**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to inform and enable participation in treatment in a way she could understand for 1 of 13 residents (Resident #16) reviewed for care plans, in that: Resident #16 did not have a comprehensive care plan completed to address her communication-barrier within 7 days after the completed of her comprehensive assessment. This failure placed residents at risk of not receiving services that could maintain the resident's highest practicable mental, and psychosocial well-being. Findings Included: Record review of Resident #16's face sheet, dated 06/20/2023, revealed a [AGE] year-old female resident who was admitted into the facility on [DATE] and was diagnosed with metabolic encephalopathy, overactive bladder and cognitive communication deficit. Record review of Resident #16's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating the resident's cognition was severely impaired and was assessed to not need or want an interpreter to communicate with staff. In an interview with Resident #16 on 06/18/23 at 9:39AM, surveyor attempted to complete the interview in English but Resident #16 could not respond. With the use of a Vietnamese translator via phone, she stated she had no way to communicate with the staff and she felt like the nurses were rude to her. Record review of Resident #16's care plan, dated, dated 06/14/2023, revealed the care plan was not completed and did not address the communication-barrier the resident had. In an interview with RN B on 06/18/2023 at 11:00PM, she revealed she called Resident #16's family member sometimes to talk with the resident and see what she needs. She said Resident #16's Physician Assistant also speaks Vietnamese and is able to talk to her when she visits. In an interview with the family member of Resident #16 on 06/19/23 at 02:08 PM, she stated Resident #16's main complaint was that she often felt ignored by the staff even after pressing the call light and telling them what she needed. In an interview with CNA R on 06/20/2023 at 10:48 AM, she stated Resident #16 spoke Vietnamese and communicated with staff by pointing and making gestures to let them know when she wanted to use the restroom or go to bed. In an interview with the Regional MDS Coordinator on 06/20/23 at 11:26 AM, he stated he worked for multiple facilities. He said the rule for care plans was that it had to be completed within 7 days after the comprehensive MDS assessment is completed. He said care plans were important for informing the team about the resident's special needs and how the resident is to be cared for. He stated communication barriers and ADLs should be care planned for all residents, but the facility did not have an MDS Coordinator to manage all the care plans, so that was a contributing reason as to why Resident #16 did not have a comprehensive care plan. In an interview with the DON on 06/20/23 at 11:36 AM, she stated the facility had one part-time MDS and a regional MDS Coordinator helping with comprehensive assessments and care plans, but the facility was in need of a full-time MDS Nurse for the constant turnover of residents. She stated communication barriers and ADLs need to be included in comprehensive care plans, as they serve as communication for the interdisciplinary team to know necessary interventions to prevent any further decline in the resident. Record review of the facility's policy on comprehensive care plans, dated 08/17/2022, revealed, . The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs . a comprehensive care plan must be- i) developed within 7 days after completion of the comprehensive assessment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 13 residents (Resident #16) reviewed for care plans, in that: Resident #16 did not have a comprehensive care plan completed to address her communication-barrier r within 7 days after the completed of her comprehensive assessment. This failure placed residents at risk of not receiving services that could maintain the resident's highest practicable mental, and psychosocial well-being. Findings Included: Record review of Resident #16's face sheet, dated 06/20/2023, revealed a [AGE] year-old female resident who was admitted into the facility on [DATE] and was diagnosed with metabolic encephalopathy, overactive bladder and cognitive communication deficit. Record review of Resident #16's MDS, dated [DATE], revealed the resident had a BIMS score of 4 indicating the resident's cognition was severely impaired and was assessed to not need or want an interpreter to communicate with staff. In an interview with Resident #16 on 06/18/23 at 9:39AM, surveyor attempted to complete the interview in English but Resident #16 could not respond. With the use of a Vietnamese translator via phone, she stated she had no way to communicate with the staff and she felt like the nurses were rude to her. Record review of Resident #16's care plan, dated, dated 06/14/2023, revealed the care plan was not completed and did not address the communication-barrier the resident had. In an interview with RN B on 06/18/2023 at 11:00PM, she revealed she called Resident #16's family member sometimes to talk with the resident and see what she needs. She said Resident #16's Physician Assistant also speaks Vietnamese and is able to talk to her when she visits. In an interview with the family member of Resident #16 on 06/19/23 at 02:08 PM, she stated Resident #16's main complaint was that she often felt ignored by the staff even after pressing the call light and telling them what she needed. In an interview with CNA R on 06/20/2023 at 10:48 AM, she stated Resident #16 spoke Vietnamese and communicated with staff by pointing and making gestures to let them know when she wanted to use the restroom or go to bed. In an interview with the Regional MDS Coordinator on 06/20/23 at 11:26 AM, he stated he worked for multiple facilities. He said the rule for care plans was that it had to be completed within 7 days after the comprehensive MDS assessment is completed. He said care plans were important for informing the team about the resident's special needs and how the resident is to be cared for. He stated communication barriers and ADLs should be care planned for all residents, but the facility did not have an MDS Coordinator to manage all the care plans, so that was a contributing reason as to why Resident #16 did not have a comprehensive care plan. In an interview with the DON on 06/20/23 at 11:36 AM, she stated the facility had one part-time MDS and a regional MDS Coordinator helping with comprehensive assessments and care plans, but the facility was in need of a full-time MDS Nurse for the constant turnover of residents. She stated communication barriers and ADLs need to be included in comprehensive care plans, as they serve as communication for the interdisciplinary team to know necessary interventions to prevent any further decline in the resident. Record review of the facility's policy on comprehensive care plans, dated 08/17/2022, revealed, . The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs . a comprehensive care plan must be- i) developed within 7 days after completion of the comprehensive assessment .

Based on interview and record review the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 (Sunday 01/01/2023, Sunday 01/08/2023 and Sunday 02/25/2023, Saturday 03/25/2023 and Sunday 03/26/2023 of 90 days reviewed for RN coverage. The facility failed to maintain registered nurse coverage for 8 hours a day/7days a week on Sunday 01/01/2023, Sunday 01/08/2023,Sunday 02/25/2023, Saturday 03/25/2023 and Sunday 03/26/2023. This failure could place residents at risk of adverse events and not having staff to attend to events. The findings were: Record review of the staffing schedule from Sunday 01/01/2023, Sunday 01/08/2023, Sunday 02/25/2023, Saturday 03/25/2023 and Sunday 03/26/2023 revealed 5 of 90 days there was not eight-hour continuous registered nurse coverage on the weekends (Saturday/Sunday) for the dates reviewed. Interview with the DON on 6/19/2023 12:30 pm, she stated the reason an RN's are needed at least 8 hours a day to oversee and manage residents in the event of emergency, triage and/or skilled intervention. She stated she was notified when an RN is scheduled and doesn't show up, and she will attempt to staff it or come to the facility herself to assure proper RN coverage. She stated she is aware there was no RN coverage on 01/01/2023, 01/08/2023, 02/25/2023, 03/25/2023 and 03/26/2023. DON stated she was not employed during this time. Interview with the Staffing Coordinator on 6/19/2023 12:40 pm revealed she performed scheduling and has full time coverage for RNs during the week and on weekends; the schedule was reviewed and verified. She states she is notified when the registered nurse doesn't come in and will try to staff the vacancy and will call the DON when needed. Review of the facility's Policy and Procedure for staffing did not address the need for RN coverage 7 days a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to have physician orders for the resident's immediate care for 1 of 8 (CR #1) of one resident reviewed for admission physician orders. - The facility failed to enter physician's orders for immediate care for CR #1's surgical site throughout her residency from 01/18/23 to 01/20/23. These failure could place residents at risk for adverse reactions, deterioration of wounds and infection. Findings Included: Record review of CR #1's face sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] and discharged on 01/20/23 with diagnoses of: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (innermost layer of the skin) and encounter for cosmetic surgery. Record review of CR #1's MDS dated [DATE] revealed, entrance from an acute hospital stay and independent cognitive skills for daily decision making. Record review of CR#1's Order Details dated 01/20/23 at 06:36 AM revealed, there were no orders for wound care or dressing changes before 01/20/23. Record review of CR #1's January 2023 TAR revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. Record review of CR #1's January 2023 Progress Notes revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. In an interview on 01/23/23 at 03:57 PM, CR #1 said she admitted to the facility on [DATE] following a cosmetic surgery to remove excess skin on both her arms with orders to change her bandages every 12 hours. CR #1 said she discharged AMA because for the 2 days she was at the facility she did not receive any wound care and even though she had bloody drainage, her dressing was never changed. An attempt was made to interview LVN A on 01/25/23 at 12:26 PM, a message was left on the voicemail. In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any wounds. She said nurses should immediately order standard wound care orders for monitoring/cleaning/dressing changes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter wound care orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. She said all residents admitted with wounds/surgical incisions should have standard orders entered to clean and monitor the area if the resident did not enter with specific physician orders. The DON said she was unaware of CR #1's wound care orders, but the facility had identified issues with admissions orders associated with the use of agency staff. The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and is currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with wounds, and these orders included tasks needed for care of wounds or surgical incision sites Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites Record review of facility provided list of batch orders dated 01/24/23 revealed IV: Midline Catheter Orders- change site transparent dressing admit, at least every 7 days/PRN . observe every shift with intermittent therapy or when not in use . IV: PICC line orders- Change IV administration tubing every 24 hrs change PICC line dressing on admission change PICC line transparent dressing weekly/PRN .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 8 residents (CR #1) reviewed for quality of care. - The facility failed to provide care to CR #1's surgical site throughout her residency from 01/18/23 to 01/20/23. This failure could place residents at risk for adverse reactions, deterioration of wounds and infection. Findings Included: Record review of CR #1's face sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] and discharged on 01/20/23 with diagnoses of: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (innermost layer of the skin) and encounter for cosmetic surgery. Record review of CR #1's MDS dated [DATE] revealed, entrance from an acute hospital stay and independent cognitive skills for daily decision making. Record review of CR#1's Order Details dated 01/20/23 at 06:36 AM revealed, there were no orders for wound care or dressing changes before 01/20/23. Record review of CR #1's January 2023 TAR revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. Record review of CR #1's January 2023 Progress Notes revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. In an interview on 01/23/23 at 03:57 PM, CR #1 said she admitted to the facility on [DATE] following a cosmetic surgery to remove excess skin on both her arms with orders to change her bandages every 12 hours. CR #1 said she discharged AMA because for the 2 days she was at the facility she did not receive any wound care and even though she had bloody drainage, her dressing was never changed. An attempt was made to interview LVN A on 01/25/23 at 12:26 PM, a message was left on the voicemail. In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any wounds. She said nurses should immediately order standard wound care orders for monitoring/cleaning/dressing changes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter wound care orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. She said all residents admitted with wounds/surgical incisions should have standard orders entered to clean and monitor the area if the resident did not enter with specific physician orders. The DON said she was unaware of CR #1's wound care orders, but the facility had identified issues with admissions orders associated with the use of agency staff. The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and is currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with wounds, and these orders included tasks needed for care of wounds or surgical incision sites Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services provided by the facility met professional standards of quality for 4 of 8 residents (Resident #1, CR #1, Resident #2 and Resident #4) reviewed for professional standards. - The facility failed to accurately transcribe Resident #1's hospital discharge medications upon admission resulting in the resident receiving the wrong dose of Ethacrynic Acid (a diuretic) from 01/11/23 to 01/20/23 resulting in the resident developing edema (swelling) in her lower leg and discomfort. - The facility failed to monitor Resident #1's weights as ordered by the physician. - The facility administered Ciprofloxacin (an antibiotic) to Resident #1 without an indication or a physician directed order. - The facility failed to enter wound care orders for CR #1 upon admission resulting in the resident not receiving wound care from 01/18/23 to 01/20/23. - The facility failed to enter IV catheter site dressing change orders for Resident #2 upon admission resulting in the resident receiving no dressing changes from 12/30/22 to 01/23/23. - The facility failed to enter IV catheter care and dressing change orders for Resident #4 upon readmission from the hospital resulting in the resident receiving no catheter flushes or dressing changes from 01/17/23 to 01/23/23. - The facility continued to perform NS flushes and Heparin (a blood thinner) locks to Resident #4's IV catheter, that should only be performed when an IV antibiotic is administered , against the MD's orders after IV medications had been discontinued. These failures could place residents at risk of inadequate wound care, infection and, and adverse reactions. Findings Included Resident #1 Record review of Resident #1's Face sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: heart failure, chronic pulmonary edema (fluid buildup in the lungs), stage 5 CKD, and hypertension. Record review of Resident #1's Care Plan last revised 01/25/23 revealed, Focus- the resident has congestive heart failure- compression stockings, ethacrynic acid; Goal- the patient will have no complications r/t peripheral edema (swelling at the extremities) through review date; Interventions- give cardiac medications as ordered, observe and report prn any s/sx of CHF, development of edema of legs and feet, weight gain unrelated to intake Record review of Resident #1`s MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 13 out of 15, limited assistance with most ADLs and occasionally incontinent with both bladder and bowel. Record review Resident #1's facility provided Hospital Discharge Instructions dated 01/09/23 revealed, What- Ethacrynic acid 25 mg oral tablet; how much- 2 tab(s) by mouth; When- 2 times daily; Duration- 30 days; Next dose 01/10/23 at 9 AM. Record review of Resident #1's Order Summary dated 01/09/23 revealed Ethacrynic Acid 25 mg- give 1 tablet by mouth every 12 hours for CHF. Order entered by LVN B. Record review of Resident #1's admission assessment dated [DATE] and signed by LVN B revealed, resident has diagnosis of heart failure- No; Edema Present: No Record review of Resident #1's Medication Reconciliation Form dated 01/09/23 and signed by LVN B revealed, an admission reconciliation was completed and no clinically significant medication issues were identified during reconciliation. Record review of Resident #1's MD Progress Notes dated 01/10/23 revealed, History of Present Illness: Patient was seen sitting up EOB, she is very anxious that her meds were changed at the last hospitalization, and that she is not sure what she is currently on. D/W, that her Lasix (a diuretic) was changed to Ethacrynic acid 2/2 (2 tablets twice a day) to her CKD She says her pain is ok, but her main concerns is the medications. Plan- On Ethacrynic acid, weights MWF, if unable to get ethacrynic acid, cautious use Lasix, would like to first get bmp results back, d/w her that given her previous regiment is what led to her SOB, would be prudent to try and keep on hospital regimen for now . Record review of Resident #1's January 2023 MAR revealed- Ethacrynic acid 25 mg-give 1 tablet by mouth every 12 hours for CHF was administered on: 01/11/23 scheduled for 09:00 PM 01/12/23 scheduled for 09:00 AM and 09:00 PM 01/13/23 scheduled for 09:00 AM and 09:00 PM 01/14/23 scheduled for 09:00 AM and 09:00 PM 01/15/23 scheduled for 09:00 AM and 09:00 PM 01/16/23 scheduled for 09:00 AM and 09:00 PM 01/17/23 scheduled for 09:00 AM and 09:00 PM 01/18/23 scheduled for 09:00 AM and 09:00 PM 01/19/23 scheduled for 09:00 AM and 09:00 PM Record review of Resident #1's January 2023 MAR revealed; Ethacrynic Acid 25 mg- 2 tablet by mouth every 12 hours for swelling for 5 days was first administered on 01/20/22 at 09:00 PM. Record review of Resident #1's Order Summary dated 01/11/23 revealed, Weights MWF- Three times a week every Monday, Wednesday and Friday. Record review of Resident #1's January TAR revealed, resident weight task was documented as performed on 01/11/23, 01/13/23, 01/16/23, 01/18/23, 01/20/23, 01/23/23, 01/25/23. Record review of Resident #1's Physician's Orders dated 01/12/23 at 12:53 PM revealed, Ciprofloxacin 100 mg- give 1 tablet by mouth two times a day related to acute respiratory failure with hypoxia (low blood oxygen). The order was discontinued on 01/13/23 at 12:57 PM. Record review of Resident #1's January 2023 MAR revealed, Ciprofloxacin 100 mg- give 1 tablet by mouth twice a day r/t acute respiratory failure with hypoxia for 10 days was administered for 2 days before the order was discontinued: - 01/12/23 scheduled for 08:00 PM - 01/13/23 scheduled for 08:00 AM. Record review of Resident #1's Weights and Vitals revealed, no weights were documented for Resident #1 for January. Resident #1's vitals indicated no hypoxia, her O2 saturation rate was > 90% during the duration of her residency. Record review of Resident #1's January 2023 Progress Notes revealed, no mention of a prescription for ciprofloxacin, worsening of symptoms, change of conditions, acute respiratory failure, assessments, hypoxia or indication for the use of Ciprofloxacin. Record review of Resident #1's PA Progress Note dated 01/13/23 revealed, Patient is evaluated sitting in WC comfortably. She appears to be no acute distress. Patient notes generally feeling well. No reported coughing, wheezing, shortness of breath. There is no mention of initiating or discontinuing Ciprofloxacin. Record review of Resident #1's MD Progress Note dated 01/17/23 revealed, Physical Exam- no edema. Record review of Resident #1's PA Progress Note dated 01/18/23 revealed, Physical Exam- trace pedal edema (slight swelling due to fluid in the feet). Record review of Resident #1's PA Progress Note dated 01/20/23 revealed. Physical Exam- 1-2+ edema bilateral lower extremity to mid tib (from foot to mid leg). Diagnosis-Assessment-Plan: systemic heart failure- bilateral lower extremity edema noted, cardiopulmonary exam without irregular findings, we will increase Ethacrynic Acid to 50 mg twice a day, Monitor blood pressure. Record review of Resident 1's PA, progress Note dated 01/23/23 revealed, Physical Exam- Trace/1+ bilateral (on both sides) pedal (foot) and ankle edema. Diagnosis-Assessment-Plan: systolic heart failure- lower extremity edema improving with increase of Ethacrynic acid. Record review of Resident #1's MD Progress Note dated 01/24/23 revealed, History of Present Illness- Patient noted to have some increased pedal edema (swelling in the foot); started on increased dose of Ethacrynic acid on 01/20/23. An observation and interview on 01/24/23 at 10:32 AM revealed, Resident #1 lying in bed, the resident appeared well-groomed in no immediate distress with swelling observed on her ankle and foot of both feet. Resident #1 said she was very concerned because she had not been receiving her diuretic as ordered. She said when she was in the hospital she was changed from Furosemide because it was a strain on her kidneys and placed on another diuretic (Ethacrynic Acid) but the facility did not have it for the first 3 days she was there. Resident #1 said when she admitted to the facility from the hospital she never had swelling in her ankle or feet but her feet started swelling because she had not received her diuretic. She said the doctor changed her medication a few days ago so the swelling had improved, but her feet and ankle were much worse before. Resident #1 said she had not been weighed since she admitted to the facility but denied any shortness of breath. In an interview on 01/24/23 at 11:43 AM, the MD said Resident #1 admitted to the facility with CHF. She said that the resident did not tolerate Furosemide so she was changed to Ethacrynic acid in the hospital. The MD said that she entered orders for weights to be performed on Resident #1 MWF to assess for exacerbation of her CHF but she had not seen any weights in the patients record. The MD said failure to monitor weights could reduce the ability to identify CHF exacerbation. The MD said Resident #1 developed edema while admitted to the facility so the PA increased her diuretic, but she had no chest pain or SOB. The MD said the risk of not receiving a diuretic as ordered placed residents at risk of exacerbation of heart failure, SOB and Hypoxia (low oxygen in the blood). In an interview on 02/02/23 at 4:29 PM, the MD said that besides developing edema Resident #1 had not shown any worsening of symptoms like hypoxia and no signs of an infection. She said that her orthopedic surgeon recommend the resident take a prophylactic antibiotic (doxycycline) but to her knowledge there was no indication for Resident #1 to receive any other antibiotics. She said she did not place an order for the resident to receive ciprofloxacin and was not aware the resident received Cipro. In an interview on 02/03/23 at 03:36 PM, the PA said that he increased Resident #1's Ethacrynic Acid 25 mg to 2 tablets twice daily because the resident developed edema and that he was unaware that the resident was supposed to be receiving Ethacrynic Acid 25 mg 2 tablets twice daily as ordered from the hospital. He said failure to receive a diuretic as ordered would place residents at risk for increased edema or exacerbation of their HF but besides the edema the resident did not have any other s/sx like SOB or abnormal lung sounds. The PA said the resident had no signs or indications of infection and he did not place an order for Ciprofloxacin because there was no need for it and he was unaware Resident #1 received 2 doses of Cipro CR #1 Record review of CR #1's face sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] and discharged on 01/20/23 with diagnoses of: encounter for surgical aftercare following surgery on the skin and subcutaneous tissue (innermost layer of the skin) and encounter for cosmetic surgery. Record review of CR #1's MDS dated [DATE] revealed, entrance from an acute hospital stay and independent cognitive skills for daily decision making. Record review of CR#1's Order Details dated 01/20/23 at 06:36 AM revealed, clean bilateral arms sutures with normal saline and cover with DSD, wrap with kerlix and ace wrap twice a day and PRN. Entered by LVN A. There were no orders for wound care or dressing changes entered at admission or before 01/20/23. Record review of CR #1's January 2023 TAR revealed, the resident received no wound care for her duration of her residency from 01/18/23 to 01/20/23. In an interview of 01/23/23 at 03:57 PM, CR #1 said she admitted to the facility on [DATE] following a cosmetic surgery to remove excess skin on both her arms with orders to change her bandages every 12 hours. CR #1 said she discharged AMA because for the 2 days she was at the facility she did not receive any wound care and even though she had bloody drainage, her dressing was never changed. An attempt was made to interview LVN A on 01/25/23 at 12:26 PM, a message was left on the voicemail. Resident #2 Record review of Resident #2's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis which included; Cellulitis (skin infection) of the left lower limb, and cutaneous abscess of the left lower limb. Record review of Resident #2's Care Plan dated 01/13/23 revealed, Focus- resident has infection, Interventions- administer antibiotics as per MD order. Record review of Resident #2's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #2's Order Summary dated 01/25/23 at 04:39 AM revealed, Midline (a catheter inserted in the upper arm used to administer medication) to right arm entered 01/11/23. The resident did not have any orders to monitor the midline, or changed the midline dressing until 01/24/23. Record review of Resident #2's Orders dated 12/30/22 revealed, Ertapenem 1 gm intravenously every 24 hours for infection for 36 days. Record review of Resident #2s December 2022 MAR dated 01/25/23 revealed, no documented dressing change for the resident's midline. Record review of Resident #2's January 2023 MAR dated 01/25/23 revealed, the only day in January Resident #1's midline dressing was changed was on 01/24/23 during the night shift. An observation on 01/24/23 at 01:57 PM revealed, Resident #2 lying in bed. The resident appeared well fed, well dressed, in no immediate distress with an IV site to her left upper arm. The IV dressing appeared in tact, with no visible labeling. Dark old blood could be observed around the site at which the catheter entered the resident's arm. Resident #2 said she was receiving antibiotics via an IV site on her right arm and she could not remember when her dressing was last changed. Resident #4 Record review of Resident #4's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included: Osteomyelitis (bacterial bone infection) with an onset date of 11/21/22, streptococcal infection, UTI infection with an onset date of 01/17/22 (active on readmission ), and suspected carrier of MRSA (a drug resistant bacteria). Record review of Resident #4's Care Plan printed 01/25/23 at 05:04 AM revealed, Focus- expresses pain/ discomfort, Goal- resident will express pain relief through the review date, Intervention- pain meds as ordered. The resident's use of IV antibiotics was not included in the patient's care plan. Record review of Resident #4's MDS dated [DATE] revealed, no documented BIMS score, no documented assessment of cognitive skills for daily decision making, extensive assistance for most ADLs, presence of an indwelling urinary catheter and always incontinent of bowel. Record review of Resident #4's Progress Notes dated 01/10/23 at 6:09 PM revealed, resident discharged to the hospital increased confusion, blood in catheter tubing/urine and an elevated WBC (an indication of infection) of 33.1. Record review of Resident #4's Physician Orders dated 01/18/23 at 1:50 AM revealed, Cefepime (an antibiotic) 1 gm/50 ml- give 1 gram intravenously two times a day to other acute osteomyelitis unspecified site until 01/24/23. Record review of Resident #4's Progress Notes dated 01/24/23 at 1:48 PM revealed, Double lumen PICC ( an IV catheter with more than one internal [NAME]) line dressing changed to right upper arm and tolerated well. No visible signs of pain noted at this time. Record review of Resident #4's Order Summary Report dated 01/25/23revealed, prior to discharge from the hospital on [DATE] the resident had orders for the maintenance of her IV catheter: - Heparin Lock Flush 10 unit/ml- use 5 ml intravenously every shift for antibiotic use, flush line after post medication with NS flush. This order was discontinued on 01/16/23 while Resident #4 was in the hospital. Record review of Resident #4's Physician's Orders dated 01/24/23 revealed, the resident had no PICC line care orders from 01/17/23 until 01/23/23. The following orders were entered on 01/24/23 after the surveyor notified the facility of missing catheter orders: Change PICC line transparent dressing weekly every Wed Measure upper arm circumference (10cm above antecubital). Measure external catheter length. Notify if length has changed since last measurement., Change IV administration tubing every day shift every 24 hours, Change needleless connector as needed, Observe PICC line insertion site every shift for s/s of infection. Notify MD accordingly. Normal Saline Flush Solution (Sodium Chloride Flush) Use 10 ml intravenously every shift Flush PICC line after medication. Normal Saline Flush Solution (Sodium Chloride Flush) Use 10 ml intravenously every shift Flush PICC line before medication. Heparin Lock Flush Solution 10 UNIT/ML Use 5 ml intravenously every shift for flush, Flush PICC line Record review of Resident #4's January 2023 MAR revealed, no dressing changes occurred to Resident #4's IV catheter site from readmission [DATE]) till after the facility was notified by the surveyor on 01/24/23. No heparin flushes were performed on Resident #4's IV catheter from readmission [DATE]) until after the facility was notified by the surveyor on 01/24/23. No NS flushes were performed on Resident #4's IV catheter from readmission [DATE]) until after the facility was notified by the surveyor on 01/24/23. Record review of Resident #4's January 2023 MAR revealed, nursing staff continued to perform a Heparin Lock Flush on Resident #4 IV catheter after the resident completed her IV antibiotic course on 01/24/23 even though the MD order specified the flush was only to be performed after the post-medication NS flush. - 01/25/23 scheduled for the night shift was performed - 01/26/23 scheduled for the night shift was performed - 01/27/23 to 01/29/23 scheduled for the morning and night shifts were performed - 01/30/23 scheduled for the morning shift was performed Record review of Resident #4's January 2023 MAR revealed, nursing staff continued to perform NS flushes on Resident #4's IV catheter after the resident completed her IV antibiotic course on 01/24/23 even though the MD order specified the NS flushes were only to occur before and after medications. - 01/25/23 scheduled for the night shift was performed - 01/26/23 scheduled for the night shift was performed - 01/27/23 to 01/29/23 scheduled for the morning and night shifts were performed - 01/30/23 scheduled for the morning shift was performed An observation and interview on 01/24/23 at 11:10 AM revealed, Resident #4 lying in bed well dressed, well fed and in no immediate distress. Resident had an IV catheter on her right upper arm with no visible date. Resident #4 said that she was receiving IV antibiotics and her dressing had not been changed since she readmitted to the facility (01/17/23). In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any wounds or IV catheter sites. She said nurses should immediately enter standard wound care orders for monitoring/cleaning/dressing changes and IV catheter sites should have scheduled dressing changes as well as flushes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter wound care or IV catheter site related orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. She said all residents admitted with wounds/surgical incisions should have standard orders entered to clean and monitor the area if the resident did not enter with specific physician orders. The DON said she was unaware of the missing IV catheter care orders for Resident #2 and Resident #4 and CR #1's wound care orders, but the facility had identified issues with admissions orders associated with the use of temporary staff from a staffing agency . The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and is currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with wounds, or IVs and these orders included tasks needed for care of wounds or IV catheter sites. Record review of the facility provided policy titled Admissions Policy revised 01/05/23 revealed, no specific directions for processing admissions orders. Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for managing catheter sites and surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites Record review of facility provided list of batch orders dated 01/24/23 revealed: IV: Midline Catheter Orders- change site transparent dressing admit, at least every 7 days/PRN . observe every shift with intermittent therapy or when not in use . IV: PICC line orders- Change IV administration tubing every 24 hrs change PICC line dressing on admission change PICC line transparent dressing weekly/PRN . observe line insertion site every shift for signs and symptoms of infection . flush line with 10 ml NS before medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to administer parenteral fluids consistent with professional standards of practice and care plans for 2 of 8 resident (Resident #2 and Resident #4) reviewed for parenteral intravenous (IV) antibiotic care and services through a peripherally inserted central catheter (PICC) therapy in that: - The facility failed to provide care or dressing changes to Resident #2's IV catheter site from 12/30/22 to 01/23/23. - The facility failed to provide care or dressing changes to Resident #'s 4 IV catheter site from 01/17/23 to 01/23/23. These failures could place residents at risk for adverse reactions, deterioration of wounds and infection. Resident #2 Record review of Resident #2's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnosis which included; Cellulitis (skin infection) of the left lower limb, and cutaneous abscess of the left lower limb. Record review of Resident #2's Care Plan dated 01/13/23 revealed, Focus- resident has infection, Interventions- administer antibiotics as per MD order. Record review of Resident #2's MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 15 out of 15, extensive assistance with most ADLs, occasionally incontinent of bladder and always continent of bowel. Record review of Resident #2's Order Summary dated 01/25/23 at 04:39 AM revealed, Midline to right arm entered 01/11/23. The resident did not have any orders to monitor the midline, change the midline or change the midline dressing until 01/24/23. Record review of Resident #2 December 2022 MAR revealed, no documented dressing change for the resident's midline. Record review of Resident #2's January 2023 MAR dated 01/25/23 revealed, between 01/01/23 to 01/23/23 there were no documented dressing changes performed to Resident #2's PICC line. The only day in January Resident #1's midline dressing was changed was on 01/24/23 during the night shift. An observation on 01/24/23 at 01:57 PM revealed, Resident #2 lying in bed. The resident appeared well fed, well dressed, in no immediate distress with an IV site to her left upper arm. The IV dressing appeared in tact, with no visible labeling. Dark old blood could be observed around the site at which the catheter entered the resident's arm. Resident #2 said she was receiving antibiotics via an IV site on her right arm and she could not remember when her dressing was last changed. Resident #4 Record review of Resident #4's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included: Osteomyelitis (bacterial bone infection) with an onset date of 11/21/22, Streptococcal infection, UTI infection with an onset date of 01/17/22 (active on readmission ), and carrier pr suspected carrier of MRSA (methicillin antibi biotic resistant bacterial infection). Record review of Resident #4's Care Plan saved 01/25/23 at 05:04 AM revealed, Focus- expresses pain/ discomfort, Goal- resident will express pain relief through the review date, Intervention- pain meds as ordered. The resident's use of IV antibiotics was not included in the patient's care plan. Record review of Resident #4's MDS dated [DATE] revealed, no documented BIMS score, no documented assessment of cognitive skills for daily decision making, extensive assistance for most ADLs, presence of an indwelling urinary catheter and always incontinent of bowel. Record review of Resident #4's Progress Notes dated 01/10/23 at 6:09 PM revealed, resident discharged to the hospital increased confusion, blood in catheter tubing/urine and an elevated WBC of 33.1. Record review of Resident #4's Physician Orders dated 01/18/23 at 1:50 AM revealed, Cefepime (an antibiotic) 1 gm/50 ml- give 1 gram intravenously two times a day to other acute osteomyelitis unspecified site until 01/24/23. Record review of Resident #4's Physician's Orders dated 01/24/23 revealed, no PICC line care orders from 01/17/23 to 01/23/23., The following orders were entered after the surveyor notified the facility of missing catheter orders on 01/24/23: Change PICC line transparent dressing weekly every Wed Measure upper arm circumference (10cm above antecubital). Measure external catheter length. Notify if length has changed since last measurement., Change IV administration tubing every day shift every 24 hours, Change needleless connector as needed, Observe PICC line insertion site every shift for s/s of infection. Notify MD accordingly. Record review of Resident #4's Progress Notes dated 01/24/23 at 1:48 PM revealed, Double lumen PICC ( an IV catheter with more than one internal channel) line dressing changed to right upper arm and tolerated well. No visible signs of pain noted at this time. Record review of Resident #4's January 2023 MAR revealed, no dressing changes occurred to Resident #4's IV catheter site from readmission [DATE]) till after the facility was notified by the surveyor on 01/24/23. An observation and interview on 01/24/23 at 11:10 AM revealed, Resident #4 lying in bed well dressed, well fed and in no immediate distress. Resident had an IV catheter on her right upper arm with no visible date. Resident #4 said that she was receiving IV antibiotics and her dressing had not been changed since she readmitted to the facility (01/17/23). In an interview on 01/24/23 at 1:24 PM, the DON said when any resident admits to the facility, the admitting nurse is responsible for completing an initial assessment with the patient identifying any IV catheter sites. She said nurses should immediately order standard orders for residents admitting with IVs and IV catheter sites should have scheduled dressing changes as well as flushes. The DON said that the admitting nurse is responsible for ensuring admitting orders are entered correctly but the DON is responsible for auditing orders to ensure all orders are entered correctly. She said failure to enter IV catheter site related orders could place residents at risk of infection. The DON said all nursing services should be provided pursuant to a physicians order and providing care against orders could place residents at risk for adverse reactions. In an interview on 02/06/23 at 12:26 PM, the DON said at admissions nursing staff should follow the admissions checklist to ensure that medication and physicians orders are entered to meet the needs of the residents. The DON said she was unaware of the missing IV catheter care orders for Resident #2 and Resident #4, but the facility had identified issues with admissions orders associated with the use of temporary nurses from staffing agencies. The DON said she was responsible for ensuring that admissions orders are entered correctly by admissions nurses, she was behind on her audits and she was currently catching up on them. She said she has initiated in-service training with nursing staff about entering admissions orders and using the admissions checklist since there was no specific facility procedure guide for entering admissions orders. The DON said batch orders should be used when admitting residents with IVs and these orders included tasks needed for care IV catheter sites. Record review of the facility provided policy titled Areas of Focus: Basic Skin Management revised 11/28/22 revealed, no directions for managing catheter sites and surgical incision sites. The policy only addressed pressure ulcers. Record review of the facility provided policy titled Areas of Focus: Wound Assessment and Wound Report revised 11/28/22 revealed, New admissions and new wounds need timely assessment/documentation and treatments implemented preferably at time of admission or within 24 hrs There were no specific directions for managing catheter sites and surgical incision sites Record review of facility provided list of batch orders dated 01/24/23 revealed IV: Midline Catheter Orders- change site transparent dressing admit, at least every 7 days/PRN . observe every shift with intermittent therapy or when not in use . IV: PICC line orders- Change IV administration tubing every 24 hrs change PICC line dressing on admission change PICC line transparent dressing weekly/PRN .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 3 of 8 residents (Resident#1, Resident #3 and Resident #4) reviewed for pharmaceutical services. - The facility failed to acquire and dispense Ethacrynic Acid 25 mg , a diuretic, to Resident #1 as ordered from 01/09/23 to 01/11/23 . - The facility failed to acquire and dispense Oxycodone 80 mg , a pain medication, to Resident # 4 as ordered from 01/20/23 to 01/22/23 leaving the resident in pain. - The facility failed to acquire and administer IV antibiotic Cefepime and Vancomycin as ordered to Resident #4 for a bone infection with antibiotic resistant bacteria. - The facility failed to timely investigate Resident #3's IV medication error and to timely put measures in place to prevent future medication errors. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Resident #1 Record review of Resident #1's Face sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: heart failure, chronic pulmonary edema (fluid buildup in the lungs), stage 5 CKD, and hypertension. Record review of Resident #1's Care Plan last revised 01/25/23 revealed, Focus- the resident has congestive heart failure- compression stockings, ethacrynic acid; Goal- the patient will have no complications r/t peripheral edema (swelling at the extremities) through review date; Interventions- give cardiac medications as ordered, observe and report prn any s/sx of CHF, development of edema of legs and feet, weight gain unrelated to intake Record review of Resident #1`s MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 13 out of 15, limited assistance with most ADLs and occasionally incontinent with both bladder and bowel. Record review of Resident #1's Order Summary dated 01/09/23 revealed Ethacrynic Acid 25 mg- give 1 tablet by mouth every 12 hours for CHF. Order entered by LVN B. Record review of Resident #1's January MAR revealed, Resident #1 did not receive Ethacrynic Acid on the following days because the medication was not available: 01/09/23 scheduled for 09:00 AM 01/10/23 scheduled for 09:00 AM and 9 PM 01/11/23 scheduled for 09:00 AM An observation and interview on 01/24/23 at 10:32 AM revealed, Resident #1 lying in bed, the resident appeared well fed, well-groomed in no immediate distress with swelling observed on her ankle and foot of both feet. Resident #1 said she was very concerned because she has not been receiving her diuretic as ordered. She said when she was in the hospital she was changed from Furosemide because it was a strain on her kidneys and placed on another medication( Ethacrynic Acid) but the facility did not have it for the first 3 days she was there. Resident #1 said when she admitted to the facility from the hospital she never had swelling in her ankle prior to admission to the facility or feet but her feet started swelling because she had not received her diuretic. She said the doctor changed her diuretic (Ethacrynic Acid) a few days ago so the swelling had improved, but her feet and ankle were much worse before. In an interview on 01/24/23 at 11:43 AM, the MD said Resident #1 admitted to the facility with CHF. She said that the resident did not tolerate Furosemide so she was changed to Ethacrynic acid and when Resident #1 admitted the facility did not have the medication available for administration because it didn't arrive from the pharmacy. The MD said Resident #1 experienced stress due to her missed medications which resulted in her BP being elevated. She said the resident later developed edema while admitted to the facility so the PA increased her diuretic, but she had no chest pain or SOB. The MD said the risk of not receiving a diuretic as ordered placed residents at risk of exacerbation of heart failure, SOB and Hypoxia (low oxygen in the blood). In an interview on 01/25/23 at 1:29 PM, the Pharmacist said the first delivery for Resident #1's Ethacrynic acid was on 01/11/23 and signed by LVN C at 10:18 PM. Resident #4 Record review of Resident #4's Face Sheet dated 01/25/23 revealed, a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included: Osteomyelitis (bacterial bone infection) with an onset date of 11/21/22, Streptococcal infection, UTI infection with an onset date of 01/17/22 (active on readmission ), and a suspected carrier of MRSA. Record review of Resident #4's Care Plan printed 01/25/23 at 05:04 AM revealed, Focus- expresses pain/ discomfort, Goal- resident will express pain relief through the review date, Intervention- pain meds as ordered. The resident's use of IV antibiotics was not included in the patient's care plan. Record review of Resident #4's MDS dated [DATE] revealed, no documented BIMS score, no documented assessment of cognitive skills for daily decision making, extensive assistance for most ADLs, presence of an indwelling urinary catheter and always incontinent of bowel. Record review of Resident #4's Physician Orders dated 01/18/23 at 1:50 AM revealed, Cefepime (an antibiotic) 1 gm/50 ml- give 1 gram intravenously two times a day to other acute osteomyelitis unspecified site until 01/24/23. Oxycodone ER 80 mg- give 1 tablet by mouth every 12 hours as needed for pain. Vancomycin 1 gm intravenously at bed time for wound infection until 01/24/23. Record review of Resident #4's January MAR revealed, Resident #4 did not receive her Cefepime antibiotic for 7 out of 14 doses scheduled between 01/18/23 to 01/24/23. - Non administered on 01/19/23 for the 08:00 PM dose. - Non administered on 01/20/23 for the 08:00 PM dose. - Non administered on 01/21/23 for the 08:00 AM dose. - Non administered on 01/22/23 for the 08:00 PM dose. - Non administered on 01/23/23 for the 08:00 PM dose. - Non administered on 01/24/23 for the 08:00 AM and 8:00 PM dose. Record review of Resident #4's Progress Notes dated 01/22/23 at 10:00 AM revealed, Writer went to resident's room to give her scheduled medication and resident requested PRN pain medication at this time. Gave resident PRN oxycodone 5mg and resident stated that she wanted Oxycodone 80mg. Informed resident that medication is unavailable at this time that I will have to call MD. Resident started to yell and curse writer out and calling degrading names. Redirected resident to not yell and degrade and she continues to yell stating I better give her medication right now otherwise she is leaving her and going to report me. Resident started to throw thing in room and says she will continue to yell and throw things if she has to break the window she will. Record review of Resident #4's Progress Notes dated 01/22/23 at 11:10 PM revealed, the PA was notified that Resident #4 did not have her Oxycodone 80 mg . Informed resident that MD is calling her medication into pharmacy and will be available soon. Resident stated that was not good enough. Record review of Resident #4's January MAR revealed, Resident #4 did not receive any Oxycodone 80 mg from 01/20/23 to 01/22/23. Record review of Resident #4's January MAR revealed, Resident #4 did not receive her 11 PM scheduled dose of Vancomycin on 01/19/23. In an interview on 01/23/23 at 12:09 PM, Agency Nurse #1 said she was unable to administer Vancomycin to Resident #4 on 01/19/23 because the medication was not available. She said Resident #4 asked for pain medication but there was non available in the facility. An observation and interview on 01/24/23 at 11:10 AM revealed, Resident #4 lying in bed well dressed, well fed and in no immediate distress. Resident #4 had an IV catheter on her right upper arm with no visible date. Resident #4 said that she was receiving IV antibiotics. She said over the weekend (01/20/23 to 01/21/23) she was in intense pain and the facility did not have her Oxycontin 80 mg tablet. Resident #4 said over the weekend the facility had agency nurses who did not understand her pain control regimen. Resident #4 said she was receiving antibiotics but did not know the facility failed to administer any doses of her antibiotics. In an interview on 01/24/23 at 11:25 AM, LVN B said Resident #4 informed her that over the weekend of 01/20-01/21/23 she was in pain because she did not receive her Oxycodone 80 mg. In an interview on 01/24/23 at 11:43 AM, the MD said she was informed that the facility did not have Oxycodone 80 mg for Resident #4 over the weekend because it did not arrive from the pharmacy. She said the resident complained to her about not receiving the medication and being in pain. She said failure to provide pain medication as ordered could place residents at risk for inadequate pain management. In an interview on 01/25/23 at 01:29 PM, the Pharmacist said the pharmacy delivered 14 tablets of Oxycodone 80 mg on 01/24/23 at 11:08 PM. In an interview on 02/02/23 at 04:29 PM, the MD said the facility did not notify her any missed IV antibiotic doses for Resident #4 and it was her expectation that nursing staff inform her or the PA about any medication administration discrepancies. The MD said Resident #4 appeared clinically stable with no elevated temperatures or signs of wound deterioration but failure to administer IV antibiotics as ordered could place the resident at risk of worsening of infection or the development of resistance to the antibiotic being used. In an interview on 02/06/23 at 12:26 PM, the DON said that she was hospitalized during the period in which Resident #1 did not receive her diuretic and she was unaware of the specifics of that incident. She said nursing staff are responsible for entering medication orders into the EMR system which is interconnected to the pharmacy system. She said once an order is entered the pharmacy immediately processes the order for delivery but if the medication is not received, nursing staff can retrieve medication from the EKit or order a stat delivery from the pharmacy. The DON said she was unaware that Resident #4 did not receive her IV antibiotics as scheduled nor was she aware that Resident #4's pain medication was unavailable from 01/20/23 to 01/24/23. The DON said failure to administer IV antibiotics, diuretics and pain medication as ordered places residents at risk of decreased efficacy of the antibiotic treatment leading to infection, uncontrolled pain and exacerbation of CHF. Resident #3 Record review of Resident #3's Face Sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: sepsis (bacterial blood infection) unspecified organism, acute respiratory failure with hypoxia, hypertension, pressure ulcer of sacral region and unspecified bacterial pneumonia. Record review of Resident #3's Care Plan dated 01/24/23 revealed, focus- infection sepsis/bacteremia pneumonia; intervention- medication as ordered. Record review of Resident #3's MDS dated [DATE] and completed 01/25/23 revealed, no BIMS assessment, no assessment of cognitive patterns, antibiotic use, extensive assistance with most ADLs and always incontinent of both bladder and bowel. Record review of Resident #3's Order Summary Report dated 01/25/23 revealed, Meropenem (antibiotic) intravenous solution- use 500 mg intravenously every 8 hours for sepsis for 42 days. Record review of Resident #3's January MAR revealed, LVN E administered Resident #3's scheduled dose of IV Meropenem antibiotics on 01/16/23 at 06:30 AM. Record review of Resident #3's Progress Notes dated 01/17/23 at 5:07 PM revealed- LVN D found a bag of antibiotics belonging to another resident that was administered by LVN E to Resident #3 on 01/16/23. The resident was on Meropenem but LVN D found Ertapenem was administered to Resident #3. MD notified and she said ok to continue to monitor. Record review of Resident #3's January Clinical Assessments revealed- no assessments were documented following the medication error. Record review of Resident #3's January Progress notes revealed, no further documentation/assessments/notes about Resident #3's medication error. Record review of the Facility Incident Report dated 01/24/23 revealed, Resident #3 had a medication discrepancy incident on 01/17/23 at 04:57 PM. In an interview on 01/24/23 at 11:43 AM, the MD said she was informed that Resident #3 received Ertapenem instead of Meropenem, but she was not informed of whose medication Resident #3 received. The MD said that Resident #3 experienced no side effects or ADRs and she instructed LVN D to submit a report for the medication error. The MD said she had not heard any increase patient concerns about medication errors nor has she observed an increase in medication errors in the facility. An attempt was made to interview LVN D on 01/24/23 at 2:00 PM but staff was out sick. In an interview on 01/25/23 at 3:26 PM, the DON said Resident #3 received another patient's antibiotic on 01/17/23 but she had not completed her investigation of the incident. She said that she did not know whose medication Resident #3 received, nor did she know the individual who administered the medication to Resident #3. The DON could not provide details as to how the error occurred but said she provided an in-service to staff about medication errors. She could not provide further details on what the in-service about medication errors covered and could not state what corrective action was taken since she was still investigating the allegation. The DON said since the antibiotic Resident #3 received was in the same class as what was prescribed she believed the medication error was not a risk to the patient. An attempt was made to interview LVN D on 01/26/23 at 3:07 PM, revealed the facility provided contact number was disconnected. An attempt was made to interview LVN D on 02/06/23 at 11:23 AM, revealed the facility provided contact number was disconnected. In an interview on 02/06/23 at 02:10 PM, the Administrator said medication errors are expected to be investigated promptly within 24 hours to identify what caused the error and to put measures in place to prevent the reoccurrence. Record review of the facility policy titled Incident and Reportable Event Management revised 06/17/22 revealed, to help reduce the risk of an event, all residents receive assistance and supervision as addressed in their care plan. If an event occurs, the facility will follow the 5 Is in an effort to minimize the potential for recurrence. 1- Incident (what happened or was reported as happening), 2- Injury (provide care and document the injury), 3- Interview (who saw the resident last or at the time of the event), 4- Investigated (why did it happen), 5- Intervention (what mitigation effort are we using). Event management includes, but is not limited to, the following type of events: Medication Discrepancy. Record review of the facility policy titled Administration of Medications revised 08/25/22 revealed, The facility will ensure medications are administered safely and appropriately per physician's order to address residents' diagnosis and signs and symptoms. The documented contained no specific instructions on medication acquisition. Record review of the facility policy titled General Dose Preparation and Medication Administration revised 01/01/13 revealed, no specific instructions on medication acquisition. Record review of the facility provided inventory list titled EKit Contents dated 01/18/23 revealed, there was no Ethacrynic Acid or Oxycodone contained in the emergency kit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain medical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 5 residents (Resident #1 and Resident #4) whose records were reviewed for accuracy and completeness. - The facility failed to document accurately in Resident #1's EMR by documenting the performance of weights that were not performed. - Facility staff failed to document accurately in Resident #1's and #4's EMR by using log in credentials assigned to other users. These failures could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings Include: Resident #1 Record review of Resident #1's Face sheet dated 01/25/23 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: heart failure, chronic pulmonary edema (fluid buildup in the lungs), stage 5 CKD, and hypertension. Record review of Resident #1's Care Plan last revised 01/25/23 revealed, Focus- the resident has congestive heart failure- compression stockings, ethacrynic acid; Goal- the patient will have no complications r/t peripheral edema (swelling at the extremities) through review date; Interventions- give cardiac medications as ordered, observe and report prn any s/sx of CHF, development of edema of legs and feet, weight gain unrelated to intake Record review of Resident #1`s MDS dated [DATE] revealed, use of corrective lenses, intact cognition as indicated by a BIMS score of 13 out of 15, limited assistance with most ADLs and occasionally incontinent with both bladder and bowel. Record review of Resident #1's Order Summary dated 01/11/23 revealed, Weights MWF- Three times a week every Monday, Wednesday and Friday. Record review of Resident #1's January TAR revealed, resident weight task was documented as performed on 01/11/23, 01/13/23, 01/16/23, 01/18/23, 01/20/23, 01/23/23, 01/25/23. Record review of Resident #1's Weights and Vitals revealed, no weights were documented for Resident #1 for the entire month of January An observation and interview on 01/24/23 at 10:32 AM revealed, Resident #1 lying in bed, the resident appeared well-groomed in no immediate distress with swelling observed on her ankle and foot of both feet. Resident #1 said she had not been weighed since she admitted to the facility In an interview on 02/06/23 at 12:26 PM, the DON said weights are performed by CNAs and not Nurses, so documentation of weights being performed in the nursing MAR would not be an accurate reflection of the task being performed. Credential Use Record review of the facility schedule dated 01/19/23 revealed, Agency Nurse #1 was scheduled to work the 4th floor on the 06:00 PM to 06:00 AM shift. Record review of Agency Nurse #1's payroll punches dated 01/19/23 revealed, she started her shift in at 06:12 PM on 01/19/23 and ended her shift at 06:08 AM on 01/20/23. Record review of the facility schedule dated 01/19/23 revealed, LVN B was scheduled to work the 4th floor on the 06:00 AM to 06:00 PM shift. Record review of LVN B's payroll punches dated 01/19/23 revealed, she started her shift on 06:04 AM and ended her shift at 07:04 PM. Resident #1 Record review of Resident #1's MAR dated 01/19/23 reveled, LVN B was documented as administering medications when she was clocked out and no longer in the building: - Doxycycline 100 mg, 1 tablet every 12 hours- dose scheduled for 09:00 PM administered by LVN B. - Trazodone 50 mg, 1 tablet for insomnia- administered at 10:08 PM by LVN B. - Bio freeze external gel (a topical analgesic)- dose scheduled for 08:00 PM administered by LVN B. - Calcium Carbonate 600 ( a dietary supplement) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Carvedilol 12.5 mg ( for high blood pressure) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Ethacrynic Acid 25 mg (a diuretic) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Nifedipine ER 30 mg ( for high blood pressure) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. - Senna 8.6 mg ( for constipation) 1 tablet- dose scheduled for 09:00 PM administered by LVN B. Resident #4 Record review of Resident #4's MAR dated 01/19/23 reveled, LVN B was documented as administering medications when she was clocked out and no longer in the building: - Xanax 1 mg (for anxiety) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Apixaban 5 mg (blood thinner) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Nortriptyline 50 mg (for high blood pressure) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Atorvastatin 20 mg (for cholesterol) 1 tablet- dose scheduled for 08:00 PM administered by LVN B. - Gabapentin 800 mg (for nerve pain) 1 tablet- dose scheduled for 08:00 PM administered by LVN B.- In an interview on 01/23/23 at 12:09 PM, Agency Nurse #1 said she was scheduled to work the evening overnight shift on 01/19/23 and received an email from the administrator sending that included a user name to access the EMR but she never received a password. She said she was informed her password was the same as previously used at another facility but to her knowledge she had not worked at any of the sister facilities. Agency Nurse #1 said she made attempts to contact the DON by phone on multiple occasions during her shift but she was unsuccessful so when she arrived at the facility the day shift nurse (LVN B) provided her log in credentials on a sheet of paper, so she documented under the day shifts nurse credentials for the beginning of the shift. Agency Nurse #1 said that at some point during her shift she lost the sheet of paper with the log in credentials resulting in her having no access to the EMR and being unable to document any tasks completed or administration any medications from 04:00 AM to 06:00 AM. In an interview on 01/24/23 at 11:25 AM, LVN B said the facility has been using a lot of agency staff as of late. She said at the end of the previous week there was an agency nurse (a temporary nurse provided through a staffing agency) who did not have access to the EMR so she had no choice but to provide the agency nurse her log in credentials on a sheet of paper so patient care could be completed. LVN B said that she and the agency nurse attempted to get in touch with management to get the appropriate EMR access but they were unsuccessful. In an interview on 01/25/23 at 03:26 PM, the DON said that facility staff are expected to document timely and accurately. She said documentation should paint a picture of the resident's state and include: vitals, pertinent information, concerns, assessments and communications with physicians. She said that nursing staff must use their own credentials to document in each resident's EMR and failure to do so would result in inaccurate medical records. The DON said she was unaware of a situation in which an agency nurse was forced to use a full time nurse's login credentials or unable to perform medication administration due to not receiving access to the EMR from the Administrator. She said failure to document timely and accurately placed residents at risk of not having a true picture of their status resulting in adequate care. In an interview on 01/25/23 at 03:26 PM, the Administrator said that nursing staff, including agency staff, have individual log ins and are expected to chart with their unique identifiers. She said prior to any agency staff's first shift an EMR access is created and it is emailed to the staff. The Administrator said that she was not aware of agency staff using full time staff log in credentials, and that each user must use their individually assigned credentials because accurate documentation must include the person who actually completed the task. She said by nursing staff using another person's credentials resident would result in inaccurate administration/task completion records and was against facility policy. The Administrator said she was unaware of she was unaware of a situation in which an agency nurse was forced to use a full time nurse's login credentials or unable to perform medication administration due to not receiving access to the EMR. She said that she was responsible for ensuring all agency nurses received access to the EMR and she personally sent the email with their login credentials. The DON said she was available by email or phone and there was a 24 hours line that nursing staff could contact if they had problems accessing the EMR . The Administrator said the inappropriate use of EMR credentials could place residents at risk for inadequate medical records. Record review of the facility policy titled Computer and Electronic Communications with no revision date revealed, Associates must not share their user name or password with anyone, including supervisors, other associates and family members. Record review of the facility policy titled Nursing Documentation revised 05/07/21 revealed, Staff must document a resident's medical and non-medical status when any positive or negative condition change occurs . The medical record must also reflect the resident's condition and the care and services provided across all disciplines . The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress .