**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to review the resident ' s total program of care, including medications and treatments, at each visit for 1 of 8 residents (Resident #50) reviewed for resident records. The facility failed to ensure the physician's order was accurate and appropriate for Resident #50's levothyroxine order. The levothyroxine was ordered for 1:00 PM, when professional standards and practices for that medication indicated it should be given early in the morning before breakfast. This failure could place residents at risk for incorrect treatment decisions, evaluation, and plans compromising patient safety due to ineffective levels of thyroid hormone. The findings included: Record review of Resident #50's face sheet dated 11/21/24 reflected an [AGE] year-old female with an admission date of 02/07/24. Pertinent diagnoses included Acute Kidney Failure and dysphagia (difficulty swallowing). Record review of Resident #50's Quarterly MDS assessment section C, cognitive patterns, dated 11/05/24 reflected a BIMS score of 15 (no cognitive impairment). Record review of Resident #50's care plan revealed the problem I have a feeding tube in place r/t dysphagia initiated on 02/11/24 and revised on 11/11/24. Interventions listed to treat the problem revealed the following: Enhanced barrier precautions when in contact with feeding tube initiated on 11/18/24. HOB should be elevated when in bed, avoid flat while providing water flushes initiated on 02/11/24 and revised on 11/11/24. Provide local care to G-Tube site as ordered and monitor for s/sx of infection initiated on 02/11/24. RD to evaluate as indicated initiated on 11/11/24. Report to MD all abnormal findings as indicated initiated on 11/11/24. Further record review of Resident #50's care plan revealed the problem I have chronic health conditions & co-morbid conditions that have affected my physical function and may further affect my quality of life. Heart Disease, Thyroid Disorder initiated on 02/11/24 and revised on 11/11/24. Interventions listed to treat the problem revealed the following: Refer to skilled therapy services for strengthening, mobility as well as oxygen conservation techniques as indicated initiated on 02/11/24. Administer my medications, treatments, respiratory treatments/therapy and diet as recommend by physician. Provide care as tolerated and needed initiated on 11/11/24. Labs as ordered & report abnormal findings to MD as indicated initiated on 11/11/24. Monitor my vital signs & weights as indicated initiated on 11/11/24. Report all changes in condition to doctor and resident representative as indicated initiated on 11/11/24. Notify MD PRN any s/sx of complications of extremities: coldness of extremity, pallor [pale appearance], rubor [redness of the skin], cyanosis [shortage of oxygen in the blood] and pain initiated on 11/11/24. Observe MD PRN and s/sx of hypotension: dizziness, fainting, syncope [fainting or passing out], blurred vision, lack of concentration, nausea, fatigue, cold clammy pale skin initiated on 11/11/24. Record review of Resident #50's order summary revealed an active order dated 02/29/24 for Levothyroxine Sodium Oral Tablet 50 MCG, Give 1 tablet by mouth one time a day for Hypothyroidism signed by MD on 03/01/24. Further review of Resident #50's order summary revealed an active order dated 05/09/24 for Regular diet, Regular Texture texture [sic], Thin/Regular consistency. Record review of progress notes for Resident #50 revealed a progress note dated 02/29/24 from Therapy that reflected ST note: Diet recommendation: puree/thin with *assisted dining* for all meals. Med pass: crushed medications PO. Further review of progress notes for Resident #50 revealed a progress note dated 02/29/24 from Nursing that reflected received recommendation from ST for pureed texture meals with thin liquids, meds crushed, MD notified, approved recommendation, orders carried through, RP, DON notified. Record review of Resident #50's MAR dated 11/21/24 revealed Levothyroxine Sodium Oral Tablet 50 MCG was administered to the resident every day in March 2024 at 1:00 PM. Record review of Resident #50's MAR dated 11/21/24 revealed Levothyroxine Sodium Oral Tablet 50 MCG was administered to the resident every day in November 2024 up to 11/20/24 at 1:00 PM. Record review of Resident #50's laboratory results dated [DATE] revealed a TSH of 74.50 mIU/mL (TSH is thyroid stimulating hormone produced in the pituitary gland. TSH signals to the thyroid to produce more T3, or thyroxine, and T4, triiodothyronine. An elevated TSH indicates hypothyroidism, or and underactive thyroid). Review of the ranges listed on the laboratory results for TSH revealed the normal range to be 0.47 - 4.68 mIU/mL. During an observation of Resident #50 on 11/21/24 at 1:49 PM revealed the resident was administered Levothyroxine Sodium Oral Tablet 50 MCG by MA B. During an interview with MA B on 11/21/24 at 1:55 PM, MA B stated Resident #50 had received levothyroxine after lunch for as long as she could remember. MA B stated it was unusual, since every other resident that received levothyroxine always received it in the morning before breakfast. During an interview with the DON on 11/21/24 at 2:44 PM, the DON stated he had already spoken to the MD about the levothyroxine administered after lunch, and the MD had approved a new order to move it to be given at sunrise starting 11/22/24. The DON stated Resident #50 had not shown any symptoms of hypothyroidism since her admission at the facility. The DON stated Resident #50 received her medications via G-tube when she first arrived at the facility. The DON stated she received levothyroxine at 1:00 PM when she first arrived because that was her fasting time between receiving her feeding formula. The DON stated once she was able to eat a little, the levothyroxine was switched to be taken by mouth. The DON stated the timing of the levothyroxine order did not change. The DON stated levothyroxine was typically given in the morning before breakfast to best help with its absorption into the body. The DON stated that it was best practice to receive levothyroxine in the morning, but that given Resident #50's clinical picture, he could not say if the timing of the medication resulted in Resident #50's elevated TSH. During an interview with the MD on 11/21/24 at 3:19 PM, the MD stated the best time to take levothyroxine was 30 to 45 minutes before the first meal of the day. The MD stated the reason the medication should be taken at that time was because that was the best time for the medication to be absorbed into the body. The MD stated if there was a resident that was switching from taking meds and eating via G-tube to by mouth, he would move the levothyroxine timing to 30-45 minutes before the first meal of the day. The MD stated a lack of good absorption of levothyroxine into the body could result in weight gain and slowed movements. The MD stated he had not noticed any clinical sign or changes in Resident #50 demonstrating hypothyroidism. Record review of the facility policy titled Physician Services: Medical Director implemented on 02/17 and revised on 01/23 revealed the following: The medical director's responsibilities include but are not limited to: Directing and coordinating medical care in the organization; Participating in establishing policies, procedures, and guidelines designed to ensure the provision of adequate, comprehensive services; The medical director has administrative authority, responsibility, and accountability for the functions and activities of the medical staff at the community.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, 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 each resident for 1 (Resident # 88) of 6 residents reviewed for pharmacy services. 1. The facility failed to ensure that MA A accurately documented Resident #88's blood pressure when administering or holding Resident #88's blood pressure increasing medication. 2. The facility failed to ensure that MA A did not administer Resident #88's blood pressure increasing medication when Resident #88's blood pressure was outside of administration parameters or when MA A did not document a blood pressure on 12 opportunities. 3. The facility failed to ensure that MA B accurately documented Resident #88's blood pressure when administering Resident #88's blood pressure increasing medication. 4. The facility failed to ensure that MA B did not administer Resident #88's blood pressure medication when Resident #88's blood pressure was outside of administration parameters or when MA B did not document a blood pressure on 10 opportunities. 5. The facility failed to ensure that MA C did not administer Resident #88's blood pressure increasing medication when Resident #88's blood pressure was outside of administration parameters on 5 opportunities. 6. The facility failed to ensure that LVN D did not administer Resident #88's blood pressure increasing medication when Resident #88's blood pressure was outside of administration parameters on 6 opportunities. These deficient practices could place residents at risk for not receiving the therapeutic effects of their prescribed medications. The findings included: Record review of Resident #88's admission record reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #88's diagnoses included incomplete quadriplegia c5-c7 (weakness or paralysis of all four limbs due to a cervical spinal cord injury), cervical region spinal stenosis (the space inside the bones of the neck becomes too narrow and press on the spinal cord and nerves), bed confinement status, hyperlipidemia (high cholesterol), and essential hypertension (high blood pressure). Record review of Resident #88's quarterly MDS assessment dated [DATE] reflected a BIMS score of 12 which indicated that Resident #88 was cognitively intact. Record review of Resident #88's care plan on 11/19/24 reflected the following problems: 1. I have hypertension r/t CAD (narrowing of the arteries in the heart) and hyperlipidemia initiated on 7/30/21 and revised on 11/6/24. Interventions included the following: Obtain blood pressure readings QD (every day). Take blood pressure readings under the same conditions each time. For example, when I am sitting, use right arm initiated on 7/30/21. 2. I have chronic health conditions and comorbid conditions that have affected my physical function and may further affect my quality of life. Heart disease, neuropathic pain associated with other disease/ condition initiated on 10/9/24. Interventions included the following: Administer my medications, treatments, and diet as recommended by physician initiated on 10/9/24. Monitor my vital signs and weights as indicated initiated on 10/9/24. Notify MD PRN of any s/sx of hypotension: dizziness, fainting, blurred vision, lack of concentration, nausea, fatigue, and/or cold clammy pale skin initiated on 10/9/24. Record review of Resident #88's Order Summary Report on 11/19/24 reflected an active order dated 9/9/24 for Midodrine HCl Tablet 10mg, give 1 tablet my mouth three times a day for hypotension (low blood pressure). Do not give if systolic BP (the top number in a blood pressure) is 120mmHg or higher. Record review of Resident #88's BPS (Blood Pressure Summary) and MAR (Medication Administration Record) in PCC (the facility's electronic health record) dated 11/1/24 through 11/20/24 reflected the following: On 11/1/24 at 8:53pm BP was documented on the BPS as 156/89 by MA C. On 11/1/24 MA C documented on the MAR that the 7:00pm BP was 156/89 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/2/24 at 6:45pm BP was documented on the BPS as 148/70 by MA C. On 11/2/24 MA C documented on the MAR that the 7:00pm BP was 148/70 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/3/24 at 8:59am BP was documented on the BPS as 134/86 by MA A. On 11/3/24 MA A documented on the MAR that the 7:00am BP was 134/86 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/3/24 there was no documentation of the BP on the BPS between 8:59am and 7:33pm. On 11/3/24 MA A documented on the MAR that the BP at 1:00pm was 134/86 and the 1:00pm dose of Midodrine was administered (even though the BP documented was the same as the 8:59am BP on the BPS and the 7:00am BP on the MAR, and it was outside of parameters for administration). On 11/3/24 at 7:33pm BP was documented on the BPS as 146/83 by MA C. On 11/3/24 MA C documented on the MAR that the 7:00pm BP was 146/83 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/4/24 at 8:13am BP was documented on the BPS as 138/86 by MA A. On 11/4/24 MA A documented on the MAR that the 7:00am BP was 138/86 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/4/24 there was no documentation of BP on the BPS between 8:13am and 6:31pm. On 11/4/24 MA A documented on the MAR that the 1:00pm BP was 138/86 and the Midodrine was administered (even though the BP documented was the same as the 8:13am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/4/24 at 6:31pm BP was documented on the BPS as 134/80 by LVN D. On 11/4/24 LVN D documented on the MAR that the 7:00pm BP was 134/80 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/5/24 there was no BP documented on the BPS prior to 11:18am. On 11/5/24 MA A documented on the MAR that the 7:00am BP was 132/71 and the Midodrine was not administered due to BP being outside of parameters for administration (even though the BP documented was the same as the 11:18am BP on the BPS and the 1:00pm MAR) On 11/5/24 at 11:18am BP was documented on the BPS as 132/71 by MA A. On 11/5/24 MA A documented on the MAR that the 1:00pm BP was 132/71 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/5/24 at 6:40pm BP was documented on the BPS as 122/70 by LVN D. On 11/5/24 LVN D documented on the MAR that the 7:00pm BP was 122/70 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/6/24 there was no BP documented on the BPS prior to 5:17pm. On 11/6/24 MA A documented on the MAR that the 7:00am and 1:00pm BP was 122/70 and the Midodrine was administered (even though the BP documented for both 7:00am and 1:00pm were the same as the BP documented on 11/5/24 on the BPS at 6:40pm and on the MAR at 7:00pm, and it was outside of parameters for administration). On 11/6/24 at 5:14pm BP was documented on the BPS as 149/80 by MA C. On 11/6/24 MA C documented on the MAR that the 7:00pm BP was 149/80 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/7/24 at 7:14am BP was documented on the BPS as 133/74 by MA B. On 11/7/24 MA B documented on the MAR that the 7:00am BP was 133/74 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/7/24 there was no BP documented on the BPS between 7:14am and 7:12pm. On 11/7/24 MA B documented on the MAR that the 1:00pm BP was 133/74 and the Midodrine was administered (even though the BP documented was the same as the 7:14am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/8/24 there was no BP documented on the BPS prior to 12:17pm. On 11/8/24 at 12:17pm BP was documented on the BPS as 140/86 by MA A. On 11/8/24 MA A documented on the MAR that the 7:00am BP was 140/86 and the Midodrine was not administered because it was outside of parameters for administration (even though there was no BP documented on the BPS prior to 12:17pm and the BP documented on the MAR was the same as the 12:17pm BP on the BPS). On 11/8/24 at 8:51pm BP was documented on the BPS as 132/70 by MA C. On 11/8/24 MA C documented on the MAR that the 7:00pm BP was 132/70 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/9/24 at 8:41am BP was documented on the BPS as 137/86 by MA A. On 11/9/24 MA A documented on the MAR that the 7:00am BP was 137/86 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/9/24 there was no BP documented on the BPS between 8:41am and 8:52pm. On 11/9/24 MA A documented on the MAR that the 1:00pm BP was 137/86 and the Midodrine was administered (even though the BP documented was the same as the 8:41am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/10/24 there was no BP documented on the BPS prior to 1:42pm. On 11/10/24 MA A documented on the MAR that the 7:00am BP was 132/79 and the Midodrine was not administered due to BP being outside of parameters for administration (even though the BP documented was the same as the 1:42pm BP on the BPS and the 1:00pm MAR). On 11/10/24 at 1:42pm BP on the BPS was documented as 132/79 by MA A. On 11/10/24 MA A documented on the MAR that the 1:00pm BP was 132/79 and the Midodrine was administered (even though the BP documented was the same as the BP on the 7:00am MAR, and it was outside of parameters for administration). On 11/10/24 at 6:15pm the BP was documented on the BPS as 130/76 by LVN D. On 11/10/24 LVN D documented on the MAR that the 7:00pm BP was 130/76 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/11/24 at 6:49am BP was documented on the BPS as 142/87 by MA A. On 11/11/24 MA A documented on the MAR that the 7:00am BP was 142/87 and the Midodrine was not administered due to BP being outside of parameters for administration. On 11/11/24 there was no documentation of BP on the BPS between 6:49am and 6:41pm. On 11/11/24 MA A documented on the MAR that the 1:00pm BP was 142/87 and the Midodrine was administered (even though the BP documented was the same as the 6:49am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/11/24 at 6:41pm BP was documented on the BPS as 140/78 by LVN D. On 11/11/24 LVN D documented on the MAR that the 7:00pm BP was 140/78 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/12/24 at 6:59am BP was documented on the BPS as 122/84 by MA B. On 11/12/24 MA B documented on the MAR that the 7:00am BP was 122/84 and the Midodrine was administered (even though the BP was outside of parameters for administration). On 11/12/24 there was no documentation of BP on the BPS between 6:59am and 6:26pm. On 11/12/24 MA B documented on the MAR that the 1:00pm BP was 122/84 and the Midodrine was administered (even though the BP documented was the same as the 6:59am BP on the BPS and the 7:00am MAR, and it was outside of parameters for administration). On 11/12/24 at 6:26pm BP was documented on the BPS as 120/69 by MA B. On 11/12/24 MA B documented on the MAR that the 7:00pm BP was 120/69 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/13/24 at 7:33am BP was documented on the BPS as 114/72 by MA B. On 11/13/24 there was no documentation of BP on the BPS between 7:33am and 7:00pm. On 11/13/24 MA B documented on the MAR that the 1:00pm BP was 114/72 and the Midodrine was administered (even though the BP documented was the same as the 7:33am BP on the BPS and the 7:00am MAR). On 11/14/24 at 7:52am BP was documented on the BPS as 117/62 by MA B. On 11/14/24 there was no documentation of BP on the BPS between 7:52am and 6:53pm. On 11/14/24 MA B documented on the MAR that the 1:00pm BP was 117/62 and the Midodrine was administered (even though the BP documented was the same as the 7:52am BP on the BPS and the 7:00am MAR). On 11/15/24 there was no documentation of BP on the BPS prior to 12:03pm. On 11/15/24 MA A documented on the MAR that the 7:00am BP was 140/82 and the Midodrine was not administered due to BP being outside of parameters for administration (even though the BP documented was the same as the 12:03pm BP on the BPS and the 1:00pm MAR). On 11/15/24 at 12:03pm BP on the BPS was documented as 140/82 by MA A. On 11/15/24 MA A documented on the MAR that the 1:00pm BP was 140/82 and the Midodrine was administered (even though the BP documented was the same as the BP on the 7:00am MAR, and it was outside of parameters for administration). On 11/15/24 at 5:01pm the BP was documented on the BPS as 189/97 by MA C. On 11/16/24 there was no BP documented on the BPS prior to 7:00pm. On 11/6/24 MA A documented on the MAR that the 7:00am and 1:00pm BP was 189/97 and the Midodrine was administered (even though the BP documented for both 7:00am and 1:00pm were the same as the BP documented 11/15/24 on the BPS at 5:01pm and on the MAR at 7:00pm, and it was outside of parameters for administration). On 11/16/24 at 7:00pm BP was documented on the BPS as 120/79 by LVN D. On 11/16/24 LVN D documented on the MAR that the 7:00pm BP was 120/79 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/17/24 there was no BP documented on the BPS between 9:39am and 8:00pm. On 11/17/24 there was no documentation on the MAR at 1:00pm of a BP or administration or non-administration of Midodrine. (Both the BP and the administration boxes were blank.) On 11/17/24 at 8:00pm BP was documented on the BPS as 137/79 by LVN D. On 11/17/24 LVN D documented on the MAR that the 7:00pm BP was 137/79 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/18/24 at 7:53am BP was documented on the BPS as 119/66 by MA B. On 11/18/24 there was no BP documented on the BPS between 7:53am and 7:09pm. On 11/18/24 MA B documented on the MAR that the 1:00pm BP was 119/66 and the Midodrine was administered (even though the BP documented was the same as the 7:53am BP on the BPS and the 7:00am MAR). On 11/19/24 at 7:41am BP was documented on the BPS as 122/66 by MA B. On 11/19/24 MA B documented on the MAR that the 7:00am BP was 122/66 and the Midodrine was administered (even though it was outside of parameters for administration). On 11/19/24 at 1:58pm BP was documented on the BPS as 120/70 by MA B. On 11/19/24 MA B documented on the [NAME] that the 1:00pm BP was 120/70 and the Midodrine was administered (even though it was outside of parameters for administration). In an interview on 11/21/24 at 10:30am, MA A stated she had been an MA since 2012. MA A stated for the majority of the patients that had parameters, the parameters were in the system. MA A stated if the resident's BP was not within the parameters, she would let the nurse know, the nurse would tell her to hold the medication, and then she would document it on the MAR as held. MA A stated she checked the blood pressure before giving the medication and the BP got documented in the MAR and they were documented manually. MA A stated there was a box at the top of the page that had the last set of v/s, but they did not auto populate into the MAR. MA A stated she had never not checked the BP before giving a medication. In reference to Resident #88, MA A stated his BP was usually high in the morning then dropped lower in the afternoon. MA A stated on 11/16/24, she apparently failed to document the correct blood pressure when she administered the medication for the 7:00am and 1:00pm doses. MA A further stated on the days that it (the MAR) showed the same blood pressures for the 7:00am and 1:00pm doses that were the same as the night before (7:00pm dose), she just failed to document the correct BPs. MA A stated, I do always check the BP before I give or hold the medication and the BPs are documented as soon as I do them. MA A stated it was important to always check v/s because if someone was given a medication to raise their blood pressure and the blood pressure was already high, it could cause the resident to have a stroke, be hospitalized , or even pass away. MA A stated it was important to document correctly so that everyone knew what was going on with the resident, how he or she was doing and if the doctor was needing to make medication changes, they needed accurate documentation of vitals to be able to manage care appropriately. MA A stated the last in service on med admin was last month. In an interview on 11/21/24 at 10:55am, MA B stated if a resident was on medication that had vital sign parameters, she would check the v/s before she gave the medication, document it after she gave the medication, and if not within parameters, she would tell the nurse so she could hold the medication. MA B stated, I always check the v/s before I give the medication. I would not give the medication without checking the v/s to make sure it was within parameters, if there were any. In reference to Resident #88's Midodrine and the days that the same BPs were documented on the MAR at 7:00am and 1:00pm, MA B stated that she did check the BP on those days, but she guessed she did not document the BP, she just used the same ones as the morning check. MA B stated it was important to always document the BP because if there was a problem with it going up and down the doctor could change the medication if necessary. MA B stated it was important to always check it (the BP) first to make sure it was within the parameters to give. MA B stated if a BP was high, but it was not checked, and the resident was given this medication (Midodrine), it could cause them to have a heart attack or stroke, go the hospital, and possibly die. MA B stated the last in service on medication administration was sometime this year. In an interview on 11/21/24 at 11:54am the ADON stated that v/s were supposed to be checked right before a medication was given that had parameters for v/s. The ADON stated the v/s and the administration or hold of the medication was supposed to be documented right away. The ADON stated it was not appropriate to use v/s that were done with previous administrations or holds. The ADON stated it was important to check the v/s before administration because you had to know if the resident needed the medication or not and if a medication was given that was outside of parameters, it could cause the resident to have an adverse reaction, be hospitalized , or if the blood pressure went too high it could cause a hypertensive crisis, stroke, or death. The ADON further stated it was important to document v/s accurately and timely so the provider could make adjustments if needed, based on the correct information. The ADON stated, My expectation is for everyone to assess their residents and check their v/s as ordered by the provider and on the MAR. The ADON stated the last in-service on medication administration was within the last 3 days and that she would be doing another in-service with each medication aide and nurse to address these specific issues. The ADON stated usually when the BP was documented on the MAR, it would transfer to the v/s (BP) section of PCC (Point Click Care, the facility's electronic health record) and she was not sure why it did not transfer. In an interview on 11/21/24 at 12:15pm, the DON stated he talked to corporate about the v/s documentation on the MAR on 11/20/24 to see if there was a way to get the system to send an alert if any of the vital signs were outside of parameters. The DON stated, My expectation is for the MAs or the nurses to check the BP before giving the medication and to document immediately the v/s and whether it was administered or held. The DON further stated if the blood pressure was high and the Midodrine was given it could cause the resident's blood pressure to be higher which could lead to harm. The DON stated the last in-service on medication administration was 11/20/24 and that they would be doing another one today (11/21/24). The DON stated, In terms of oversite, we will be looking at which residents are getting meds that have parameters and reviewing their MARs to ensure that the medications and v/s are being done and charted appropriately. Record review of the facility's Medication Administration policy implemented March 2019 and revised January 2023 reflected in part: Compliance Guidelines: Resident medications are administered in an accurate, safe, timely, and sanitary manner. Responsible Disciplines: Licensed Nurses, CMAs 2. Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength, and route. a. The nurse/ medication aide shall be responsible to read and follow precautionary or instructions on prescription labels. 5. If applicable and/ or prescribed, take vital signs or tests prior to administration of the dose. 6. Administer medications as ordered by the physician. Documentation: Initial the electronic administration record after the medication is administered to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure drugs and biologicals were stored securely for 1 (Resident #34) of 5 residents reviewed for storage of medications. The facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards. As a result, this failure placed residents at risk of not getting ordered medications, and/or medications could have been diverted or ingested by another resident. Findings Included: Record review of Resident #34's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with an original admission date of 10/14/2019. Diagnoses included Unspecified Dementia, Type 2 Diabetes, Primary Osteoarthritis, Osteoporosis, Stiffness of Joint, and Pain in Right Shoulder. Record review of Resident #34's MDS dated [DATE] revealed a BIMS score of 11. BIMS score 13-15 suggests resident's cognition is intact. Resident #34's care plan does not indicate that resident is allowed to administer own medications. Record review of care plan initiated 6/26/24 revealed Resident #34 had impaired cognitive function or impaired thought process related to dementia. Record review on 11/20/24 of physician's orders revealed no order for a pain cream for Resident #34's pain. The physician's orders also revealed there were multiple medications that the two tablets could have been, such as Metformin, Tylenol, Multivitamin, Potassium and Gabapentin. Observation 11/19/24 09:00 AM revealed Resident #34 was in bed rubbing her arm and shoulder. Bedside table was noted to have 2 large, white, oblong pills sitting on a napkin next to a souffle cup that had a thick, white paste in it. Interview on 11/19/24 at 09:15 AM with Resident #34, she stated she did not know what the pills were or where they came from. She stated the nurse probably left them there for her to take, but she did not like to take pills because they make her sick to her stomach. Resident #34 was also complaining of pain to her right arm and right shoulder. She stated the nurse was supposed to bring her a cream to put on it, but never brought it. Resident #34 stated she asks for the cream all the time, but they never bring her anything. She stated sometimes she can take Tylenol for the pain, but other times it upsets her stomach. Interview with LVN - E on 11/19/24 at 09:30 AM, she stated she had not passed any medication to Resident #34, and she wasn't sure if they were Resident 34's medication as they look like many other medications, so she would not have left the medications at the bedside. If the patient had refused them, she would have discarded them in her trash on her cart. She also stated Resident #34 does not have an order for a cream for pain, but that she would reach out to the provider to get an order. Interview with MA - J on 11/19/24 at 09:45 AM, she stated she never noticed the two white tablets or a cream sitting at the resident's bedside table, but stated they did not come from her because she actually watched the resident swallow her morning pills. If the resident had refused, she would have disposed of the medication appropriately in the trash or sharps container. Interview with LVN - I on 11/19/24 at 10:30 AM, she stated she doesn't remember seeing the pills or the cream at the bed side, but she didn't place them there because the resident took all the medication that she administered to her. She stated that if the resident had refused the medication, she would dispose of it properly. Interview with the Administrator on 11/20/24 at 04:45 PM, he stated that nurses are not supposed to leave medications at bedside. If medications are refused by resident, they should be disposed of properly. If medications are left at bedside a lot of things could happen like another resident could take them. Interview with the DON on 11/21/24 at 09:58 AM, he stated medications should never be left at bedside, and if a resident refused medication the nurse should dispose of meds appropriately in the sharps or use the chemical that is designated to dispose the medication in. If medications are left at bedside another resident could end up swallowing them. Record review of Medication Administration Policy revealed never administer medications from an unmarked container, never administer medications supplied for one resident to another resident, administer medications as ordered and according to the established medication administration schedule, avoid leaving medications with the resident to self-administer, and follow the medication/pharmacy guidelines for storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident environments remained free of hazards for four (602, 608, 610, 616) of 10 resident rooms in the 600 hall reviewed for environmental hazards. The facility failed to keep spray bottles with a yellow cleaning solution locked while not in use. This deficient practice could place residents at risk of an unsafe environment. The findings included: Record review of Resident #92's face sheet dated 11/19/24 revealed she was a [AGE] year-old female admitted [DATE] with a diagnosis of Dementia. During an observation on 11/19/24 at 8:41 AM, revealed in room [ROOM NUMBER] in the 600 hall, there was a spray bottle with a yellow cleaning solution labeled Halt Disinfectant, Cleaner, Deodorizer with approximately 3/4 full, was found out in the open on the floor next to the toilet. On 11/19/24 at 8:42 AM, Resident #92 was attemped to be interviewed however, she was not interviewable. Record review of Resident #386's face sheet dated 11/19/24 revealed he was a [AGE] year-old admitted [DATE] with a diagnosis of Dementia. During an observation on 11/19/24 at 8:45 AM, revealed in room [ROOM NUMBER] in the 600 hall, there was a full spray bottle with a yellow cleaning solution labeled Halt Disinfectant, Cleaner, Deodorizer was found out in the open on the counter next to the bathroom sink. On 11/19/24 at 8:46 AM, Resident #386 was attemped to be interviewed however, he was not interviewable. Record review of Resident #388's face sheet dated 11/19/24 revealed she was a [AGE] year-old admitted [DATE] with a diagnosis of Dementia During an observation on 11/19/24 at 8:53 AM, revealed in room [ROOM NUMBER] in the 600 hall, a spray bottle with a yellow cleaning solution labeled Halt disinfectant, Cleaner, Deodorizer was found out in the open on the counter in front of Resident #388's bed. On 11/19/24 at 8:42 AM, Resident #388 was attemped to be interviewed however, she was not interviewable. Record review of Resident #391's face sheet dated 11/19/24 revealed she was a [AGE] year-old admiitted 11/06/24 with a diagnosis of Dementia During an observation on 11/19/24 at 8:53 AM, in room [ROOM NUMBER] in the 600 hall, there was a spray bottle, approximately 3/4's full, with a yellow solution labeled Super HDQ L10 Cleanser/Disinfectant/Detergent/Fundicide that was found out in the open on the counter in the bathroom. On 11/19/24 at 8:42 AM, Resident #391 was attempted to be interviewed however, she was not interviewable. In an interview with LVN F on 11/18/24 at 03:45 PM, he stated that the spray bottles were for disinfecting purposes used by the facility staff when needed. LVN F said there was a risk that a resident could get poisoned if drank, eye irritation or blindness if the chemical was swollowed or spilled. In an interview with the housekeeping supervisor, HSKS, on 11/19/24 at 4:14PM, she stated the contents inside the spray bottles were used for disinfecting. The HSKS stated if ingested it could be harmful. The HSKS then stated that the Administrator asked for the spray bottles were to be available to staff. All other chemicals used to clean are locked in the housekeeping carts. In an interview with the DON on 11/20/24 at 04:08 PM, he stated all 4 spray bottles filled with disinfectant were removed immediately from the resident bathrooms that contained them. The DON stated the liquid in the bottles was used mainly for disinfecting beds, not a general disinfectant for all items. The DON said the bottles were stored in the bathrooms for a couple of weeks. He stated the spray bottles were stored in the bathrooms only the in 600 hall which was used for new admissions. The DON stated it depended if the resident had risky behaviors and dementia, they would not leave anything close to the resident that would pose a risk to him or her. The DON stated The disinfectant could cause harm to the resident if it was ingested. I do not think there are any residents in the facility currently that would ingest or spray the disinfectant inappropriately. In an interview with Administrator on 11/20/24 at 04:30 PM he stated he was unaware there were spray bottles in the bathrooms. He stated that every single one was removed from bathrooms to his knowledge. He stated the spray bottles were normally stored in a storage closet in the housekeeping closet secured. The DON stated a person with a mental condition could get harmed if they got a hold of the spray bottle and potentially ingested it or came in contact with eyes or skin. Record review of the facility's Cleaning and Disinfection of Resident Care Items and Equipment Policy and Procedure revised January 2023 revealed the policy did not include a procedure to store disinfecting products.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for storage, preparation and sanitation. The facility failed to ensure kitchen equipment was in good condition. The facility failed to ensure kitchen equipment was kept clean. The facility failed to ensure items in the refrigerator were labeled and dated. These failures could place residents at risk for complications from food contamination. Observation of the kitchen and initial tour on 11/19/24 at 8:35 AM revealed 2 non-stick pans on the clean rack that were eroded to the metal on the bottoms and sides. There was a metal spatula in use with sharp jagged edges and the handle was melted with deep crevasses that had brown and black substances in and around them. There was a plastic spatula in use that had jagged edges. There was a serving scoop that had a reddish substance on the inside in the clean drawer with other utensils. There were two glasses of milk in the refrigerator that were unlabeled and undated. In an interview with the RD on 11/19/24 at 8:40 AM, she said the eroded non-stick pans looked like they needed to be replaced because the coating should not be coming off. She said kitchen staff should not be using the eroded non-stick pans because bits of the coating could be coming off and getting into the resident s' food. She said if the resident ' s consumed the bits of non-stick coating, they could get sick. She said if the residents drank the milk that was unlabeled and undated, it could be potentially spoiled and make the residents sick. She said the spatulas looked dangerous because of the sharp edges on the metal one and the plastic one looked like bits of it could come off, get in the resident ' s food and make them ill. In an interview with the [NAME] on 11/19/24 at 8:45 AM, she said she was going to throw away the eroded non-stick pans but had not gotten to it. She said they used the eroded pans to make grilled cheese sandwiches. She said the coating on the eroded non-stick pans could get into the food and make residents sick or make the food taste differently. She said the metal spatula could cut someone with the jagged edges and she had not noticed it before. She said the melted plastic handle of the metal spatula had crud in the crevasses. She said touching the dirty handle of the metal spatula could cause cross contamination and make resident sick. She said she used the metal spatula and other metal utensils in the non-stick pans. She said she was unaware they were supposed to be using plastic or nylon utensils in the non-stick pans. She said the jagged edges on the plastic spatula could break off into the food and the residents could chew the bits of plastic and get them stuck in their teeth or hurt their gums. She said the dirty scoop in the clean drawer should not have been there because she did not know what the substance was that was in it. She said the scoop should have been removed and re-washed. She said she did not know how long the glasses of milk were in the refrigerator. In an interview with the FSS food service supervisor since 11/2007 on 11/19/24 at 8:45 AM, she said all kitchen staff were responsible for making sure broken utensils and pans were taken out of service and discarded. She said she had 2 new non-stick pans (they were on the stove). She said the cooks were supposed to be using plastic or nylon utensils in the non-stick pans to avoid the coating from flaking into the food. She said the non-stick coatings were toxic and could get into the food and make residents sick. She said the dirty scoop in the clean drawer should not have been there. She said she was ultimately responsible for making sure equipment used in the kitchen was clean and in good condition. She said kitchen staff should know when utensils and equipment should be replaced and remove them from service so she could order replacements. She said the scoop should have been removed and re-washed. She said the metal spatula was an injury hazard because the jagged edges on the sides of it were very sharp and looked like bits of the metal were missing. She said all items in the refrigerator, freezer, and dry storage should be labeled and dated always. She said none of her staff knew how long the glasses of milk had been in the refrigerator because they were not labeled and dated. She said if items were not labeled and dated, they would not know when the item should be discarded. She said if a resident was to consume anything that was outdated it could make them sick because that was why they had use-by dates. The kitchen equipment policy was requested but not provided. Record review of the undated facility policy titled, Food Preparation and Handling revealed under Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and guidelines. Record review of the undated facility policy titled, Food Storage revealed under Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be prepared and handled according to the state and US Food Codes and guidelines. Under Procedure: 2. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. References: FDA (Food and Drug Administration) Food Code Ch. 4-1-101.11 Characteristics. Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion- resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated ware washings; (D) finished to have a smooth, easily cleanable surface; and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. Ch. 4-101.18 Nonstick Coatings, Use Limitation. Multiuse kitchenware such as frying pans, griddles, saucepans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with non-scoring or non-scratching utensils and cleaning pads.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one (Resident # 1) of five residents that were reviewed for infection control and transmission-based precautions policies and practices, in that: a. On 10/27/2024, CNA A touched multiple surfaces and did not perform hand hygiene prior to commencing Resident #1's perineal care . These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of Resident #1's Face Sheet dated 10/27/2024, revealed the resident was admitted originally on 05/27/2019, Resident #1 was an [AGE] year-old female with the following diagnoses: Alzheimer's (degenerative cognition), atherosclerotic heart disease of native coronary artery (heart disease), acute kidney failure, type 2 diabetes mellitus (endocrine disease), pleural effusion (abnormal build-up of fluid in the space around lungs) muscle weakness, and hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] documented 6 out of 15 BIMS score suggesting severe cognitive impairment. As well as extensive dependency of staff to assist in activities of daily living. Resident #1 was coded for always incontinent. Record review of Resident #1's Comprehensive Care Plan date initiated 06/28/2019 and revised 01/24/2024 revealed, Focus: Resident #1 have bladder incontinence r/t diuretic, dementia and Alzheimer's. Goal: I will remain free from skin breakdown due to incontinence and brief use through the review date. Intervention: clean peri-area with each incontinence episode. During an observation on 10/27/2024 at 1:23PM, CNA A entered Resident #1's room, washed her hands then immediately applied clean gloves. With the clean gloves on, CNA A closed Resident #1's curtain, retrieved the bed remote, lowered the head of bed, followed by raising the bed to hip height, removed the pillows and Resident #1's brief, then proceeded to grab clean cleansing wipes and began cleaning Resident #1's perineal area without performing hand hygiene after touching the multiple surfaces were touched. During an interview on 10/27/2024 at 1:36PM CNA A stated she was nervous and had forgotten to change her gloves and perform hand hygiene prior to her care performance. CNA A stated she should have removed her contaminated gloves after touching the multiple surfaces, followed by performing hand hygiene and application of new clean gloves. CNA A stated by not performing hand hygiene nor glove change, she could have potentially introduced infectious microorganism onto Resident #1. CNA A also stated Resident #1 has multiple skin irregularities and infectious organisms could also be introduced through those skin openings. CNA A stated she could not recall when she last attended an hand hygiene or infection control in-service. During an interview on 10/27/2024 at 2:59PM the DON stated the facility's expectation would be for all clinical staff to follow the facility's policy and procedures regarding hand hygiene. The DON stated the facility does follow the CDC guidelines regarding hand hygiene. The DON stated his expectation would be for the clinical staff to remove contaminated gloves and perform hand hygiene prior to performing perineal care. The DON stated by adhering to the hand hygiene policy and procedures, the facility promotes infection control. The DON stated he could not for certain state that microorganisms were on Resident #1, but proceeded to state that microorganisms could live on various surfaces. The DON stated he could not definitively state that microorganisms were potentially introduced onto Resident #1, as he could not conclude a specific transmissional route. The DON stated infectious microorganism could potentially negatively affect the well-being of all residents, especially those who have chronic co-morbidities, which would include diabetes mellitus. The DON stated he does not believe microorganism would migrate upwards vaginally to cause infection as there are microorganisms present in the vaginal flora to the urinary tract. The DON continued by stating there could be a possible chance that unknown microorganisms, that potentially were on other surfaces around Resident #1, could have been introduced onto Resident #1, which could have potentially caused infection. The DON stated he would address hand hygiene adherence by conducting an impromptu hand hygiene in-service starting 10/27/2024. Record review of the facility's Handwashing/Hand Hygiene policy and procedure date implemented 2019, date revised January 2023 documented, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for situations such as this (including but not limited to): Before moving from contaminated/soiled to clean care or procedures; after handling used dressings, contaminated equipment etc.; between gloves changes/after removing gloves. Record review of the facility's Infection Control, Hand Hygiene and Perineal Care In-service dated 10/27/2024, documented topic: Remove gloves and wash hands before touching any items such as bed control, blankets, follow proper handing washing techniques was reviewed. Record Review of the CDC Guidelines regarding Clinical Safety: Hand Hygiene for Healthcare Workers, last reviewed February 27, 2024, stated, Healthcare providers should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, 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 resident's choices for 2 (Resident #2 and Resident #3) of 12 residents reviewed for quality of care. 1a. The facility failed to ensure that Resident #2's admission Assessment was accurately and timely documented in PCC on 9/16/23 when she returned to the facility from the hospital after having surgery. 1b. The facility failed to ensure that an incident in which Resident #2 cut her surgical incision drain tubing on 9/16/23 was timely documented. 2a. The facility failed to ensure that Resident #3's Post Fall Review was documented accurately and timely in PCC after she fell on 6/15/24. 2b. The facility failed to ensure that Resident #3's Neuro Checks were accurately and timely documented in PCC after she fell on 6/15/24. 2c. The facility failed to ensure that Resident #3's progress notes were timely documented in PCC on 6/15/24 and 6/16/24. 2d. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she began to experience pain on her right leg on 6/16/24. 2e. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she had bleeding from her surgical site incision on her right leg on 6/21/24. These failures could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Record review of Resident #2's admission record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included Alzheimer's disease, unspecified dementia, anxiety disorder, depressive episodes, hypertension (high blood pressure), hypertensive chronic kidney disease (kidney disease due to kidney damage done by high blood pressure), malignant neoplasm of left female breast (breast cancer), acquired absence of left breast and nipple (surgical removal of the breast), and cognitive communication deficit (difficulty with communication). Record review of Resident #2's quarterly MDS dated [DATE] reflected that Resident #2 had a BIMS score of 3 out of 15 which indicated that she had severe cognitive impairment. Resident #2 required total assistance with bathing/ showering. Resident #2 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off shoes, personal hygiene, rolling left and right in bed, sitting to lying flat on the bed, lying on the bed to sitting on the edge of the bed (without back support), transferring from bed to chair or chair to bed, getting on or off a toilet, getting into or out of a tub or shower, walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet. Record review of Resident #2's care plan reflected that Resident #2 had focuses of: A. Impaired cognitive function or though processes r/t Alzheimer's and dementia with interventions that included cue, reorient, and supervise as needed which was initiated and created on 5/10/21, B. ADL self-care performance deficit r/t Alzheimer's with interventions that included Resident #2 requiring set up assistance for toileting, transfers, repositioning in bed, dressing and eating which was initiated and created on 5/10/21, C. Bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21, and D. Requirement of anti-depressant medication r/t anxiety which was created and initiated on 4/3/21. E. Risk for falls r/t wandering which was created and initiated on 4/3/21. Record review of Resident #2's Provider Order Summary Report reflected that Resident #2 had the following side effect monitoring and medication orders: a. Side effects- anti-convulsant order date 4/2/21. b. Side effects- anti-depressant order date 4/2/21. c. Side effects- sedative/ hypnotic order date 6/27/22. d. Depakote Delayed Release 125mg. Give 1 tablet PO BID for agitation. e. Lamotrigine 25mg. Give 2 tablets PO every morning and at bedtime for convulsions. f. Losartan Potassium 50mg. Give 1 tablet PO one time a day for HTN. g. Trazadone HCl 50mg. Give 1 tablet PO BID for anxiety and agitation. Record review of Resident #2's admission assessment dated [DATE] at 4:41pm and signed by RN B on 9/21/23 reflected the following: a. The resident required catheter care/ catheter change. b. No EBP (enhanced barrier precautions) were clinically indicated. (Resident #2 had a surgical incision and a surgical drain from a left breast mastectomy that was done on 9/15/23) c. Actual or risk for infection- Focus: at risk for infection or recurrent/ chronic infection r/t compromised medical condition with interventions of report changes in condition to provider as clinically indicated and enhanced barrier precautions practices as clinically indicated. d. A catheter was required post-surgery J [NAME] (a surgical suction drain that gently draws fluid from a surgical site) with intervention of monitor for s/s (signs or symptoms) of infection. e. Vitals, Height, Weight: 1. Most recent weight: 167.5 pounds dated 9/1/23 at 3:58pm 2. Most recent height: 56 inches dated 4/5/21 at 8:24am 3. Most recent blood pressure: 109/83 dated 9/17/23 at 8:01am (1 day AFTER the effective date of this assessment which was 9/16/23 at 4:41pm) 4. Most recent temperature: 97.0 F dated 7/31/23 at 11:35pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 5. Most recent pulse: 72 dated 9/4/23 at 9:37am (12 days PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 6. Most recent respiration: 18 dated 7/31/23 at 11:24pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 7. Most recent O2 sats (oxygen saturation): 98% dated 7/31/23 at 11:25pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 8. Most recent pain level: 0 dated 9/16/23 at 7:15pm (2 hours AFTER the effective date/time of this assessment which was 9/16/23 at 4:41pm) f. Resident's communication is impaired related to: Not Applicable. (Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment) g. Head to toe skin assessment: 1. General skin condition: normal (Resident #2 had a left breast mastectomy on 9/15/23) 2. Skin condition: skin is intact, no identified skin issues (Resident #2 had a left breast mastectomy on 9/15/23) 2e. Skin concern/ risk plan of care: Focus: actual or at risk for skin impairment Interventions: apply treatment as ordered, keep clean and dry and apply skin barrier cream as indicated, pressure relieving cushion device in wheelchair as indicated, therapeutic pressure reducing mattress. (Did not address the surgical incision from Resident #2's left breast mastectomy on 9/15/23) h. Degree of physical activity- Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) i. Mobility- Ability to change and control body position: No limitations: makes major and frequent changes in position. (Contradictory to the above assessment answer that Resident #2's ability to walk was severely limited or non-existent). j. Friction and shear- No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. (Contradictory to assessment answer (h) that Resident #2's ability to walk was severely limited or non-existent). k. Incontinence- Resident is incontinent to: Neither. (Contradictory to Resident #2's care plan which reflected bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21). l. Fall risk assessment: 1. Recent falls: none in the last 12 months. (Resident #2 had an actual fall dated 9/20/22) 2. Medications (hypnotics, sedatives, anxiolytics, anti-depressants, anti-Parkinson's, diuretics, anti-hypertensives): Not taking any of these medications. (Contradictory to Resident #2's order summary report which reflected she was taking an anxiolytic, anti-depressant, and an anti-hypertensive). 3. Psychological (anxiety, depression, decline in cooperativeness, decline in insight/judgement): Does not appear to have any of these. 4. Cognitive status: Intact. (Contradictory to Resident #2's BIMS score of 3 which indicated severe cognitive impairment). 5. Automatic high risk status: Recent change in functional status and/or medications with the potential to affect safe mobility. (This answer contradicted the answer to (2) above which stated Resident #2 was not on medications with the potential to affect safe mobility). m. Exit seeking Tool: Is the resident physically able to leave the building on their own? no n. Hot liquid evaluation: None of the boxes are checked. o. If any boxes are checked yes, indicate which interim measures were put into place to enhance safety while therapy screen is pending: Focus- Resident has the potential for skin impairment/ burn r/t hot liquid encounters; needs disposable plastic lid on coffee cup for safety. (None of the boxes were checked for hot liquid evaluation). p. 48 hour care planning: 1. Care plan for self-care deficit- Focus: I have a self-care deficit. Intervention: Mobility- I use a wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) 2. Care Plan- Cognitive function/ dementia or impaired thought Process is not included. 3. Fall risk plan of care- Focus: at risk for falls r/t wandering. Actual fall 9/20/22. Record review of Resident #2's progress notes in PCC reflected an entry as follows: Late Entry Effective date: 9/16/23 at 12:47pm Created by: DON Created date: 10/9/23 at 12:52pm Note text: During rounds, was advised by SN (skilled nurse) and supervisor noted Jackson Pratt to have an incision made by the resident on the Jackson Pratt's tubing. This information was communicated to the PA (physician's assistant) and orders were given to seal the drainage tube and follow up with the surgeon. Nursing was able to seal the Jackson Pratt tube and drainage was noted at the end of the shift. No s/s of infection were noted in the area or to the resident's mastectomy area. 2. Record review of Resident #3's admission record reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Alzheimer's disease, dementia, fall from bed (1/18/24), displaced intertrochanteric fracture of right femur (non-aligned fracture of the right thigh bone at the hip) (1/18/24), age-related osteoporosis (bone disease that causes bones to become weak and more likely to break) without current pathological fracture (broken bone not caused by force or impact) (1/16/24), polyosteoarthritis (pain in five or more joints at the same time), and generalized muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] reflected that Resident #3 had a BIMS score of 0 of 15 and a cognitive skills for daily decision making score of 3 which indicated severe impairment- resident never/rarely made decisions. Resident #3 required substantial/ maximal assistance for toileting hygiene, shower/ bathing self, lower body dressing, and putting on/ taking off footwear, rolling left and right in bed, sit on side of bed to lying flat on the bed, and transferring to and from a bed to chair (or wheelchair). Resident #3 required partial/ moderate assistance for upper body dressing, standing from a sitting position, and walking 10 feet. Resident #3 required supervision or touch assistance for personal hygiene. Resident #3 required set up or clean up assistance for eating and oral hygiene. Resident #3 did not attempt to walk 50 feet with two turns or to walk 150 feet due to medical condition or safety concerns nor did Resident #3 attempt to get on or off a toilet or get into or out of a tub/shower as she did not perform these activities in the past. Record review of Resident #3's care plan reflected Resident #3 had focuses of: A. Risk for falls r/t impaired cognition/mobility, poor safety awareness with goals of 1-3 fewer falls through next review date, not experiencing any significant injuries associated with a fall through next review date, and safety r/t falls will be managed with interventions for orthostatic hypotension (a condition where blood pressure drops when changing positions from saying to sitting and sitting to standing) through review date. Interventions included anticipate and meet needs, call bell within reach, bed at appropriate height when unattended, room rearrange Resident #7's bed closer to hers, routine rounds to help with safety checks by all team members, and call light sign B. Requirement of psychotropic medications and at potential risk for side effects with an intervention of educate care givers that sometimes a behavior outburst can indicate pain, hunger, thirst, or need of toileting, rest, activity, or comforting. C. Risk for experiencing discomfort or pain r/t history of right hip fractur and left distal femur fracture with interventions including Resident #3 being able to participate in pain assessment using the numerical pain scale. Record review of Resident #3's provider order summary report as of 6/15/24 reflected that Resident #3 had the following side effect monitoring and medication orders: a. Anti-depressant side effect monitoring. b. Anti-anxiety side effect monitoring. c. Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety. Ordered on 6/11/24) d. Amlodipine Besylate 10mg. Give 1 tablet PO once a day for HTN. Record review of Resident #3's Post Fall Review in PCC dated 6/15/24 at 7:08pm and signed by the DON on 6/19/24 reflected the following: 1. Date and time of fall: 6/15/24 at 7:00pm 2. Was the fall observed: No. 3. Most recent blood pressure: 152/74 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 4. Most recent pulse: 71 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 5. Most recent O2 sats: 97% on 6/18/24 at 11:20am (3 days AFTER the Post Fall Review effective date of 6/15/24). 6. Has patient received 1 or more of the following in the past 24 hours (antianxiety, anticoagulant, antipsychotic, cardiovascular, diuretic, hypnotic, or pain medication)? None of the boxes were checked. (Contradictory to Resident #3's order summary report which reflected that she was taking an anti-anxiety and an anti-hypertensive medication). Record review of Resident #3's Neuro Checks in PCC dated 6/15/24 at 7:00pm and signed by the DON on 6/19/24 reflected the following: The neuro checks were to be done every 15 minutes- 4 times (6/15/24 at 7:15pm, 7:30pm, 7:45pm, and 8:00pm), every 30 minutes- 4 times (6/15/24 at 8:30pm, 9:00pm, 9:30pm, and 10:00pm), every 1 hour- 4 times (6/15/24 at 11:00pm, 6/16/24 at 12:00am, 1:00am, and 2:00am), every 2 hours- 4 times (6/16/24 at 4:00am, 6:00am, 8:00am, and 10:00am), every 4 hours- 2 times (6/16/24 at 2:00pm and 6:00pm) and every 8 hours- 6 times (6/17/24 at 2:00am, 10:00am, 6:00pm, 6/18/24 at 2:00am, 10:00am, and 6:00pm). 1. 15 minute check-1st: A. Date/time: 6/15/24 at 7:15pm B.1. Level of consciousness: Alert C.1. Pupil response: Pupils equal and reactive to light: yes 2. Right pupil: Brisk 3. Left pupil: Brisk D.1.Motor functions: Hand grasps: Hand grasps are equal. 2. Moves all extremities: Yes 3. Moves right arm: Yes 4. Moves left arm: Yes 5. Moves right leg: Yes 6. Moves left leg: Yes 7. Unable to follow commands: No 8. Absent: No E.1. Resident response to pain: Appropriate pain response 2. Most recent pain level: 0 on 6/17/24 at 6:53am. (2 days AFTER the Neuro checks effective date of 6/15/24) F.1. Vitals: Most recent blood pressure: 128/79 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 2. Most recent temperature: 98.0 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). 3. Most recent pulse: 66 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 4. Most recent respiration: 18 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). G. Observations: no neuro deficits The next 11 of the Neuro Checks were dated and timed correctly for when Resident #3 was supposed to be neurologically assed, however ALL of the vital signs (Sections E2 and F1-4) were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 2 days AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) these neurological assessments were documented as being completed. The 1st 2 hour check was incorrectly timed for 3:00am on 6/16/24. The correct date/time was 6/16/24 at 4:00am. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 2nd 2 hour check was incorrectly timed for 5:00am on 6/16/24. The correct date/time was 6/16/24 at 6:00am. The only documentation done was: B.1. Level of consciousness: Alert C.1. Pupil response: Pupils are equal and reactive to light: Yes 2. Right pupil: Brisk 3. Left pupil: Brisk Sections D.1-8 (motor function) and E.1 (Resident response to pain) were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 3rd and 4th 2 hour check were dated correctly but timed incorrectly. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) the neurological assessments were documented as being completed. The 1st and 2nd 4 hour checks, and all 6 of the 8 hour checks were blank where the assessment date and time were to be documented. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 6/17/24 (pain level, blood pressure, and pulse) or 4/18/24 (temperature and respirations). Record review of Resident #3's progress notes dated 6/11/24 to 6/28/24 in PCC reflected that Hydroxyzine (an anti-anxiety medication) was ordered on 6/11/24. Resident #3 received Hydroxyzine on 6/14/24 at 12:23pm. The following progress notes were late entries: 1. Type: Nursing progress note Effective: 6/15/24 at 9:28am Created: 6/18/24 at 10:30am Created by: DON Note: Resident performing restorative therapy with Restorative aide at this time, patient tolerated well restorative therapy. RP was notified. 2. Type: Nursing progress note Effective: 6/15/24 at 3:30pm Created: 6/18/24 at 10:31am Created by: DON Note: Family member was present at this time with resident. RP was helping resident to ambulate around the facility, resident was ambulating with the help of a walker. No pain noted at this time. 3. Type: Nursing progress note Effective: 6/15/24 at 7:00pm Created: 6/18/24 at 10:38am Created by: DON Notes: Informed by medication aide that resident was found on her knees next to her family member's bed. Upon entering the room, nurse noted resident was on her knees beside the bed. Resident stated she was trying to go and check on her family member, who is her roommate. With the assistance of CNA, SN carefully transferred the resident back to her own bed. A thorough head-to-toe assessment was conducted immediately, and no skin injuries, edema, or bruising were noted. ROM as previously noted with no s/s of pain to all four extremities. Notified MD and RP of incident. 4. Type: Nursing progress note Effective: 6/15/24 at 9:00pm Created: 6/18/24 at 10:40am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. RP was notified. 5. Type: Nursing progress note Effective: 6/15/24 at 11:15pm Created: 6/18/24 at 10:46am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. 6. Type: Nursing progress note Effective: 6/16/24 at 12:30am Created: 6/18/24 at 10:49am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 7. Type: Nursing progress note Effective: 6/16/24 at 4:00am Created: 6/18/24 at 10:50am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 8. Type: eINTERACT SBAR Summary for Providers Effective 6/18/24 at 7:00am Created: 6/18/24 at 11:01am Created by: RN B Situation: Pain to right leg with movement This started on: 6/16/24 (no time or time of day documented) Summarize your observations, evaluation, and recommendations: This morning, nurse was informed by the CNA that while changing resident and preparing for breakfast, noticed swelling above her right knee. Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg. Describe functional status changes: (Choices were needs more assistance with ADLs, general weakness, decreased mobility, fall, swallowing difficulty, no changes observed, and other). No changes were observed was checked. (Contradictory to the summarized statement that Resident #3 experienced pain when moving her leg. Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 128/79 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent pulse: 66 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent respiration: 18 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent temperature: 98.0 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent O2 sats: 98% dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Provider notification and feedback: Date and time of clinician notification: 6/16/24 at 12:00am (7 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Recommendations of primary clinician: No bruising or signs of trauma noted at this time. Nurse immediately administered pain medication, advised CNA to leave the resident in bed, and notified the doctor of the situation. New orders were received for an x-ray of the right hip and knee. Pain status evaluation: Is a pain assessment relevant to the change in condition being reported? Answer: Not clinically applicable to the change in condition being reported. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Does the resident have pain: Not answered. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Pain location: Not answered. (See above) General background information: Primary diagnosis: not answered. List any medication changes made in the past week: Not answered. (Contradictory to the Order Summary Report as of 6/15/24 which reflected Resident #3 had an order for Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety that was ordered on 6/11/24) Resident representative notification: Date and time of family/ RP notification: 6/16/24 at 12:00am (7 hours before the effective date/time of 6/16/24 at 7:00am) 9. Type: Nursing progress note Effective: 6/16/24 at 3:00pm Created: 6/18/24 at 10:57am Note: The resident applied a right knee orthopedic brace. At this time, resident was noted trying to get out of bed. SN was at bedside. CNA stayed at the bedside to provide immediate supervision to prevent further injury. The resident was reoriented to time and place and rested comfortably in bed. RP was notified of nursing intervention at this time. 10. Type: eINTERACT SBAR Summary for Providers Effective: 6/21/24 at 9:15am Created: 6/23/24 at 11:17pm Created by: RN B Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 133/70 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent pulse: 74 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent respiration: 18 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent temperature: 97.8 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent weight: 127.0 dated 6/1/24 at 7:29pm. Most recent O2 sats: 97% dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Provider notification and feedback: Were the change in condition and notifications reported to primary care clinician: Yes Date and time of clinician notification: 6/21/24 at 12:00am (9 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). In an interview on 10/30/24 at 1:57pm RN C stated she had been working at the facility for 5 years. When asked about the readmission process, RN C stated when a resident was admitted after a hospital stay as a readmission, a progress note was put in the computer, and admission assessment was done, the primary provider would be notified, and any new orders would be entered. RN C stated the readmission assessment was done immediately upon the resident's arrival in the facility. RN C stated in reference to the resident's most recent vital signs, that they were on the top of the page in PCC. RN C stated there was a button to click that had recent vital signs that showed the previous vital signs, but you had to click on each one individually. In reference to what would be documented in the progress notes, RN C stated that any orders that were given, any risk management documentation, appointments, and any information that would need to be passed on to the next shift should be documented in the progress notes. RN C stated the SBAR was its own assessment but showed up in progress notes. RN C stated an SBAR and change in condition would be done for fever, abnormal vital signs, lethargy, and anything that has to do with a change in the resident's condition. RN C stated that progress notes were to be documented immediately. RN C stated notifications to the RP, provider, and ADON/ DON were done and documented immediately in PCC in the change in condition documentation. RN C stated she was familiar with Resident #2 and had her as a patient after her mastectomy. RN C stated she was not working the day of the incident with Resident #2's JP drain, but she was told that Resident #2 pulled out her JP drain. RN C stated Resident #2 had dementia, forgot things right away, and had to be redirected frequently. RN C stated the nurse who was in charge when the JP drain incident happened fixed the drain and it was still draining. LVN C stated if something like that happened on her shift, she would notify the surgeon, the RP and the DON immediately to see what the plan of action was. RN C stated the documentation would include the change in condition form or a risk management form in PCC and a progress note would be written, also in PCC. RN C stated the progress note would have a summary of what happened, who was contacted, and what the plan of care was. RN C stated the risk management documentation would have more detailed information and it would automatically generate the date, time, and resident information at the top of the form. In an interview on 10/30/24 at 2:37pm, the ADON stated she had been working at the facility as a floor nurse for 2 years, became the DCE (Director of Clinical Education) for 2 ½ years and then became the ADON. The ADON stated when a resident was gone for a little while (to the hospital) a readmission assessment, medication reconciliation, and the whole screening and care planning were done again when the resident returned. The ADON stated anything that was new or changed was revised in orders and/ or care plans. The ADON stated when someone returned to the facility, the head to toe assessment and vital signs were done as soon as they got to the facility. The ADON stated the vital signs were pulled automatically to the admission form and the nurse had to change them to the correct vital signs. The ADON stated progress notes were used for documenting any changes, new orders, appointments, and anything related to the resident's clinical status. The ADON stated that change in condition documentation was used for any changes, critical laboratory result and any change in a resident's condition. The ADON stated it was done at the time of the change in condition. The ADON stated the provider, RP and DON were notified for any change in condition immediately. The ADON stated that falls were to be documented and notifications made immediately. The ADON stated she was familiar with Resident #2 but that she (the ADON) was the DCE when Resident #2 got her mastectomy and was not familiar with the JP drain issue. The ADON stated if a JP drain got pulled out or the tubing cut, she would notify the surgeon and the RP right away and the notification would be documented on the progress notes and the SBAR. The

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that were accurately documented for 2 (Resident #2 and Resident #3) of 12 residents reviewed for clinical records. 1a. The facility failed to ensure that Resident #2's admission Assessment was accurately and timely documented in PCC on 9/16/23 when she returned to the facility from the hospital after having surgery. 1b. The facility failed to ensure that an incident in which Resident #2 cut her surgical incision drain tubing on 9/16/23 was timely documented. 2a. The facility failed to ensure that Resident #3's Post Fall Review was documented accurately and timely in PCC after she fell on 6/15/24. 2b. The facility failed to ensure that Resident #3's Neuro Checks were accurately and timely documented in PCC after she fell on 6/15/24. 2c. The facility failed to ensure that Resident #3's progress notes were timely documented in PCC on 6/15/24 and 6/16/24. 2d. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she began to experience pain on her right leg on 6/16/24. 2e. The facility failed to ensure that Resident #3's Change in Condition Evaluation was documented accurately and timely in PCC when she had bleeding from her surgical site incision on her right leg on 6/21/24. These failures could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment. The findings included: 1. Record review of Resident #2's admission record reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2's diagnoses included Alzheimer's disease, unspecified dementia, anxiety disorder, depressive episodes, hypertension (high blood pressure), hypertensive chronic kidney disease (kidney disease due to kidney damage done by high blood pressure), malignant neoplasm of left female breast (breast cancer), acquired absence of left breast and nipple (surgical removal of the breast), and cognitive communication deficit (difficulty with communication). Record review of Resident #2's quarterly MDS dated [DATE] reflected that Resident #2 had a BIMS score of 3 out of 15 which indicated that she had severe cognitive impairment. Resident #2 required total assistance with bathing/ showering. Resident #2 required supervision or touch assistance with eating, oral hygiene, toileting hygiene, upper and lower body dressing, putting on/ taking off shoes, personal hygiene, rolling left and right in bed, sitting to lying flat on the bed, lying on the bed to sitting on the edge of the bed (without back support), transferring from bed to chair or chair to bed, getting on or off a toilet, getting into or out of a tub or shower, walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet. Record review of Resident #2's care plan reflected that Resident #2 had focuses of: A. Impaired cognitive function or though processes r/t Alzheimer's and dementia with interventions that included cue, reorient, and supervise as needed which was initiated and created on 5/10/21, B. ADL self-care performance deficit r/t Alzheimer's with interventions that included Resident #2 requiring set up assistance for toileting, transfers, repositioning in bed, dressing and eating which was initiated and created on 5/10/21, C. Bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21, and D. Requirement of anti-depressant medication r/t anxiety which was created and initiated on 4/3/21. E. Risk for falls r/t wandering which was created and initiated on 4/3/21. Record review of Resident #2's Provider Order Summary Report reflected that Resident #2 had the following side effect monitoring and medication orders: a. Side effects- anti-convulsant order date 4/2/21. b. Side effects- anti-depressant order date 4/2/21. c. Side effects- sedative/ hypnotic order date 6/27/22. d. Depakote Delayed Release 125mg. Give 1 tablet PO BID for agitation. e. Lamotrigine 25mg. Give 2 tablets PO every morning and at bedtime for convulsions. f. Losartan Potassium 50mg. Give 1 tablet PO one time a day for HTN. g. Trazadone HCl 50mg. Give 1 tablet PO BID for anxiety and agitation. Record review of Resident #2's admission assessment dated [DATE] at 4:41pm and signed by RN B on 9/21/23 reflected the following: a. The resident required catheter care/ catheter change. b. No EBP (enhanced barrier precautions) were clinically indicated. (Resident #2 had a surgical incision and a surgical drain from a left breast mastectomy that was done on 9/15/23) c. Actual or risk for infection- Focus: at risk for infection or recurrent/ chronic infection r/t compromised medical condition with interventions of report changes in condition to provider as clinically indicated and enhanced barrier precautions practices as clinically indicated. d. A catheter was required post-surgery J [NAME] (a surgical suction drain that gently draws fluid from a surgical site) with intervention of monitor for s/s (signs or symptoms) of infection. e. Vitals, Height, Weight: 1. Most recent weight: 167.5 pounds dated 9/1/23 at 3:58pm 2. Most recent height: 56 inches dated 4/5/21 at 8:24am 3. Most recent blood pressure: 109/83 dated 9/17/23 at 8:01am (1 day AFTER the effective date of this assessment which was 9/16/23 at 4:41pm) 4. Most recent temperature: 97.0 F dated 7/31/23 at 11:35pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 5. Most recent pulse: 72 dated 9/4/23 at 9:37am (12 days PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 6. Most recent respiration: 18 dated 7/31/23 at 11:24pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 7. Most recent O2 sats (oxygen saturation): 98% dated 7/31/23 at 11:25pm (2 months PRIOR to the effective date of this assessment which was 9/16/23 at 4:41pm) 8. Most recent pain level: 0 dated 9/16/23 at 7:15pm (2 hours AFTER the effective date/time of this assessment which was 9/16/23 at 4:41pm) f. Resident's communication is impaired related to: Not Applicable. (Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment) g. Head to toe skin assessment: 1. General skin condition: normal (Resident #2 had a left breast mastectomy on 9/15/23) 2. Skin condition: skin is intact, no identified skin issues (Resident #2 had a left breast mastectomy on 9/15/23) 2e. Skin concern/ risk plan of care: Focus: actual or at risk for skin impairment Interventions: apply treatment as ordered, keep clean and dry and apply skin barrier cream as indicated, pressure relieving cushion device in wheelchair as indicated, therapeutic pressure reducing mattress. (Did not address the surgical incision from Resident #2's left breast mastectomy on 9/15/23) h. Degree of physical activity- Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) i. Mobility- Ability to change and control body position: No limitations: makes major and frequent changes in position. (Contradictory to the above assessment answer that Resident #2's ability to walk was severely limited or non-existent). j. Friction and shear- No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. (Contradictory to assessment answer (h) that Resident #2's ability to walk was severely limited or non-existent). k. Incontinence- Resident is incontinent to: Neither. (Contradictory to Resident #2's care plan which reflected bladder incontinence r/t Alzheimer's and dementia with interventions that included check me as needed and as required for incontinence which was initiated and created on 5/10/21). l. Fall risk assessment: 1. Recent falls: none in the last 12 months. (Resident #2 had an actual fall dated 9/20/22) 2. Medications (hypnotics, sedatives, anxiolytics, anti-depressants, anti-Parkinson's, diuretics, anti-hypertensives): Not taking any of these medications. (Contradictory to Resident #2's order summary report which reflected she was taking an anxiolytic, anti-depressant, and an anti-hypertensive). 3. Psychological (anxiety, depression, decline in cooperativeness, decline in insight/judgement): Does not appear to have any of these. 4. Cognitive status: Intact. (Contradictory to Resident #2's BIMS score of 3 which indicated severe cognitive impairment). 5. Automatic high risk status: Recent change in functional status and/or medications with the potential to affect safe mobility. (This answer contradicted the answer to (2) above which stated Resident #2 was not on medications with the potential to affect safe mobility). m. Exit seeking Tool: Is the resident physically able to leave the building on their own? no n. Hot liquid evaluation: None of the boxes are checked. o. If any boxes are checked yes, indicate which interim measures were put into place to enhance safety while therapy screen is pending: Focus- Resident has the potential for skin impairment/ burn r/t hot liquid encounters; needs disposable plastic lid on coffee cup for safety. (None of the boxes were checked for hot liquid evaluation). p. 48 hour care planning: 1. Care plan for self-care deficit- Focus: I have a self-care deficit. Intervention: Mobility- I use a wheelchair. (Resident #2 was ambulatory with a walker and required only supervision or touch assistance with walking 10 feet, walking 50 feet with 2 turns, and walking at least 150 feet which was reflected in her MDS.) 2. Care Plan- Cognitive function/ dementia or impaired thought Process is not included. 3. Fall risk plan of care- Focus: at risk for falls r/t wandering. Actual fall 9/20/22. Record review of Resident #2's progress notes in PCC reflected an entry as follows: Late Entry Effective date: 9/16/23 at 12:47pm Created by: DON Created date: 10/9/23 at 12:52pm Note text: During rounds, was advised by SN (skilled nurse) and supervisor noted Jackson Pratt to have an incision made by the resident on the Jackson Pratt's tubing. This information was communicated to the PA (physician's assistant) and orders were given to seal the drainage tube and follow up with the surgeon. Nursing was able to seal the Jackson Pratt tube and drainage was noted at the end of the shift. No s/s of infection were noted in the area or to the resident's mastectomy area. 2. Record review of Resident #3's admission record reflected an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Alzheimer's disease, dementia, fall from bed (1/18/24), displaced intertrochanteric fracture of right femur (non-aligned fracture of the right thigh bone at the hip) (1/18/24), age-related osteoporosis (bone disease that causes bones to become weak and more likely to break) without current pathological fracture (broken bone not caused by force or impact) (1/16/24), polyosteoarthritis (pain in five or more joints at the same time), and generalized muscle weakness. Record review of Resident #3's quarterly MDS dated [DATE] reflected that Resident #3 had a BIMS score of 0 of 15 and a cognitive skills for daily decision making score of 3 which indicated severe impairment- resident never/rarely made decisions. Resident #3 required substantial/ maximal assistance for toileting hygiene, shower/ bathing self, lower body dressing, and putting on/ taking off footwear, rolling left and right in bed, sit on side of bed to lying flat on the bed, and transferring to and from a bed to chair (or wheelchair). Resident #3 required partial/ moderate assistance for upper body dressing, standing from a sitting position, and walking 10 feet. Resident #3 required supervision or touch assistance for personal hygiene. Resident #3 required set up or clean up assistance for eating and oral hygiene. Resident #3 did not attempt to walk 50 feet with two turns or to walk 150 feet due to medical condition or safety concerns nor did Resident #3 attempt to get on or off a toilet or get into or out of a tub/shower as she did not perform these activities in the past. Record review of Resident #3's care plan reflected Resident #3 had focuses of: A. Risk for falls r/t impaired cognition/mobility, poor safety awareness with goals of 1-3 fewer falls through next review date, not experiencing any significant injuries associated with a fall through next review date, and safety r/t falls will be managed with interventions for orthostatic hypotension (a condition where blood pressure drops when changing positions from saying to sitting and sitting to standing) through review date. Interventions included anticipate and meet needs, call bell within reach, bed at appropriate height when unattended, room rearrange Resident #7's bed closer to hers, routine rounds to help with safety checks by all team members, and call light sign B. Requirement of psychotropic medications and at potential risk for side effects with an intervention of educate care givers that sometimes a behavior outburst can indicate pain, hunger, thirst, or need of toileting, rest, activity, or comforting. C. Risk for experiencing discomfort or pain r/t history of right hip fractur and left distal femur fracture with interventions including Resident #3 being able to participate in pain assessment using the numerical pain scale. Record review of Resident #3's provider order summary report as of 6/15/24 reflected that Resident #3 had the following side effect monitoring and medication orders: a. Anti-depressant side effect monitoring. b. Anti-anxiety side effect monitoring. c. Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety. Ordered on 6/11/24) d. Amlodipine Besylate 10mg. Give 1 tablet PO once a day for HTN. Record review of Resident #3's Post Fall Review in PCC dated 6/15/24 at 7:08pm and signed by the DON on 6/19/24 reflected the following: 1. Date and time of fall: 6/15/24 at 7:00pm 2. Was the fall observed: No. 3. Most recent blood pressure: 152/74 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 4. Most recent pulse: 71 on 6/19/24 at 7:41am (4 days AFTER the Post Fall Review effective date of 6/15/24). 5. Most recent O2 sats: 97% on 6/18/24 at 11:20am (3 days AFTER the Post Fall Review effective date of 6/15/24). 6. Has patient received 1 or more of the following in the past 24 hours (antianxiety, anticoagulant, antipsychotic, cardiovascular, diuretic, hypnotic, or pain medication)? None of the boxes were checked. (Contradictory to Resident #3's order summary report which reflected that she was taking an anti-anxiety and an anti-hypertensive medication). Record review of Resident #3's Neuro Checks in PCC dated 6/15/24 at 7:00pm and signed by the DON on 6/19/24 reflected the following: The neuro checks were to be done every 15 minutes- 4 times (6/15/24 at 7:15pm, 7:30pm, 7:45pm, and 8:00pm), every 30 minutes- 4 times (6/15/24 at 8:30pm, 9:00pm, 9:30pm, and 10:00pm), every 1 hour- 4 times (6/15/24 at 11:00pm, 6/16/24 at 12:00am, 1:00am, and 2:00am), every 2 hours- 4 times (6/16/24 at 4:00am, 6:00am, 8:00am, and 10:00am), every 4 hours- 2 times (6/16/24 at 2:00pm and 6:00pm) and every 8 hours- 6 times (6/17/24 at 2:00am, 10:00am, 6:00pm, 6/18/24 at 2:00am, 10:00am, and 6:00pm). 1. 15 minute check-1st: A. Date/time: 6/15/24 at 7:15pm B.1. Level of consciousness: Alert C.1. Pupil response: Pupils equal and reactive to light: yes 2. Right pupil: Brisk 3. Left pupil: Brisk D.1.Motor functions: Hand grasps: Hand grasps are equal. 2. Moves all extremities: Yes 3. Moves right arm: Yes 4. Moves left arm: Yes 5. Moves right leg: Yes 6. Moves left leg: Yes 7. Unable to follow commands: No 8. Absent: No E.1. Resident response to pain: Appropriate pain response 2. Most recent pain level: 0 on 6/17/24 at 6:53am. (2 days AFTER the Neuro checks effective date of 6/15/24) F.1. Vitals: Most recent blood pressure: 128/79 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 2. Most recent temperature: 98.0 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). 3. Most recent pulse: 66 on 6/17/24 at 7:48am (2 days AFTER the Neuro checks effective date of 6/15/24). 4. Most recent respiration: 18 on 4/18/24 at 4:11am (2 months BEFORE the Neuro checks effective date of 6/15/24). G. Observations: no neuro deficits The next 11 of the Neuro Checks were dated and timed correctly for when Resident #3 was supposed to be neurologically assed, however ALL of the vital signs (Sections E2 and F1-4) were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 2 days AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) these neurological assessments were documented as being completed. The 1st 2 hour check was incorrectly timed for 3:00am on 6/16/24. The correct date/time was 6/16/24 at 4:00am. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 2nd 2 hour check was incorrectly timed for 5:00am on 6/16/24. The correct date/time was 6/16/24 at 6:00am. The only documentation done was: B.1. Level of consciousness: Alert C.1. Pupil response: Pupils are equal and reactive to light: Yes 2. Right pupil: Brisk 3. Left pupil: Brisk Sections D.1-8 (motor function) and E.1 (Resident response to pain) were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) this neurological assessment was documented as being completed. The 3rd and 4th 2 hour check were dated correctly but timed incorrectly. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 1 day AFTER (pain level, blood pressure, and pulse) or 2 months BEFORE (temperature and respirations) the neurological assessments were documented as being completed. The 1st and 2nd 4 hour checks, and all 6 of the 8 hour checks were blank where the assessment date and time were to be documented. All the questions in sections A through E.1 were blank. Sections E.2 and F.1-4 were documented with the same date/time and values that were documented for the neurological assessment that was completed for 6/15/24 at 7:15pm. Those vital signs were dated either 6/17/24 (pain level, blood pressure, and pulse) or 4/18/24 (temperature and respirations). Record review of Resident #3's progress notes dated 6/11/24 to 6/28/24 in PCC reflected that Hydroxyzine (an anti-anxiety medication) was ordered on 6/11/24. Resident #3 received Hydroxyzine on 6/14/24 at 12:23pm. The following progress notes were late entries: 1. Type: Nursing progress note Effective: 6/15/24 at 9:28am Created: 6/18/24 at 10:30am Created by: DON Note: Resident performing restorative therapy with Restorative aide at this time, patient tolerated well restorative therapy. RP was notified. 2. Type: Nursing progress note Effective: 6/15/24 at 3:30pm Created: 6/18/24 at 10:31am Created by: DON Note: Family member was present at this time with resident. RP was helping resident to ambulate around the facility, resident was ambulating with the help of a walker. No pain noted at this time. 3. Type: Nursing progress note Effective: 6/15/24 at 7:00pm Created: 6/18/24 at 10:38am Created by: DON Notes: Informed by medication aide that resident was found on her knees next to her family member's bed. Upon entering the room, nurse noted resident was on her knees beside the bed. Resident stated she was trying to go and check on her family member, who is her roommate. With the assistance of CNA, SN carefully transferred the resident back to her own bed. A thorough head-to-toe assessment was conducted immediately, and no skin injuries, edema, or bruising were noted. ROM as previously noted with no s/s of pain to all four extremities. Notified MD and RP of incident. 4. Type: Nursing progress note Effective: 6/15/24 at 9:00pm Created: 6/18/24 at 10:40am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. RP was notified. 5. Type: Nursing progress note Effective: 6/15/24 at 11:15pm Created: 6/18/24 at 10:46am Created by: DON Note: Resident was rounded at this time, no c/o pain or discomfort noted, and no s/s of distress. 6. Type: Nursing progress note Effective: 6/16/24 at 12:30am Created: 6/18/24 at 10:49am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 7. Type: Nursing progress note Effective: 6/16/24 at 4:00am Created: 6/18/24 at 10:50am Created by: DON Note: CNA provided incontinent care at this time; no signs and symptoms of pain were noted, and the resident continued to sleep in bed comfortably. 8. Type: eINTERACT SBAR Summary for Providers Effective 6/18/24 at 7:00am Created: 6/18/24 at 11:01am Created by: RN B Situation: Pain to right leg with movement This started on: 6/16/24 (no time or time of day documented) Summarize your observations, evaluation, and recommendations: This morning, nurse was informed by the CNA that while changing resident and preparing for breakfast, noticed swelling above her right knee. Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg. Describe functional status changes: (Choices were needs more assistance with ADLs, general weakness, decreased mobility, fall, swallowing difficulty, no changes observed, and other). No changes were observed was checked. (Contradictory to the summarized statement that Resident #3 experienced pain when moving her leg. Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 128/79 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent pulse: 66 dated 6/17/24 at 7:48am (1 day AFTER the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent respiration: 18 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent temperature: 98.0 dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Most recent O2 sats: 98% dated 4/18/24 at 4:11am (2 months BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Provider notification and feedback: Date and time of clinician notification: 6/16/24 at 12:00am (7 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/time of 6/16/24 at 7:00am). Recommendations of primary clinician: No bruising or signs of trauma noted at this time. Nurse immediately administered pain medication, advised CNA to leave the resident in bed, and notified the doctor of the situation. New orders were received for an x-ray of the right hip and knee. Pain status evaluation: Is a pain assessment relevant to the change in condition being reported? Answer: Not clinically applicable to the change in condition being reported. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Does the resident have pain: Not answered. (Contradictory to the summarized statement of, Upon assessment, resident complained of tender pain and could move her feet from side to side without pain but experienced pain when moving her leg.) Pain location: Not answered. (See above) General background information: Primary diagnosis: not answered. List any medication changes made in the past week: Not answered. (Contradictory to the Order Summary Report as of 6/15/24 which reflected Resident #3 had an order for Hydroxyzine HCl. Give 12.5 mg by mouth every 8 hours as needed for anxiety that was ordered on 6/11/24) Resident representative notification: Date and time of family/ RP notification: 6/16/24 at 12:00am (7 hours before the effective date/time of 6/16/24 at 7:00am) 9. Type: Nursing progress note Effective: 6/16/24 at 3:00pm Created: 6/18/24 at 10:57am Note: The resident applied a right knee orthopedic brace. At this time, resident was noted trying to get out of bed. SN was at bedside. CNA stayed at the bedside to provide immediate supervision to prevent further injury. The resident was reoriented to time and place and rested comfortably in bed. RP was notified of nursing intervention at this time. 10. Type: eINTERACT SBAR Summary for Providers Effective: 6/21/24 at 9:15am Created: 6/23/24 at 11:17pm Created by: RN B Vital signs evaluation: Are these the most recent vital signs taken after the change in condition occurred: Yes Most recent blood pressure: 133/70 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent pulse: 74 dated 6/23/24 at 7:21pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent respiration: 18 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent temperature: 97.8 dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Most recent weight: 127.0 dated 6/1/24 at 7:29pm. Most recent O2 sats: 97% dated 6/23/24 at 2:38pm (2 days AFTER the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). Provider notification and feedback: Were the change in condition and notifications reported to primary care clinician: Yes Date and time of clinician notification: 6/21/24 at 12:00am (9 hours BEFORE the eINTERACT SBAR Summary for Providers effective date/ time of 6/21/24 at 9:15am). In an interview on 10/30/24 at 1:57pm RN C stated she had been working at the facility for 5 years. When asked about the readmission process, RN C stated when a resident was admitted after a hospital stay as a readmission, a progress note was put in the computer, and admission assessment was done, the primary provider would be notified, and any new orders would be entered. RN C stated the readmission assessment was done immediately upon the resident's arrival in the facility. RN C stated in reference to the resident's most recent vital signs, that they were on the top of the page in PCC. RN C stated there was a button to click that had recent vital signs that showed the previous vital signs, but you had to click on each one individually. In reference to what would be documented in the progress notes, RN C stated that any orders that were given, any risk management documentation, appointments, and any information that would need to be passed on to the next shift should be documented in the progress notes. RN C stated the SBAR was its own assessment but showed up in progress notes. RN C stated an SBAR and change in condition would be done for fever, abnormal vital signs, lethargy, and anything that has to do with a change in the resident's condition. RN C stated that progress notes were to be documented immediately. RN C stated notifications to the RP, provider, and ADON/ DON were done and documented immediately in PCC in the change in condition documentation. RN C stated she was familiar with Resident #2 and had her as a patient after her mastectomy. RN C stated she was not working the day of the incident with Resident #2's JP drain, but she was told that Resident #2 pulled out her JP drain. RN C stated Resident #2 had dementia, forgot things right away, and had to be redirected frequently. RN C stated the nurse who was in charge when the JP drain incident happened fixed the drain and it was still draining. LVN C stated if something like that happened on her shift, she would notify the surgeon, the RP and the DON immediately to see what the plan of action was. RN C stated the documentation would include the change in condition form or a risk management form in PCC and a progress note would be written, also in PCC. RN C stated the progress note would have a summary of what happened, who was contacted, and what the plan of care was. RN C stated the risk management documentation would have more detailed information and it would automatically generate the date, time, and resident information at the top of the form. In an interview on 10/30/24 at 2:37pm, the ADON stated she had been working at the facility as a floor nurse for 2 years, became the DCE (Director of Clinical Education) for 2 ½ years and then became the ADON. The ADON stated when a resident was gone for a little while (to the hospital) a readmission assessment, medication reconciliation, and the whole screening and care planning were done again when the resident returned. The ADON stated anything that was new or changed was revised in orders and/ or care plans. The ADON stated when someone returned to the facility, the head to toe assessment and vital signs were done as soon as they got to the facility. The ADON stated the vital signs were pulled automatically to the admission form and the nurse had to change them to the correct vital signs. The ADON stated progress notes were used for documenting any changes, new orders, appointments, and anything related to the resident's clinical status. The ADON stated that change in condition documentation was used for any changes, critical laboratory result and any change in a resident's condition. The ADON stated it was done at the time of the change in condition. The ADON stated the provider, RP and DON were notified for any change in condition immediately. The ADON stated that falls were to be documented and notifications made immediately. The ADON stated she was familiar with Resident #2 but that she (the ADON) was the DCE when Resident #2 got her mastectomy and was not familiar with the JP drain issue. The ADON stated if a JP drain got pulled out or the tubing cut, she would notify the surgeon and the RP right away and the notification would be documented on the progress notes and the SBAR. The AD[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to promptly notify the residents' representatives immediately of a fall that occurred for one (Resident #1) of two residents reviewed for resident rights. The facility failed to immediately notify Resident #1's responsible party (RP) of a fall that occurred on 9/27/24. This failure could place residents who had falls with injury at risk for not receiving appropriate care and interventions. The findings included: Record review of Resident #1 face sheet dated 10/11/24 reflected an [AGE] year-old-female with an original admission date of 4/27/24. Diagnoses included urinary tract infection, heart failure, diabetes type 2 (insufficient production of insulin in the body), and chronic kidney disease. Record review of Resident #1's care plan dated 5/24/24 reflected Resident #1 was prescribed medication/medications that lends to a risk for abnormal bleeding, easily bruised and/or skin issues/injury. Resident # 1 had chronic health conditions & co-morbid conditions that have affected her physical function and may further affect her quality of life. Record review of Resident #1's MDS dated [DATE] reflected a BIM score of 5 (severe cognitive impairment) and was dependant for toileting, transfers, dressing, and bathing. In an interview with the ADM on 7/23/24 at 10:50 am. She stated there was no specific timeframe of when the family needed to be notified as long as they were notified of the fall that day. The ADM stated the doctor was aware Resident #1 rolled out of bed and did not order any x-rays and Resident #1 did not require to be sent out to the hospital as Resident #1 was not complaining of pain and had full range of motion to the extremities that were affected. The ADM stated LVN A did address Resident #1's small cut to the eyebrow and put a bandage on it. In a phone interview on 7/23/24 at 11:45 am LVN A stated Resident #1 had fallen on Sunday morning, 7/21/24. LVN A stated the day was really busy. LVN A stated during breakfast Resident #1 ate normal and after the plates were picked up, CNA B went and told him that she found Resident #1 on the floor while doing her rounds. LVN A stated he started to assess Resident #1 and noticed some swelling to her left eyebrow and slight swelling to left knee. LVN A stated after the assessment, he notified the doctor and the doctor stated to just treat the area and continue monitoring Resident #1 for any changes in condition. LVN A stated the doctor stated Resident #1 did not need to be sent out to the hospital and did not feel any other interventions were needed at that time. LVN A stated during that time, he was taking care of another resident who was very ill and was nearing the end of life. LVN A stated he continued to monitor Resident #1 and was not able to notify Resident #1's RP immediately but was going to. LVN A stated Resident #1's family member came to visit Resident #1 approximately 4 hours after the fall and that was when he informed Resident #1's family about what happened and how the doctor did not feel Resident #1 needed to be sent out at that time. LVN A stated he offered to contact the doctor again to see if he wanted to have Resident #1 sent out and the family refused. LVN A stated the family member called 911 themselves and Resident #1 was picked up by an ambulance and transferred to the hospital. In a phone interview on 7/23/24 at 12:37 pm Resident #1's RP stated on Sunday 7/21/23, a family member went to visit Resident #1 and saw Resident #1's face and called the RP and asked what was going on. Resident #1's RP stated she spoke to LVN A on the phone and stated LVN A apologized to her and stated that during the morning he went to check Resident #1's blood sugar and everything was fine and after that CNA B stated she found Resident #1 on the floor after she had a fall trying to get out of bed. Resident #1's RP stated it had been about 4 hours since Resident #1 fell to when they were informed and LVN A apologized again and stated he had not had a chance to call to inform Resident #1's RP. Resident #1's RP stated she understood LVN A was busy, but he could have taken one minute to call them. Resident #1's RP stated the facility called for everything that was going on with Resident #1 and was upset they did not call her right away about the fall. In an interview on 10/11/24 at 11:07 am the ADM stated LVN A was working with the family of a resident who was passing away and stated that everything happened so quick, but LVN A was going to communicate with the family since Resident #1 was stable. The ADM stated in-service on notifications was conducted with all staff. In an interview on 10/11/24 at 12:37pm the DON stated what he remembered from that day was one of the CNA's was doing their rounds and found Resident #1 on the floor and went and called LVN A. The DON stated LVN A did an assessment and Resident #1 had a laceration on her forehead and swelling to her knees. The DON stated LVN A notified the doctor and treated Resident #1 as ordered. The DON stated approximately 10 to 15 minutes after Resident #'1s fall, LVN A had to tend to another resident who was nearing the end of life and since Resident #1 was stable, the family was not notified immediately. The DON stated it was not done with malicious intent as there was just circumstances that day and resident needs were being prioritized. The DON stated everything was conducted in the best manner of the residents at that time. Record review of in-services dated 7/30/24 on falls, accident prevention, transfer safety, effective communication, answering of call lights, reporting any change in condition, anticipate resident needs, customer service, and abuse/neglect/exploitation. Record review of facility's Fall Prevention policy dated 3/28/22 stated: Post fall: The resident is physically evaluated for injuries and medical attention is rendered as needed. The physician and resident's representative are notified of the fall. The resident is interviewed as appropriate to provide input on circumstances surrounding fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents, Resident #105 (R #105), reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for R #105, use of anticoagulant medication. This deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs. The findings: Record review of R #105's Face Sheet revealed an [AGE] year-old female, with an original admission date of 12/22/2022. Diagnoses included, Type 2 diabetes (insufficient production of insulin in the body), Atherosclerotic Heart Disease (arteries become narrowed and hardened due to buildup of plaque (fats) in the artery wall), and cardiac pacemaker (small battery powered device that prevents the heart from beating too slowly), and Hypertension (high blood pressure). Record review of R #105's Quarterly Minimum Data Set, dated [DATE] revealed R #105 had a BIMS (Brief Interview Mental Status) of 06 (Severe Impairment) and requires Extensive Assistance with transfers and limited assistance with bed mobility, eating, toilet use, dressing, and personal hygiene. Record review of R #105's Care Plan dated 8/17/2023 revealed no care plan for anticoagulants. Record review of R #105's MDS had no indication of anticoagulant use. Record review of R #105's orders stated; -Clopidogrel Bisulfate Tablet 75 MG Give 1 tablet by mouth one time a day for blood clot prevention dated 6/29/2023 -Anticoagulant Medication Side Effect Monitoring- Code the following if identified:0-None, 1- Discolored Urine, 2- Black Tarry Stools, 3- Sudden Severe Headache, 4- N&V (nausea and vomitting), 5- Diarrhea, 6- Muscle Joint Pain, 7- Lethargy, 8- Bruising, 9- Sudden change in Mental Status 10- Vital Signs, SOB, Nose Bleeds every day shift dated 8/30/2023 Interview on 08/30/23 at 03:03 PM DON stated he looked through care plan for R #105 and revealed Plavix (Clopidogrel) is not shown to be care planned and should be. DON stated medication such as anticoagulants should be care planned by MDS Corridinator as it was person-centered and direct care staff need to be able to identify any adverse effects of anticoagulants and potential side effects such as bruising, bleeding or any other complications. Interview on 8/31/2023 at 10:29 AM with MDS (minimum data sheet) Coordinator stated all anticoagulants should be care planned for any resident receiving anticoagulant medications MDS Coordinator stated R #105's anticoagulant medication was missed and no reason why it was not care planned other than human error. MDS Coordinator stated anticoagulants are care planned so that all staff would be aware of the risk factors associated with such medications. MDS Coordinator stated, since medication was not care planned, staff would be unaware of the potential side effects of bruising and bleeding. MDS Coordinated stated R #105's Care plan has been updated as of 8/30/2023. Record review of Care Plan Policy dated 2/2017 and revised on 3/2020 indicated; The community develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan: -is developed within seven days of the completion of the comprehensive assessment; -is prepared by the interdisciplinary team, including the attending physician, a registered nurse with responsibility for the resident, and other appropriate team members in disciplines as determined by the resident's needs. The care plan reflects intermediate steps for each outcome objective if they will enhance the resident's ability to meet his or her objectives. Team members use these objectives to monitor resident progress.