**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Resident Representative (RR) and staff interviews, the facility failed to notify the resident and/or the RR of the facility's bed hold policy when the resident was transferred to the hospital for 1 of 1 resident reviewed for hospitalization (Resident #13). The findings included: Resident #13 was admitted to the facility 7/29/24. The 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had severe cognitive impairment. A review of the nurse's notes revealed Resident #13 was discharged to the hospital 8/19/24 and did not return to the facility. A review of Resident #13's electronic medical record (EMR) revealed there was no documentation that information regarding the bed hold policy was issued when he was transferred to the hospital or that the RR was contacted concerning the bed hold. A telephone interview conducted with the RR on 11/06/24 at 2:06 PM indicated she was notified by the facility on 8/19/24 that Resident #13 was transferred to the hospital but there was no discussion concerning the bed hold policy. The RR stated on 8/25/24 she emailed the Social Service Manager that Resident #13 was being discharged from the hospital and would be returning to the facility on 8/26/24 but did not receive a response. She revealed that the Social Service Coordinator emailed her on 8/26/24 that a bed was not available and Resident #13 could not return to the facility. The RR indicated the facility did not send her information on the bed hold policy when Resident #13 was transferred to the hospital, and she was not aware a bed hold was required. A telephone interview conducted with Nurse #4 on 11/07/24 at 8:00 AM revealed she worked 3rd shift (11pm-7am) and was assigned to Resident #13 on 8/19/24. She stated the RR was notified Resident #13 was being transferred to the hospital, but they did not discuss the bed hold policy. She further stated she prepared Resident #13's transfer paperwork which included his face sheet and list of medications. Nurse #4 indicated a bed hold policy was not included in the paperwork and she was not familiar with the form. An interview with the Social Service Coordinator on 11/07/24 at 9:45 AM indicated she did not recall Resident #13 or that she communicated with his RR via email that he could not return to the facility. She stated the Social Service Manager was responsible for discussing the bed hold policy with residents and the RR and coordinating readmissions from the hospital to the facility. An interview conducted with the Social Service Manager on 11/07/24 at 10:00 AM indicated that when a resident was transferred to the hospital, she contacted the resident or the RR the next business day to discuss the bed hold policy. She revealed if the resident or RR wanted to hold the bed, she completed a form that was sent to the business office. The Social Service Manager stated she called Resident #13's RR to discuss holding his bed and emailed her the bed hold policy. She further stated the Resident #13's RR declined to hold his bed. The Social Service Manager indicated she was unable to explain why there was no documentation in the EMR that the RR declined to hold the bed, and she did not have a record of the email she sent to the RR with the bed hold policy. An interview with the Administrator on 11/07/24 at 3:09 PM revealed when a resident was admitted to the facility the bed hold policy was reviewed and signed by the resident and/or the RR. The Administrator indicated when a resident was transferred to the hospital the Social Service Manager should contact the resident and/or the RR as soon as practicable to review the bed hold policy and determine if they want to hold the bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Resident Representative (RR), Hospital Case Manager and staff interviews, the facility failed to permit a resident to return to the facility after being discharged to the hospital for evaluation due to a change of condition for 1 of 1 resident reviewed for hospitalization (Resident #13). The findings included: Resident #13 was admitted to the facility 7/29/24. The 5-day Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had severe cognitive impairment. A review of the nurse's note dated 8/19/24 at 8:05 AM indicated Resident #13 had an unwitnessed fall at 1:40 AM and was being monitored. Resident #13's vital signs were obtained around 5:00 AM and his temperature and heart rate had dropped. The on-call physician and RR were notified, and Resident #13 was transferred to the hospital for further evaluation. The discharge MDS dated [DATE] revealed Resident #13 had an unplanned discharge from the facility to the hospital and return to the facility was not anticipated. A review of an email sent from the RR to the Social Service Manager on 8/25/24 indicated that Resident #13 was being discharged from the hospital and the RR requested he return to the facility on 8/26/24. A review of an email sent from the Social Service Coordinator to the RR on 8/26/24 revealed she had communicated with the Hospital Case Manager concerning Resident #13's discharge from the hospital and informed the RR that Resident #13 could not return to the facility because a bed was not available. An interview with the Social Service Coordinator on 11/07/24 at 9:45 AM indicated the Social Service Manager was responsible for all resident admissions/discharges. She did not recall communicating with Resident #13's RR via email concerning his return to the facility. A review of an email sent from the RR to the Social Service Manager on 8/28/24 indicated Resident #13 was still in the hospital and in need of placement for short-term rehab. The RR inquired if the facility had a bed available. A review of the facility census record indicated on 8/25/24 the facility census was 15 and there were 5 beds available. The facility census on 8/28/24 was 13 and there were 7 beds available. A review of the hospital discharge plan note dated 8/28/24 revealed Resident #13 was medically ready for discharge however the facility would not accept him back. The Hospital Case Manager provided the RR with a list of skilled nursing facilities, but she was not pleased with the options. The RR was sent an updated list of facilities and discharge planning was ongoing. A telephone interview conducted with the RR on 11/06/24 at 2:06 PM indicated she was notified by Nurse #4 on 8/19/24 that Resident #13 had a fall and was transferred to the hospital for further evaluation. The RR stated on 8/25/24 the Hospital Case Manager contacted her that Resident #13 was ready to be discharged . She stated she emailed the Social Service Manager to inform her he was being discharged from the hospital and asked if he could return to the facility on 8/26/24 but did not receive a response. The RR revealed that the Social Service Coordinator emailed her on 8/26/24 that a bed was not available and Resident #13 could not return to the facility. The hospital physician had discussed hospice care due to Resident #13's frail condition but she was hopeful he was still appropriate for short term rehab, so she emailed the Social Service Manager again on 8/28/24 inquiring if a bed was available but did not receive a response. She stated she was out of town off and on during Resident #13's hospitalization and was communicating by phone and email with the physicians and the Hospital Case Manager. The RR revealed on 8/28/24 she agreed to skilled placement with hospice services. She indicated the Hospital Case Manager was assisting her with finding another facility, but she was not pleased with the options. She stated she did not want to move Resident #13 to a facility she was not sure would provide good care and then have to move him again, so Resident #13 remained in the hospital with hospice services and passed away on 9/13/24. An interview conducted with the Social Service Manager on 11/07/24 at 10:00 AM revealed that when a resident was transferred to the hospital, she contacted the resident and/or RR the next business day to discuss the bed hold policy and determine if they wanted to hold the bed. She revealed that for a resident that declined to hold their bed but requested to return to the facility when discharged from the hospital, they would be permitted to return to the first available bed if they were clinically appropriate. The Social Service Manager stated she did not recall the date, but she emailed the bed hold policy to Resident #13's RR and contacted her to discuss holding the bed which she declined. She further stated although the census indicated beds were available, there was not a bed for Resident #13 because they were being held for residents in independent living that were in the hospital and would require skilled nursing when discharged . She indicated on 8/28/24 there were 11 beds available and if Resident #13 was clinically appropriate he would have been permitted to return. She stated she did not contact Resident #13's RR when a bed was available, nor did she recall receiving an email from the RR on 8/28/24 inquiring if a bed was available. A phone interview with the Hospital Case Manager on 11/07/24 at 11:11 AM indicated she was assigned to Resident #13 during his hospitalization 8/19/24 through 9/13/24. The Hospital Case Manager revealed she contacted the facility when Resident #13 was ready for discharge, but they declined for him to return. She further stated she did not recall the date she contacted the facility or the reason why Resident #13 was not able to return. The Hospital Case Manager revealed that she worked with Resident #13's RR on finding alternative placement but due to a decline in his condition he was admitted to hospice and passed away in the hospital on 9/13/24. An interview with the Administrator on 11/07/24 at 3:09 PM indicated that when Resident #13 was discharged to the hospital on 8/19/24 the RR declined to hold his bed. She stated on 8/26/24 when Resident #13 was being discharged from the hospital the facility did not have a bed available. She revealed Resident #13 should have been permitted to return to the first bed available. The Administrator stated a bed was available 8/28/24 but she was not sure why Resident #13 was not permitted to return at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop personalized comprehensive care plans in the areas of diuretic (reduce fluid build up in the body) therapy and anticoagulation (blood thinning) therapy for 1 of 5 residents whose comprehensive care plans were reviewed (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (A-fib), edema, urinary retention, and congestive heart failure (CHF). A review of Resident #1's medical record revealed a physician order dated 10/1/2024 for Rivaroxaban (an anticoagulant medication) 15 milligram (mg), 1 tablet by mouth in the morning for A-fib (a heart condition that can lead to poor blood flow) and another order dated 10/24/2024 for Furosemide (a diuretic medication) 20 mg, 1 tablet by mouth in the morning every other day for CHF. A review of Resident #1's October and November 2024 Medication Administration Record (MAR) revealed she had been receiving the anticoagulant and diuretic medications as ordered. A review of the most recent Minimum Data Set (MDS) admission assessment dated [DATE] showed Resident #1 received anticoagulant and diuretic medications. Resident #1's care plan last reviewed on 11/4/2024 revealed there was no care plan in place for anticoagulant medication or diuretic medication. An interview was completed with the MDS Coordinator on 11/5/2024 at 2:50 PM. During the interview the MDS Coordinator revealed she was aware that Resident #1 had orders for anticoagulant and diuretic medications. The MDS Coordinator explained there was no care plan in place for either medication because the interventions that nursing was supposed to monitor were listed in the medication order. The MDS Coordinator went on to say if any medication required lab monitoring then it would be care planned, but she did not believe the medications Resident #1 was receiving needed to be care planned. An interview was conducted on 11/7/2024 at 10:55 AM with the Director of Nursing (DON) where he explained he did believe high risk medications needed to be included in the care plan. The DON also said anticoagulant and diuretic medications were high risk due to the potential side effects and complications related to both medications. On 11/7/2024 at 2:45 PM an interview with the Administrator was completed where she revealed she expected care plans to be complete and accurate to include any high-risk medications in order to provide the best care for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident (Resident #1) on two separate occasions for 1 of 2 residents reviewed for unnecessary medications. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Atrial fibrillation (A-fib), cardiac murmur, hyperlipidemia, congestive heart failure (CHF), Hypertension (HTN), edema, and chronic kidney disease. A review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had some mild cognitive impairment with no mood or behavior issues. The MDS also revealed that Resident #1 required partial assistance with her activities of daily living (ADLs). Review of Resident #1's current physician orders dated October 2024 revealed Resident #1 was ordered the following medications Flomax 0.4 milligrams (mg) times 2 capsules by mouth, Furosemide (to treat increase fluid) 20 mg every other day for CHF, Vitamin D 5000 units daily for vitamin D deficiency, Xarelto (to keep blood thin) 15 mg in the morning for A-fib, Pravastatin Sodium 20 mg daily for high cholesterol, Aspirin 81 mg daily, and Digoxin 125 mg each morning to treat Angina. A.) A review of a medication error report dated 10/24/2024 indicated the incident occurred on 10/23/2024 between 9:00 AM and 10:00 AM read in part, wrong resident (Resident #1) received Vitamin b-12 500 mg and Acetaminophen (APAP) 500 mg x 2 tablets. Medications received were not ordered for Resident #1. The type of error was marked as Wrong Resident and the reason for the error was due to Failure to identify the resident. Corrective actions included Nurse #1 (agency nurse) that administered the medications was not to return to the facility and Nurse education on the 5 rights of medication administration. Measures to prevent recurrence included no agency nurses, staff education, and medication pass audits for Resident #1. Nurse Practitioner (NP) and family members were notified. The report was signed by the Director of Nursing (DON) and Administrator. An interview was conducted via telephone on 11/7/2024 at 9:13 AM with Nurse #1. During the interview Nurse #1 was able to recall the incident that occurred with Resident #1. Nurse #1 explained on 10/23/2024 she picked up a shift through her staffing agency and upon arrival at the facility she was told her assignment but did not receive any type of orientation to the unit. Nurse #1 reported she went to medicate Resident #1, and the resident did not question what she was receiving. Afterwards Nurse #1 was approached by another Nurse (Nurse #3) and was told Resident #1 was assigned to her and she (Nurse #1) had just given Resident #1 the wrong medications and needed to report it. Nurse #1 said she notified the DON of the incident. B.) Review of medication error report dated 10/25/2024 indicated the medication error occurred on 10/24/2024 at 8:00 PM contained the following information, Nurse #2 (agency nurse) administered medication to the wrong resident (Resident #1). The medications included Atorvastatin 10 mg (to treat high cholesterol) and Tramadol 50 mg (to treat pain) were meant for another resident. The DON, MD, and family were notified. The type of error included wrong medication, wrong dose, and wrong resident with the reason being failure to identify resident. Corrective actions taken were Nurse #2 was removed from agency roster for the facility and Nurses were educated on the 5 rights of medication administration. Measures taken to prevent a recurrence included in-services provided to all nurses on medication administration policies and family requesting no agency nurses to take care of Resident #1. Signed by Unit Manager, DON, and Administrator. Interview was completed on 11/6/2024 at 4:03 PM with Nurse #2 via telephone. Nurse #2 said she was not sure how the error happened on 10/24/2024, Nurse #2 explained Resident #1 was not assigned to her and while she was preparing medication for another resident on the assisted living unit someone came out of Resident #1's room and asked her to come in and check Resident #1's vital signs. Nurse #2 said she told Resident #1 what medications were in the cup before giving them to her and the resident did not try to stop her. Nurse #2 continued by saying she was not sure why she gave Resident #1 the medications, but she had already worked an eight-hour shift and was asked to work an additional 8 hours shift. Nurse #2 also said she did not receive any type of education or orientation prior to taking her shift. Review of Nurse Practitioner note dated 10/25/2024 revealed Resident #1 had received medications that were not prescribed to her on two separate occasions, 10/23/2024 and 10/24/2024. The NP note further revealed the wrong medications that Resident #1 received on 10/23/24 included Vitamin B-12 500 mg and Acetaminophen 500 mg x 2 tablets (to treat pain). The medication received in error on 10/24/2024 included Atorvastatin 10 mg (used to treat high cholesterol) and Tramadol 50 mg (for pain). Interview was completed on 11/6/2024 at 11:19 AM with Resident #1. During the interview Resident #1 reported she received the wrong medications on 2 separate days. Resident #1 said on the morning of 10/23/2024 she noticed there were a lot of medicines in the medication cup the nurse was giving her. The resident explained she did question what medicines had been given to her and that was when she found out they were the wrong medicines. Resident #1 also said the same thing happened the next evening on 10/24/2024. Resident #1 said after she received the medications, she felt sluggish but could not blame the way she felt entirely on the medicine because she was being treated for pneumonia and urinary retention and was not feeling well at the time. Resident #1 went on to say she has not seen Nurse #1 or Nurse #2 since the incident. Resident #1 went on to say there had not been any other medication incidents since. An interview was conducted on 11/6/2024 at 11:59 AM via telephone with the NP. During the interview the NP reported she was notified of the medication errors involving Resident #1 that occurred on 10/23/2024 and 10/24/2024. The NP reported after being notified of the medication error that occurred on 10/23/2024 she gave orders to increase vital signs monitoring and to hold some of Resident #1's medications. NP explained after being notified of the second mediation error that occurred on 10/24/2024 she gave orders to hold Resident #1's atorvastatin due to risk of lowered blood pressure and draw labs that included a complete blood count (CBC) and a complete metabolic panel (CMP) to monitor for any changes. On 11/6/2024 at 3:17 PM an interview was completed with the Unit Manager (UM) that was notified of the medication error on 10/24/24. During the interview the UM reported the error was brought to her attention by Nurse #2 who had given the wrong medications to Resident #1. The UM went on to say Nurse #2 was assigned to the long-term care hallway, not the skilled care hallway where Resident #1 resided. The UM explained there was a small medication cart at the end of the skilled care hallway that was for the long-term care hallway and the cart was right beside Resident 1's room. The UM said Nurse #2 reported to her that she was preparing medication for her long-term residents at the medication cart located beside Resident 1's room when she (Nurse #2) was called into the room by the resident's sitter to check her oxygen levels and ended up giving her the medications she had been preparing. Nurse #2 was not assigned to Resident #1. An interview with the Staff Development Coordinator (SDC) on 11/7/2024 at 11:34 AM revealed there was education provided to agency staff nurses by means of a binder located on the medication carts and the nurse would know which cart she was assigned to through shift report. The SDC explained sometimes agency staff nurses would sign the agency checklist along with the employee overview and expectations but was unable to find any competencies or checklists signed by Nurse #1 or Nurse #2. The SDC further explained it would be the responsibility of the Unit Manager to go over any necessary information with agency nurses prior to starting their shift. The SDC also said despite Nurse #1 and Nurse #2 being assigned to the long-term care hallway the checklists and employee overview/expectations should have been discussed and signed. An interview was conducted on 11/7/2024 at 3:32 PM with the Medical Director (MD). During the interview the MD said she was familiar with Resident #1 and was aware of both medication errors. The MD explained the medications Resident #1 received in error were not considered significant medication errors. An interview was completed with the DON on 11/7/2024 at 3:50 PM where he explained he expected education related to medication administration to occur on an ongoing basis and nurses from any staffing agency needed to receive education and orientation prior to starting any shift. The DON went on to say he expected the correct medication to always be administered to the correct resident. On 11/7/2024 at 2:45 PM an interview was conducted with the Administrator. During the interview the Administrator said she expected to see ongoing education and orientation on all staff including agency nursing staff with focus on medication administration. The facility provided a corrective action plan with no completion date and did not provide sufficient evidence that the plan had been implemented.

Based on record review, and staff, Nurse Practitioner, and Medical Director interviews, the facility failed to provide effective orientation and education to 2 of 2 agency nurses (Nurse #1 and Nurse #2) to ensure competency when administering medications to 1 of 1 resident (Resident #1) resulting in Resident #1 receiving the wrong medication on 2 separate occasions. This deficient practice affected 1 of 1 resident reviewed for a medication error. The findings included: This tag is cross referenced to F658 Based on record review, resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews, the facility failed to ensure the correct medications were administered to the correct resident (Resident #1) on two separate occasions for 1 of 2 residents reviewed for unnecessary medications. F760 Based on record review, observation, and staff, resident, and facility Nurse Practitioner (NP) and Medical Director interviews the facility failed to prevent a significant medication error when Resident #1 received Metoprolol and Apixaban. The Apixaban was not prescribed to Resident #1, however she had an order for Metoprolol prescribed at a different dose. Nurse #1administered medications prescribed to an Assist Living Resident to Resident #1 on 10/23/2024 which included a different dose of Metoprolol 100 milligram (mg) used to treat hypertension (HTN), Angina (Chest pain) and Congestive Heart Failure (CHF). (This medication acts by decreasing blood pressure and heart rate which can cause tiredness and shortness of breath). On 10/24/2024 Resident #1 was given medication prescribed to an Assisted Living Resident by Nurse #2 that included Apixaban 2.5 mg (medication used to thin blood). This deficient practice affected 1 of 1 resident reviewed for significant medication error. (Resident #1) A review of education titled Medication Administration was reviewed on 11/7/2024. There was a list of signatures attached, however there were no dates on the education or sign-in sheets to indicate when the education occurred or if it was conducted following the medication errors that occurred on 10/23/2024 and 10/24/2024. An interview with the DON on 11/7/2024 at 10:52 AM revealed the education provided should have had a date on it to show when it occurred and moving forward all in-services would be dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff, resident, and facility Nurse Practitioner (NP) and Medical Director interviews the facility failed to prevent a significant medication error when Resident #1 received Metoprolol and Apixaban. The Apixaban was not prescribed to Resident #1, however she had an order for Metoprolol prescribed at a different dose. Nurse #1 administered medications prescribed to an Assisted Living Resident to Resident #1 on 10/23/2024 which included a different dose of Metoprolol, 100 milligrams (mg) used to treat hypertension (HTN), Angina (Chest pain) and Congestive Heart Failure (CHF). (This medication acts by decreasing blood pressure and heart rate which can cause tiredness and shortness of breath). On 10/24/2024 Resident #1 was given medication prescribed to an Assisted Living Resident by Nurse #2 that included Apixaban 2.5 mg (blood thinner). This deficient practice affected 1 of 1 resident reviewed for significant medication error (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Atrial fibrillation (A-fib), Angina, Congestive Heart Failure (CHF), and Right Lower Lobe Pneumonia. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive issues with no behaviors. Review of Resident #1's Physician orders dated September 2024 through October 2024 revealed Resident #1 was ordered the following medications: Metoprolol oral tablet, 25 mg to give 0.5 tablet to equal 12.5 mg by mouth at bedtime related to CHF ordered 9/30/2024. This medication helps to lower blood pressure. Rivaroxaban oral tablet, 15 mg to give 1 tablet by mouth in the morning for A-fib ordered 9/30/2024. This medication is used to help keep blood thin. Furosemide, 20 mg every other morning related to CHF ordered 9/30/2024. This medication is used to help remove excess fluid due to heart failure. Digoxin, 125 micrograms (mcg) 1 tablet by mouth in the morning due to Angina ordered 9/30/2024. This medication helps lower heart rate. Review of Resident #1's Medication Administration Record (MAR) for October 2024 revealed the following: Metoprolol oral tablet, 12.5 mg administered 10/1/2024 through 10/25/2024 at bedtime. Further review revealed Rivaroxaban 15 mg was administered every day, in the morning from 10/1/2024 through 10/31/2024. A.) A review of a medication error report dated 10/23/2024 indicated an incident occurred on 10/23/2024 between 9:00 AM and 10:00 AM and read in part, wrong resident (Resident #1) received Metoprolol 100 mg. Director of Nursing (DON) was notified at 12:00 PM on 10/23/2024 of the incident and the facility NP was notified at 12:30 pm on 10/23/2024. The medication was not ordered for Resident #1. The actions that were taken to help prevent negative outcomes included monitoring of vital signs (VS) including blood pressure (BP) and pulse rate every 2 hours and hold Digoxin (used to treat CHF). An additional review of Resident #1's orders revealed the following. An order dated 10/23/2024 at 1:55 PM to hold Digoxin was put into place and continued through 10/24/2024. An order for Oxygen (O2) 2 - 4 liters (L) as needed for decreased O2 saturation was started on 10/24/2024. A review of Resident #1's VS revealed the following: BP reading on 10/23/2024 at 1:25 PM while sitting was 104/66 and on 10/23/2024 at 10:35 pm while lying at 97/56. Furter review of Resident #1's vital signs showed a pulse rate on 10/23/2024 at 1:25 PM to be 55 beats per minute (BMP) and on 10/23/2024 at 10:35 PM the pulse rate was 46 bpm. Further review of Resident #1's VS dated 10/23/2024 through 10/31/2024 revealed fluctuations across all days and all shifts. An interview was conducted via telephone on 11/7/2024 at 9:13 AM with Nurse #1 (agency). During the interview Nurse #1 was able to recall the incident that occurred with Resident #1. Nurse #1 (agency nurse) explained on 10/23/2024 she picked up a shift through her staffing agency and upon arrival at the facility she was told her assignment but did not receive any type of training or orientation to the unit. Nurse # 1 further explained she was told to go one way and mistakenly went another way because she was not familiar with the hallway or the layout of the facility. She went on to say there was a medication cart right outside of Resident #1's door that was not intended for the resident's on the hallway. Nurse #1 reported she went to medicate Resident #1, and the resident did not question what she was receiving. Afterwards Nurse #1 was approached by another Nurse (Nurse #3) and was told Resident #1 was assigned to her and she (Nurse #1) had just given Resident #1 the wrong medications and needed to report it. Nurse #1said she notified the DON of the incident and was told to check Resident #1's VS. Nurse #1 went on to say the VS were within normal limits and she reported them to the DON. Afterwards Nurse #1 said she did not receive any kind of education and left the facility. An observation of the skilled nursing (SNF) hallway on 11/6/2024 at 11:00 AM revealed two medication carts on the hallway. There was a medication cart sitting directly to the left, outside of Resident #1's room. Resident #1's room was located at the end of the hallway with two rooms across the hall that were Assisted Living (ALF) rooms. B.) A review of a medication error report dated 10/25/2024 indicated an incident occurred on 10/24/2024 around 8:00 PM that read in part, Nurse #2 (agency nurse) gave the wrong resident (Resident #1) the medication Apixaban (blood thinner) 2.5 mg. The medication received was not ordered for Resident #1. The on-call Physician was notified on 10/24/2024 at 8:10 PM and the DON was notified on 10/24/2024 at 8:15 PM. The Physician ordered lab work that included complete blood count (CBC) and complete metabolic panel (CMP). A review of Resident #1's orders showed the following order dated 10/25/2024, Normal Saline intravenous (IV)) solution 0.9%. Use 125 milliliters (ml)/hour intravenously every hour for lethargy. Administer 2L of IV fluid and can discontinue IV and fluid orders when complete, ordered 10/25/2024. A review of Resident #1's electronic medication administration report (MAR) showed Normal Saline 0.9%, 125 ml/hour was administered 10/25/2024 through 10/26/2024. Additional review of Resident #1's orders showed an order change on 10/25/2024 for Metoprolol that read; Metoprolol,12.5 mg hold for heart rate less than 60 beats per minute. Review of labs drawn on 10/25/2024 revealed the following information: Kidney function was 78 with a normal reading being anything above 59. Further review of the lab report indicated Red Blood Cells (RBC) were 3.42 WNL with normal range being 3.72 -5.24. A lab was also drawn to help if determine if blood clotting was normal, the lab is International Normalized Ration Test (INR) The results were 1.2 with normal range being 0.8 - 1.2. Interview was completed on 11/6/2024 at 4:03 PM with Nurse #2 via telephone. Nurse #2 (agency) said she was not sure how the error happened on 10/24/2024, Nurse #2 explained Resident #1 was not assigned to her and while she was preparing medication for another resident someone came out of Resident #1's room and asked her to come in and check Resident #1's vital signs. Nurse #2 said she told Resident #1 what medications were in the cup before giving them to her and the resident did not try to stop her. Nurse #2 continued by saying she was not sure why she gave the resident the medication, but she had already worked an eight-hour shift and was asked to work an additional 8 hours shift. Nurse #2 also said she did not receive any type of education or orientation prior to taking her shift. Interview was completed on 11/6/2024 at 11:19 AM with Resident #1. During the interview Resident #1 reported she received the wrong medications on 2 separate days. Resident #1 said on the morning of 10/23/2024 she noticed there were a lot of medicines in the medication cup that Nurse #1 was giving to her. The resident explained she did question what medicines had been given to her and that was when she found out they were the wrong medicines. Resident #1 also said the same thing happened the next evening on 10/24/2024. Resident #1 said after she received the medications from Nurse #2, she felt sluggish but could not blame the way she felt entirely on the medicine because she was being treated for pneumonia and urinary retention and was not feeling well at the time. Resident #1 went on to say she has not seen Nurse #1 or Nurse #2 since the incident. Resident #1 also reported there had not been any other medication errors since. Review of NP note dated 10/25/2024 revealed Resident #1 had received medications that were not prescribed to her on two separate occasions, 10/23/2024 and 10/24/2024. The NP note showed the wrong medications that Resident # 1 received on 10/23/24 was Metoprolol 100 mg and on she received Apixaban 2.5 mg on the evening of 10/24/2024 after receiving her morning dose of Rivaroxaban 15 mg. The NP note also indicated after her evaluation of Resident #1 she did have increased lethargy, however the resident was receiving treatment due to ongoing pneumonia that was diagnosed on [DATE] and had poor oral intake that could be cause for dehydration. The note also revealed Resident #1 was arousable to verbal stimulus Resident #1 did tell the NP that she had no concerns but did admit to having some shortness of breath. Resident #1's O2 saturation was above 93 % on 2L of O2. The NP also indicated over the past 24 hours BP systolic number (Top number of the BP to indicate the blood being pumped out of the heart) ranged between 110s and 135, and the diastolic number (the bottom number that measure the pressure in the arteries when the heart rests between beats) ranged between 60s to 82. Her heart rate ranged between 59-67. (Average BP is 120/80 and average heart rate range is between 60 and 100 bpm) Assessment included in the NP note revealed parameters were added to the Metoprolol order. An interview was conducted on 11/6/2024 at 11:59 AM via telephone with the NP. During the interview the NP reported she was notified of the medication errors involving Resident #1 that occurred on 10/23/2024 and 10/24/2024. The NP reported after being notified of the medication error that occurred on 10/23/2024 she gave orders to increase vital signs monitoring and to hold digoxin (a medication used to treat CHF and slow down heart rate) and Furosemide (a medication used to aid in removing excess fluid) due to the risk of lowered blood pressure and heart rate. The NP further explained after being notified of the second mediation error that occurred on 10/24/2024 she gave orders to draw labs that included an INR level due to an extra dose of anticoagulant medication. In addition to the INR level the NP also ordered a Complete Blood count (CBC) and a Complete Metabolic Panel (CMP). The NP note further explained Resident #1's O2 saturation had remained above 93% on 2L of O2 and blood pressure and heart rate had remained stable over the 24 hours since the medication errors. The NP went on to say she ultimately did not believe there was harm to Resident #1 due to receiving the wrong medications and felt like the facility took the appropriate actions and follow-up. An interview was conducted on 11/7/2024 at 3:32 PM with the Medical Director (MD). During the interview the MD said she was familiar with Resident #1 and was aware of both medication errors that occurred on 10/23/2024 and 10/24/2024. The MD explained the Metoprolol does that Resident #1 received in error would be considered a significant medication errors due to the risk for decreased heart rate and blood pressure. The MD also explained that the one-time administration of Apixaban 2.5 mg in addition to the already ordered Rivaroxaban 15 mg would not necessarily have been a significant error in terms of the effect on the resident. The MD also explained Resident #1 received 2L of IV fluids following the incident related to lethargy that could have been the result of the medication error or a combination of the medication error and the status of Resident #1 at the time that included advanced age, a diagnosis of pneumonia, urinary retention and weakness. She stated Resident #1 made a total turn around after receiving the fluids in regard to lethargy. The MD further explained Resident #1 was also being treated for urinary retention and pneumonia at the time and the combination of all factors could have led to increased weakness and lethargy, however no harm came to the residents as a direct result of the medications. An interview was completed with the DON on 11/7/2024 at 3:50 PM where he explained he expected the correct medication to always be administered to the correct resident. On 11/7/2024 at 2:45 PM an interview was conducted with the Administrator. During the interview the Administrator said she expected to see all nurses administer the correct medications to the correct residents. The facility provided a corrective action plan with no completion date and did not provide sufficient evidence that the plan had been implemented.

Based on observations and staff interviews the facility failed to secure a controlled substance in a permanently affixed compartment of the refrigerator in 1 of 1 facility medication room (Medicare Hall medication room). The findings included: On 9/26/23 at 3:13 PM an observation and interview were conducted with Nurse #2. The refrigerator in the Medicare Hall medication room was not locked and had a clear permanently affixed lock box that was locked and contained a 30 ml (milliliter) multi-dose bottle of Lorazepam/Intensol (a controlled substance) oral concentrate 2 mg (milligrams/ml). In another clear lock box that was locked, but not permanently affixed in the refrigerator, contained a 30 ml multi-dose bottle of Lorazepam/Intensol (a controlled substance) oral concentrate 2mg/ml and four 2 mg/ml vials of lorazepam for injection. Nurse #2 stated the unaffixed lock box was used for pyxis (automated medication dispensing system) removal. If a resident needed a stat dose of lorazepam, they would go to the pyxis and remove the key to open that lock box. She indicated she did not notice the lock box was not affixed because she had not retrieved any medications from it. During an interview with the Director of Nursing (DON) on 9/26/23 at 4:21 PM she revealed the unaffixed lock box in the Medicare Hall medication room refrigerator was for medications Pharmacy exchanged weekly. She explained the medications in the unaffixed box were for pyxis medication removal. The medications in that box were for stat and one-time doses and the key to the box had to be retrieved from the pyxis. It was her understanding that because the medication room was locked and the box was locked, the box did not need to be affixed. She indicated that the medications that were in the unaffixed lock box were not in the affixed box because Pharmacy came weekly to exchange the unaffixed box. Pharmacy did not just exchange medications in the box, they exchanged the entire box. During an interview on 9/27/23 at 8:51 AM the Administrator revealed she had temporarily affixed the lock box in the Medicare Hall medication room refrigerator and had ordered a box to permanently affix in the refrigerator. She indicated she did not realize this was an issue.

Based on observations, record review, and staff interviews, the facility failed to discard spoiled food stored in the lower-level refrigerator, failed to discard expired food items stored for use in the lower-level dry goods storage room and in the rehabilitation hall nourishment refrigerator. This practice had the potential to affect food served to residents. The findings included: 1. An observation on 9/25/23 at 11:20 AM with the Culinary Director revealed the following: -The refrigerator located in the lower-level kitchen storage revealed had 4 green peppers covered in white/ grayish fuzzy substance and wilted brownish iceberg lettuce. -The dry storage room in the lower level kitchen revealed a) 20 8 ounce (oz) jars of sushi pickled ginger with a best buy date of 11/7/2021; b) 26 4oz cans of curry paste with a best buy date of 6/2022; c) 20 4oz cans of curry paste with a best buy date of 2/2022; d) baking flour use by date of 4/9/23; e) caramel paste best buy date of 7/4/2022; f) candy sprinkles use by date of 3/21/23; g) hazel nut paste best buy date of 7/20/22; h) chocolate shavings best buy date of 4/2023. During a follow-up observation of the refrigerator and dry storage room, an interview on 9/26/23 at 2:45 PM the Culinary Director revealed the expired green peppers and expired items in the dry storage room, listed above, were discarded on 9/25/23. He further revealed he expected all dietary staff to check and discard expired foods. 2. An observation on 9/27/23 at 10:30 AM revealed a 4 oz container of yogurt (expired 9/21/23) in the nourishment refrigerator on the rehabilitation hall. During an interview on 9/27/23 at 10:35 AM the Certified Dietary Manager (CDM) indicated the assigned Dietary Supervisor was responsible for checking for expired foods before restocking the nourishment refrigerators. She further indicated that she expected the nourishment refrigerators to be checked for expired food items on a daily basis. An interview with the Administrator on 9/28/23 at 2:45 PM indicated she was not aware of the expired foods and that she expected the dietary department to discard expired foods daily.

Based on observations and staff interviews the facility failed to remove loose garbage, food, and debris from around 1 of 1 trash receptacle located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents. The findings included: An observation (with the Director of Environmental Services) of the outdoor trash receptacle area on 9/26/23 at 3:15 PM revealed trash and food littered around the trash receptacle. During the observation, flies were swarming around the trash receptacle. The Director of Environmental Services indicated he was filling in for the Maintenance Director who was out of the office and that the Maintenance Department was responsible for maintaining the trash receptacle and the trash removal company removed the receptacle once weekly, dumped the receptacle off-site then returned it to the facility within 2 hours. During the 2-hour period, maintenance usually removed littered trash and cleaned the area before the trash receptacle was returned. Maintenance may or may not know what time the receptacle was removed and returned, but the day of the week remained the same unless otherwise notified. He further indicated maintenance was responsible for cleaning the areas under and around the trash receptacle and the dietary department was responsible for cleaning the debris on and around the grease trap that was located next to the trash receptacle as needed. He expected trash and refuse to be maintained in the receptacle area on a weekly basis and as needed. An interview with the Administrator on 9/28/23 at 2:00 PM indicated she was not aware there was an issue with garbage/ refuse cleanup and expected all garbage and refuse to be maintained by the Maintenance Department and/or dietary staff.

Based on dining observations, staff interviews and record review, the facility failed to provide or assist 4 of 4 residents with hand hygiene before meals during 2 of 2 dining observations (Resident #157, #207, #208, and #209). The findings included: The facility policy, entitled Handwashing/Hand Hygiene, revised August 2019, recorded in part, this facility considers hand hygiene the primary means to prevent the spread of infections. Residents will be encouraged to practice hand hygiene. Use an alcohol-based hand rub or alternatively, soap and water for the following situations: before and after eating or handling food. 1a. A continuous observation of the lunch meal on the rehab unit occurred on 9/25/23 from 12:47 PM until 12:55 PM. Residents #207, #208 and #209 were assisted in their rooms by Nurse Aide (NA) #4 with meal set up for the lunch meal. Meal trays were removed from the meal cart, taken into each resident's room, placed on the overbed table, and set up for each resident, per their preference. Residents #207, #208 and #209 were not asked if hand hygiene had already been performed nor were the residents encouraged to perform or assisted with hand hygiene prior to eating their meal. Residents #207 and #208 both received curly fries and Resident #209 received a sandwich and potato chips, foods each resident ate with their hands. 1b. A continuous observation of the lunch meal on the rehab unit occurred on 9/26/23 from 12:20 PM until 12:45 PM. Residents #157, and #207 were assisted in their rooms by NA #1 with meal set up for the lunch meal. Resident #209 was assisted in her room by NA #2 with meal set up for the lunch meal. Meal trays were removed from the meal cart, taken into each resident's room, placed on the overbed table, and set up for each resident, per their preference. Residents #157, #207 and #209 were not asked if hand hygiene had already been performed nor were the residents encouraged to perform or assisted with hand hygiene prior to eating their meal. Residents #157, #207, and #209 received chocolate chips cookies, which they ate with their hands. An interview with NA #1 occurred on 9/27/23 at 9:25 AM. NA #1 stated that she was trained to assist residents before and after meals with hand hygiene. NA #1 stated Residents #157 and #207 both required assistance with hand hygiene, but that she did not offer them assistance. An interview with NA #2 occurred on 9/27/23 at 9:30 AM. NA #2 stated that she was trained to assist residents before and after meals with hand hygiene. NA #2 stated Resident #209 required more assistance at admission than she did currently, but that Resident #209 would currently at least need set up assistance. NA #2 stated she did not ask or encourage Resident #209 to perform hand hygiene before her meal. An interview with Nurse #1 for the rehab unit occurred on 09/27/23 at 10:46 AM. Nurse #1 stated that he was the nurse on the rehab unit, and he expected residents at a minimum were offered to use hand sanitizer prior to meals and if possible offered hand washing with soap and water, which was a better and more effective option. An interview with the Infection Control Preventionist (ICP), Staff Development Coordinator (SDC) occurred on 09/27/23 at 10:33 AM. The ICP/SDC stated all nursing staff received an in-service in April 2023 and June 2023 on hand hygiene which instructed staff to offer/assist residents with hand hygiene before and after meals. The ICP/SDC stated that if a resident was independent with their hygiene needs, staff were trained to encourage the resident to go to the bathroom to wash their hands before and after meals and if the resident was dependent on staff to meet their hygiene needs, staff should assist the resident by offering hand sanitizer, a soapy wash cloth or assist the resident to the bathroom to wash their hands. The ICP/SDC provided documentation of nursing staff in-services on infection control for review. A signature for NA #1 and NA #2 were both included in the documentation of infection control in-services. The Director of Nursing (DON) was interviewed on 09/27/23 at 11:35 AM. The DON stated that staff were expected to follow the facility's policy on hand hygiene and assist residents with hand hygiene with either hand sanitizer or hand washing with soap and water prior to and after meals. The Administrator stated in an interview on 9/28/23 at 11:00 AM that staff received an in-service related to hand hygiene which included education to assist residents with hand hygiene prior to meals. The Administrator stated that she expected staff to assist residents with hand hygiene before and after meals.