, and they were the only CNA working on the unit. CNA H looked very overwhelmed and about to break down. CNA H replied, I guess I will just have to do it myself. Staffing is not the greatest. The nurse was supposed to mandate another staff member, but I guess that didn't happen. It is just me and an activities aide who is not certified and can't help me. I know the nurse won't help me. During the observation and interview at this time, R42 stated his back was uncomfortably itchy and driving him crazy due to skin irritation from the urine-saturated soaker pad. Resident #48 (R48) Review of R48's quarterly Minimum Data Set (MDS) assessment, dated 1/2/25, revealed R48 required total assistance for toilet and was always incontinent. R48 scored a 00 of 15 on the Brief Interview of Mental Status (BIMS) assessment, reflective of severe impairment in cognition. On 3/23/25 at 10:15 AM, an observation was made of R48 in their room and lying in bed with a sheet on and a soaker pad underneath them. A noxious smell was detected when entering R48's room. R48's soaker pad was soiled with urine, extending to the outer edges of the pad. R48's bed sheets were visibly soiled with food stains and crumbs. On 3/23/25 at 10:18 AM, an interview was conducted with CNA H who was asked when they had last checked on R48 for incontinence care. CNA H replied, I got here at 7:00 AM and I have not been in to provide care for them yet. CNA stated, 19 Residents are a lot to provide care for with one [on duty]. On 3/23/25 at 10:36 AM, an interview was conducted with CNA H and Licensed Practical Nurse (LPN) E who were asked if there was enough staff on the unit to care for all 19 Residents. LPN E and CNA H both replied, Most days it is like one nurse and one aide. CNA H stated that the night shift aide left trash and linens in the rooms. CNA H continued, Ideally every resident is a check and change every two hours, but we can't get to them on time. Review of R48's care plan, dated 12/4/23, read in part, .[Resident's name] is incontinent of bladder and bowel r/t (related to): Dementia process .Check q (every) 2 hr (hours) and prn (as needed) for incontinence .Resident uses disposable brief. Change q2h (every two hours) .Provide incontinence care with each episode . Resident #65 (R65) Review of R65's quarterly MDS assessment, dated 2/21/25, revealed R65 required partial/moderate assistance with personal hygiene. R65 scored a 04 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:48 AM, an observation was made of R65 in the hallway, and she had visible whiskers on her chin that were approximately a quarter of an inch long. Resident #81 (R81) Review of R81's quarterly MDS assessment, dated 12/6/24, revealed an uncompleted personal hygiene required assistance level. R81 scored a 04 of 15 on the BIMS assessment, reflective of severe impairment in cognition. On 3/23/25 at 11:40 AM, an observation was made of R81 walking in the hallway with disheveled and greasy hair. On 3/24/25 at 8:15 AM, no fresh water was observed in any of the 19 resident rooms on the locked unit. An interview was conducted with CNA H who was asked when residents get fresh water. CNA H replied, It usually gets passed right away at the beginning of each shift, but usually no later than 10:00 AM. Water was not passed until 12:30 PM on this day. On 3/24/25 at 10:40 AM, an interview was conducted with Housekeeper K who was asked if there was usually noxious odors on the locked unit. Housekeeper K replied, It smells strong of urine this morning and yesterday morning. I sprayed some air freshener on the curtains as I was cleaning the rooms. On 3/25/25 at 7:45 AM, an interview was conducted with Registered Nurse (RN) A who was asked if there was enough staff to care for residents on the locked unit and if they were able to mandate staff to stay over. RN A replied, No, I can't mandate staff to stay over. We had a call-in this morning. So, we are working short staffed again. I don't have time to call other staff. The front [office] does that if they are here. On 3/25/25 at 8:35 AM, an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) who were made aware of the staffing situation on the locked unit where there was one nurse, one licensed CNA, and one non-licensed staff. The locked unit had several Residents that required two-person assistance. The NHA replied, Residents should not be left incontinent for extended periods of time, should be receiving fresh water, and are provided with activities of daily living care. The DON replied, . there was a staff member who was mandated to stay over and should be on that locked unit working now. On 3/25/25 at 9:05 AM, an interview was conducted with RN D who confirmed that CNA F, who was mandated to stay over, punched out and left the facility. Review of policy titled, Activities of Daily Living (ADL) Program, dated 5/1/24, read in part, Purpose: A resident requiring skill practice and/or training in activities of daily living (ADL) is evaluated for restorative nursing. ADL may include, but are not limited to, bathing, grooming, and dressing. Restorative ADL program may be provided by nursing assistants and other staff trained in provision of ADL care under the supervision of the licensed nurse . Review of policy titled, Oral Hydration, dated 12/10/24, read in part, Policy: It is the policy of this facility to assist residents to maintain adequate hydration whenever possible .Procedure .5. Each resident will be provided bedside water unless contraindicated . Review of policy titled, Mandated after shift coverage, dated 7/17/20, read in part, .The procedure is as follows: 1. Whenever a staff member calls in or a no call / no show occurs a 12-hour employee will stay over and report to the unit that the call / no show occurred on. 2. The charge nurse will call anyone not working that day and ask if they would be willing to come in to work .4. If no one is willing to stay we will move on to the mandating list .6. The on-coming nurse will make sure staff stays over for coverage . On 3/23/25 at 11:25 AM, the lunch time meal was observed ready to serve in the steam table in the main dining room. On 3/23/25 at 11:43 AM, Culinary Aide Z was observed standing by the steam table. Culinary Aide Z stated, Lunch is ready, but I can't start serving food until a CNA is present in the dining room. When asked if kitchen staff must frequently wait for nursing staff to begin serving hot food, Culinary Aide Z said, Yes. It definitely goes in streaks. On 3/23/25 at 11:48 AM, CNA AA entered the dining room and communicated to Culinary Aide Z, I'll be down as soon as I can to serve trays, I am helping a resident with toileting needs. On 3/23/25 at 12:00 PM, CNA AA returned to the dining room and began serving lunch trays. At 12:14 PM, the last tray was served in the dining room, 49 minutes after the food was initially placed in the steam table. On 3/24/25 at 11:10 AM, the lunch time meal was observed ready to serve in the steam table in the main dining room. A total of 14 residents were seated in the dining room awaiting the lunch time meal. On 3/24/25 at 12:04 PM, the last tray was served in the dining room, 54 minutes after the food was initially placed in the steam table. On 3/24/25 at 11:11 AM, an interview was conducted with Dietary Manager (DM) Y regarding timeliness of food service expectations. DM Y stated food is placed into the steam table by 11:15 AM to allow for prompt service of the mid-day meal at 11:30 AM. DM Y stated the expectation is to serve food within 15 minutes of placing it in steam table for ideal palatability. DM Y confessed, If it's any longer than that, I myself wouldn't want to eat it. DM Y endorsed ongoing issues successfully serving meals in an acceptable timeframe due to the lack of nursing staff. DM Y speculated nursing staff may be too busy performing cares or transporting residents down to the dining to start serving at the expected time. On 3/23/25 at 11:58 AM, an interview was conducted with Resident #58 (R58) while waiting to be served lunch. R58 stated, They serve us the cheapest [expletive] they can buy. I was served a Salisbury steak recently and I couldn't even tell what it was . The food here ain't fit for man nor beast. Review of facility document titled Meal Schedule read, LUNCH: dining room [ROOM NUMBER]:30-12:30.