**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interviews and record review the facility failed ensure residents were free of any significant medication errors for 1 (Resident # 1) of 6 reviewed for significant medication errors. The facility failed to ensure Resident #1 received his prescribed medications. According to residents' #1 MAR the missed medications are: clopidogrel prescribed for atrial fibrillation, flomax prescribed for prostate, flonase prescribed for allergies, isosorbide mononitrate prescribed for angina, nifedipine for hypertension, levothyroxine for thyroid, pantoprazole for peptic ulcer, furosemide for edema, lubiprostone for constipation, metoprolol for hypertension, sucralfate for peptic ulcer, and ranolazine for myocardial infarction/chest pain. According to the physicians' orders on 06/10/25 - 06/11/25, MA D and MA F failed to ensure that Resident #1 was free of a medication error. This failure could place residents at risk of serious harm, up to and including death. Findings included: A record review of Resident #1's face sheet dated on 07/08/25 reflected that a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 had diagnoses that included of congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs, Non-ST (a serious heart attack that occurs when blood supply to the heart is reduced, causing damage) Segment Elevation Myocardial Infarction (NSTEMI) (a serious heart attack that occurs when blood supply to the heart is reduced, causing damage), hypertension (a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and chronic obstructive pulmonary disease (COPD) (a lung disease characterized by chronic respiratory symptoms and airflow limitation). On 6/12/25, Resident #1 was discharged to the emergency room due to him having chest pain and the facility had failed him by not providing prescribed medications. Review of Resident #1's baseline care plan dated 06/10/25 reflected, Resident #1 was not to self-administer medications.Review of Resident #1's MDS dated [DATE] reflected a BIMS score response was locked, and no BIMS score was not available. A record review for Resident's #1 comprehensive care plan, was not able to be reviewed. Resident #1 was at the facility for two days; a care plan was not yet in place. Review of Resident #1's MAR dated as schedule for June 2025 reflected on 07/11/25 resident had missed doses of clopidogrel, flomax, flonase, isosorbide mononitrate, nifedipine, levothyroxine, pantoprazole, furosemide, lubiprostone, metoprolol, sucralfate, and ranolazine which included medications prescribed to treat Resident #1 for atrial fibrillation, chest pain, hypertension, edema, congestive heart failure, and non - ST elevation myocardial infarction. Next to the medications, MA D and MA F noted 9 which indicated 9 = Other / See Progress Notes. Record review of Resident #1's progress notes dated 06/11/25 at 9:30 AM by MA D reflected the note had been struck out but read Declined Order - N/A. Record review of Resident #1's progress notes by dated 06/11/25 at 8:11 PM by MA F reflected Awaiting Arrival. A record review of Resident's #1 clinical physician's orders dated 06/10/25 reflected that Resident #1 was prescribed furosemide. A record review of Resident's #1 clinical physician's orders dated 06/11/25 reflected that Resident #1 was prescribed clopidogrel, flomax, flonase, isosorbide mononitrate, nifedipine, levothyroxine, pantoprazole, lubiprostone, metoprolol, sucralfate, and ranolazine. During an interview on 07/08/25 at 9:44 AM with the FM, she stated Resident #1 was in the facility on 06/12/25 and she got a call around 2 AM that resident had to go to the hospital for chest pain. She stated she found out from the facility that resident had missed some of his heart medications which included his newly ordered clopidogrel. She stated the doctor at the hospital had told her he thought that resident missing his clopidogrel is what could have caused him to have chest pain. She stated Resident #1 had discharged home with around the clock sitters after he left the hospital. In an attempt on 07/08/2025 at 10:45 AM to call the MD, he was unable to take a call at that time, detailed message was left for a return call. In an attempt on 07/08/2025 at 1:22 PM to call the MD, he was unable to take a call at that time, detailed message was left for a return call. In an interview on 07/08/25 at 1:49 PM, MA C stated she had worked in the facility for about 7 months. She stated she was in-serviced on medication administration. She stated she had not had any concerns with medication being unavailable to administer to the residents. She stated if a medication was not available, she would let the nurse know and they would get it. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could cause death. During an interview on 07/08/25 at 1:57 PM, MA D stated she had worked in the facility for about 4 years. She stated she was in-serviced on medication administration. She stated she has not had any concerns with medication being unavailable to administer to the residents. She stated they keep the medications ordered and coming in pretty good and they also have the emergency kit that they can use when needed. She stated if the emergency kit had not had a medication they needed, they marked the MAR as unavailable and called the pharmacy or hospice and notified the nurse. She stated if a resident missed doses of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused a stroke or heart attack. She stated if there was a 9 placed in a spot on the MAR, it meant the medication, or the resident was not available. She stated she was the MA that marked the 9 on Resident #1's MAR dated 06/11/25 on the morning shift. She stated she always put a progress note in to describe why the 9 was there. She stated the progress note she left on 06/11/25 at 10:54 AM was struck out and did not give any details to why the 9 was on the MAR. She stated she could not remember from a month ago what actually happened or if the medications had been available or not. She stated she was not sure why the furosemide medication was signed as given on the evening of 06/10/25 and when she worked on 06/11/25, a 9 was in the spot that showed if medication was administered. In an interview on 07/08/25 at 2:51 PM, the DON stated when they knew they were getting an admission to the facility from the hospital and the resident may be arriving later in the day or evening, the hospital sent over the residents information, and they looked through everything to check and make sure they could accept and care for the resident. He stated they looked over the medications and sent them to the doctor for approval and once the resident arrived in the facility they informed the pharmacy. He stated medications were usually delivered within 1 hour of ordering from the pharmacy. In an interview on 07/08/25 at 3:31 PM, the FM stated Resident #1 was admitted to the hospital when he discharged from the facility, for the diagnosis of chest pain unspecified type, and he stayed in the hospital from [DATE] to 06/16/25 with the diagnosis of atypical chest pain recent NSTEMI. She stated there were no new treatments and the hospital kept resident to observe him for having chest pain and he had just had a recent heart attack. She stated she did not have any names from anyone who had given her information at the facility. In an interview on 07/08/25 at 4:48 PM, MA E stated he had worked in the facility for about 3 years. He stated he was in-serviced regularly on medication administration. He stated he had not had any concerns with medication being unavailable to administer to the residents. He stated if a medication was not available, he would try to look for it in the overflow and if they had not had any he would have re-ordered the medication and notified the nurse. He stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused a stroke or even death. In an interview on 07/09/25 at 10:09 AM, LVN A stated she had worked in the facility for about a year. She stated she was in-serviced on medication administration. She stated she has not had any concerns with medication being unavailable to administer to the residents. She stated if a medication was not available, she would have called the pharmacy. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused death. She stated she was the nurse that sent Resident #1 out to the hospital for chest pain on 06/12/25. She stated she had worked a split shift that night and the nurse that was leaving had informed her that Resident #1 was having chest pain and had refused to go to the hospital. She stated she went and assessed resident, and resident still complained of chest pain and pain in his left arm. She stated residents heart rhythm was irregular and missed a beat every 7-8 beats or so. She stated resident was still refusing to go to the hospital and she pleaded with him to go, and he finally agreed and was sent out via ambulance. She stated she had not had time to look up anything when she came in, so she was not aware if resident had or had not received any of his medications that day. In an interview on 07/09/25 at 10:47 AM, MA F stated she had worked in the facility for about a year. She stated she was in-serviced on medication administration. She stated she had not had any concerns with medication being unavailable to administer to the residents. She stated anytime they did not have a medication, she would have notified the nurse and charted that the medication was not available. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused death or cardiac arrest. She stated Resident #1's medications had been delivered to the facility, besides the sucralfate and another medication that she could not remember, on the evening of 06/11/25 when she passed medications. She stated if there was not a medication she notified the nurse to try to get it out of the emergency kit and if they did not have it in there, they charted a 9 and made a progress note that they were awaiting arrival from the pharmacy, or the drug was not available. She stated she worked on 06/11/25 in the evening and documented that resident received all of his medications except the ones that were not available in the facility. She stated she put a 9 in the places of the medications that were not given and made a progress note at the time that stated she was awaiting arrival on 06/11/25 at 8:11 PM. In an interview on 07/09/25 at 11:44 AM, LVN B stated she had worked in the facility for about a year. She stated she was in-serviced on medication administration. She stated she had not had any concerns with medication not being available to administer to the residents. She stated if a medication was not available, she would have checked the emergency box to see if the medication was available there, and if not she would have reported it to the doctor, called the pharmacy, let the family and DON know, and she would have documented it. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused a lot of cardiac issues such as hypertension, chest pain, and it could affect their vital signs and their physical state. In an interview on 07/09/25 at 11:58 AM, the DON stated staff had been in-serviced staff on medication administration. He stated medication aides and nurse were responsible for administering medications to the residents. He stated it was his expectation that all residents received all of their medications as ordered. He stated he was not aware of any concerns with medication being unavailable to administer to the residents except for once and that had been addressed. He stated if a medication was not available, staff should have immediately notified the nurse and the nurse should have notified the ADON, then it comes to him, and the pharmacy would have been called to ensure the medication was gotten to the facility. He stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused adverse effects or serious consequences, such as death. He stated he was not aware that Resident #1 had not received his medications as ordered on 06/11/25 until resident had already went to the hospital. He stated after they found out about the medications they in-serviced staff on medication administration. In an interview on 07/09/25 at 12:19 PM, the ADM stated staff had been in-serviced staff on medication administration. She stated the MA's, and nurses were responsible for administering medications. She stated it was her expectation that all residents received all of their medications as ordered. She stated she was not aware of any concerns with medication being unavailable to administer to the residents. She stated if a medication was not available, staff should have checked the emergency kit and if it was not there they should have notified the ADON and DON and called the pharmacy to see what was going on. She stated if a resident missed does of medication intended for chest pain, atrial fibrillation, myocardial infarction, hypertension, or congestive heart failure it could have caused issues up to death. Review of the facility policy Administering Medications dated 2001, revised April 2019, reflected in part, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). Review of the facility policy Medication Therapy dated 2001 reflected in part, Policy Statement: 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions and address significant risks. 2. Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. 3. All medication orders will be supported by appropriate care processes and practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 1 of 5 residents (Resident #1) reviewed for quality of care in that: CNA A failed to operate the Hoyer lift with 2 staff per facility policy when transferring Resident #1 from the chair to the bed. Resident #1 sustained a fracture of the right lower tibia / fibia. This failure could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: Record review of Resident #1's face sheet dated 4/30/2022 indicated Resident #1, was a [AGE] year-old female admitted on [DATE]. She had diagnoses of Malignant neoplasm of the brain (cancer of the brain), seizure disorder, hypothyroidism (deficiency of the thyroid hormone), hemiplegia of the right side (loss of movement of the right side of the body), Anemia (low red blood cells), and Unspecified protein calorie malnutrition (lack of protein within the body). Record review of Resident#1s Annual MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 99, which indicated she was not able to complete the interview, staff interview within the same MDS indicated Resident #1 had Severely impaired cognition. Section G Functional status of the MDS reflected Resident # 1 required 2 person assist Ambulation/Transfers, bathing, hygiene, dressing and grooming. Record review of Resident #1's care plan dated 1/26/2021 reflected Resident #1 required ADL assistance that included a transfer status of Hoyer (mechanical lift) lift with assistance of 2 staff. Record review of Resident #1s care plan dated 10/09/23 reflected Resident #1 had a bone fracture of right tibia/fibula (lower leg). Interventions were included for pain relief related to fracture. Antibiotics were administered for infection prevention related to swelling and fracture of right lower leg. Support was given to right lower leg with the use of an immobilizer. Nursing was to continue to monitor right lower leg and report changes in condition to medical doctor. Record review of a incident report dated 10/08/2023 at 06:05am by RN A, indicated, Resident #1 was sent to the emergency room for right lower leg that had a large dark purple/blue bruise with a large fluid filled blister near the center of the bruise with several smaller fluid filled blisters scattered across the bruised area. Record review of a progress note dated 10/08/2023 at 11:45 am by RN A indicated, the facility was notified by the hospital that Resident #1 had a tibia/fibula (lower leg) fracture. Record review of a progress note dated 10/08/2023 at 3:08pm by RN A indicated, Resident #1 returned from the ER with a brace to her right lower leg. Resident #1 was given tramadol for pain and instructed to follow up with orthopedic specialist. In an observation on 10/20/23 at 1:00pm of Resident #1 revealed she was in bed laying with eyes open and did not respond to interview questions. A leg brace was observed in place to right lower leg. In an interview with CNA B on 10/20/23 at 2:35PM revealed, to use the Hoyer lift to transfer any resident there must always be two nursing staff present during the transfer. CNA B admitted he did transfer Resident #1 by himself on 10/7/23 at 6pm. He stated at the time of Resident #1's transfer there was no other staff on the unit. He stated he could have asked a nurse to assist him. CNA B stated he was not sure why he did not ask the nurse to assist him with the Hoyer lift. CNA B stated he has been a CNA for 36 years but had only worked at this facility 3 days. He stated He was trained on the use of the Hoyer lift during orientation on 10/5/23. CNA B stated that Resident #1 did not complain of pain and did not make any facial grimaces to indicate pain during the transfer. He denied that he bumped or injured Resident#1's leg during the transfer. CNA B stated he was trained during orientation on the Hoyer Lift Policy. In an interview with the ADM on 10/20/23 at 3:00pm, she stated Resident #1 used a Hoyer lift for transfers. She stated it was the policy of the facility that if any staff who were caught using a Hoyer lift improperly were to be terminated. The ADM stated CNA B admitted he transferred Resident #1 by himself using the Hoyer lift. The ADM reported although the facility investigation could not prove exactly when the injury occurred to Resident #1's leg, the incident investigation on 10/08/23 was able to identify the need for education for staff on an area required improvement. All staff were educated on Using a Hoyer lift on 10/9/23. All staff were educated specifically that 2 Nursing staff must be used when a resident was transferred with a Hoyer lift. In an interview with the DON on 10/20/23 at 3:15pm, revealed he was called to the facility on [DATE] upon discovery of the incident with Resident #1 and immediately began his investigation. He stated that once he learned of the improper transfer CNA B was placed on suspension. It was the facility's policy to terminate staff who improperly use the Hoyer lift. The DON stated CNA B denied resident hitting leg on lift. The DON stated he immediately in serviced all staff on ANE and Using the Hoyer and lift. Upon completion of investigation, it was the facility's decision to terminate CNA B due to failure of following the Hoyer lift policy. Record review of CNA B's employee file revealed, he was trained on Hoyer lift policy on 10/5/23 including At least two (2) nursing assistants are needed to safely move a resident with a mechanical. CNA B was suspended on 10/8/23 and terminated on 10/9/23. Records review of an in-service dated 10/8/23 and sign-in sheets regarding Lifting machine, using a mechanical policy and procedure dated 07/2017 conducted by DON, reflected the nursing staff members had been in-serviced on this process. Records review of in-service dated 10/9/23 and sign-in sheets regarding Lifting machine, using a mechanical policy and procedure dated 07/2017 conducted by DON, reflected that all staff members had been in-serviced on this process. Record review of the facility policy Titled Lifting machine, using a mechanical dated 07/2017 general guideline #1 revealed, at least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure Resident # 1 received adequate supervision and assistance to prevent a fall for 1 ( Resident #1) of 5 residents reviewed for falls. The facility failed to ensure Resident #1 remained free of falls to prevent an accident. These failures could place residents at risk for falls with possible injuries due to lack of supervision. Findings Include: Review of Resident #1's undated face sheet reflected a [AGE] year-old female was admitted to the facility on [DATE] with a diagnoses of Traumatic brain injury(caused by an outside force, usually a violent blow to the head), dementia(memory loss), Type 2 diabetes, fracture of the occiput(traumatic injuries that involve articulation between the base of the skill and the cervical spine, and) cognitive communication deficit (difficult thinking). Review of Resident #1's MDS dated [DATE] revealed Resident #1's BIMS Summary score of 7indicated severe cognitive impairment. Review of Resident #1's MDS dated [DATE] revealed toilet transfer- partial/moderate assistance. Toilet use-limited assistance. Walking-partial/moderate assistance. Review of Resident #1's care plan dated 11-19-2022 revealed Resident #1 will have their ADLs transfer toilet performed by staff. Resident # 1 required the assistance of 1 staff when toileting. Resident #1 had a communication problem due to a head injury. Resident # 1 will be able to make basic needs known on a daily basis with interventions to ensure and provide a safe environment. The facility staff would constantly remind Resident # 1 to use call light for assistance. Review of Resident #1's progress notes dated 03-22-2023 at 2:45 PM written by LVN A revealed Resident #1 had an unwitnessed fall. Progress notes revealed post unwitnessed fall, this nurse showered resident to clean feces and urine off lower extremities. Resident noted leaning heavily to left when asked to sit up straight, appearing unable or not wanting to use left arm. During transfer resident having difficulty standing up, legs appeared to weaken, and resident tried to sit down mid transfer in the middle of his room. Complaints of pain in left shoulder. Primary Care physician contacted after incident and advised to transfer out to hospital for evaluation. POA notified of transfer and incident. Review of Resident #1's progress notes dated 03-22-2023 at 2:45 PM written by LVN A revealed Resident #1 was found on the floor in the bathroom across from the toilet leaning against the door and laying on the ground. Resident # 1 stated he slipped on wet floor while standing up to get off toilet. Fecal matter and urine noted around toilet, Resident # 1 noted barefoot with fecal matter on feet and upper/lower legs. 1x1cm bump noted on the left side of head, 1 cm skin tear noted on left forearm just below the elbow. Review of Resident #1's progress notes dated 3-22-2023 at 1:40 PM written by LVN A revealed Resident # 1 noted leaning heavily to left when asked to sit up straight, appearing unable to not wanting to use the left arm. During transfer Resident # 1 noted having difficulty standing up. Legs appeared to weaken, and resident tried to sit down mid-transfer in the middle of his room. Resident # 1 complaints of pain in the left shoulder. Physician contacted after the incident and advised to transfer out to the hospital to evaluate. Review of Resident #1's incident report dated 3-22-2023 at 1:40 PM by LVN A revealed Resident # 1 was found on the floor in the bathroom across from the toilet leaning up against the door across from the toilet. Fecal matter and urine noted on the floor around the toilet, and on Resident # 1's legs and feet. Resident # 1 's toilet was stopped up with newspaper. Resident # 1's skin tear noted on left forearm 2X0.5 cm below the elbow, 1cmx1cm bump on left side back of the head. Resident self-transfers. Resident 1's description of the incident stated ' he was standing up to get off the toilet and slipped on the wet floor and hit his head on the door. Review of Resident #1's hospital notes dated 3-22-2023 revealed Resident # 1 was presented to the emergency room with complaints from a fall injury. Resident #1 was found to have a closed right fracture of the right side of the base of the skull. Intervention of procedure right craniotomy. Postoperative findings from craniotomy for right cerebral convexity subdural hematoma evacuation with the residual subdural collection and postoperative findings resulting in mass effect with associated leftward midline shift measuring 4 mm. Observation Of Resident #1 was not made during investigation. Resident #1 was in the hospital. Telephone interview attempted with POA on 3-25-2023 at 12:00 PM. Message left , no return call. Interview on 3-25-2023 at 1:31 PM, the ADON stated that she wrote up the incident report on Resident #1. Resident #1 was found on the floor in the bathroom. The fall was unwitnessed, but the resident was able to state he was standing up to get off the toilet and slipped on the wet floor. Resident #1's toilet was stopped up with newspaper and overflowed on the floor. The ADON stated the resident takes himself to the restroom without assistance. Resident # 1 transfer himself to the toilet without using the call light. The staff who came to assist Resident #1 in the bathroom was not in the facility for an interview 3-25-2023. Resident #1's roommate was not in the room when the incident occurred. The ADON stated the incident was an accident due to Resident #1 not using the call light for assistance. The ADON stated that Resident #1's sister had contacted the facility 3-24-2023 to advise of Resident #1's hematoma. Resident #1 had hit head in the same spot of previous head injury and was having surgery to repair. Interview on 3-25-2023 at 4:12 PM with CNA A stated Resident #1 rarely used the call light for assistance. CNA A would check on Resident #1 often than the two-hour rounds to remind Resident #1 to use the call light for assistance. Resident # 1 was a one-person assist and transfers himself without notifying staff for assistance. CNA A was aware Resident # 1 was to be assisted with toilet transfer. CNA A did not feel the facility were negligent regarding the incident with Resident # 1. CNA A stated it was an accident that occurred due to the resident not calling for assistance. Interview on 3-25-2023 at 4:23 PM with NA A stated Resident # 1 was a one-person assist and Resident # 1 never asked for assistance to be transferred to the toilet. Resident #1 transferred himself without notifying staff for assistance. NA A felt the incident that occurred with Resident # 1 happened due to Resident #1 not alerting staff that he needed assistance with toilet transfer which caused an accident. Interview on 3-25-2023 at 4:30 PM with the Administrator stated Resident #1's care plan reflected the assistance of one staff and the incident occurred when Resident # 1 toilet overflowed with newspaper and Resident # 1 slipped and fell. Resident # 1 did not use the call light when he went to the restroom. There was no witness to the incident and Resident # 1 was able to state what happened. Resident #1's incident was an accident that occurred due to staff not being alerted that assistance was needed by Resident# 1. Record review of the facility's fall prevention program not dated gave definitions, examples of extrinsic factors, multiple interventions, assessment performed, assessment protocols, environment rounds, medication Review, Rounding to assist with resident's needs, reduced use of restraints, proper use of technology to reduce falls, communicating with falls risks, educating residents, educating family members, if a resident falls, reporting falls, and conducting a post-fall assessment. Record review of the facility's safety measures to prevent accidents and injuries not dated gave incident/accident reporting protocols, environmental risk factors, resident risk factors, general fall risk reduction strategies, fall risk reduction, general environment safety, and fall risk reduction bathroom