Sanctuary at Wilmington Place The

Based on personnel file review, staff interview and review of information from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure a new employee received a second step Mantoux testing to screen for tuberculosis (TB). This had the potential to affect all 23 residents residing in the facility. The facility census was 23.

Findings include:

Review of Nursing Assistant (NA) #101's personnel file revealed the staff members hire date was 03/13/25. Further review of NA #101's personnel file revealed the staff receive the first step Mantoux testing for TB screening on 03/13/25. There was no evidence of a two step Mantoux testing for TB screening for NA #101.

Interview on 04/25/25 at 4:14 P.M. with Director of Nursing (DON) #104 verified NA #101 was hired on 03/13/25 and provided direct resident care. DON #104 confirmed NA #101 did not receive the second step Mantoux testing to screen for TB.

Review of CDC information titled Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 at https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm revealed all healthcare workers in a low and medium risk setting should receive baseline TB screening upon hire, using two-step tuberculin skin test (TST) or a single Blood Assay for M. tuberculosis (BAMT) to test for infection with M. tuberculosis.

Based on review of facility fire drills, staff interview, and policy review, the facility failed to ensure fire drills were conducted on the third shift as required. This had the potential to affect all 23 residents residing in the facility. The facility census was 23.

Findings included:

Review of the facility fire drills for the past year revealed the facility only held two fire drills on the third shift. The third shift fire drills were held on 06/30/24 and 03/31/25.

Interview on 04/24/25 at 1:52 P.M. with Maintenance Director (MD) #103 confirmed the facility only held two fire drills on the third shift which were on 06/30/24 and 03/31/25. MD #103 confirmed fire drills were not conducted as required on the third shift.

Review of a undated facility policy titled Drills, revealed fire exit drills is to be done quarterly on each shift.

Based on review of the medical record, interviews, observations, and policy review, the facility failed to administer medications according to physician orders. This affected three (#01, #12, and #60) of the three residents reviewed for medication administration. The facility census was 27. Findings include: 1) Review of the medical record for Resident #01 revealed an admission date of 08/16/24. Diagnoses included type two diabetes mellitus (DM II), cerebrovascular disease, and hypertension. Review of the Admission Assessment dated 08/16/24, revealed Resident #01 was alert and oriented to person, time, and place. Resident #01 was dependent on staff for medication administration. Review of a physician order dated 08/18/24, revealed Resident #01 was ordered FIASP (Insulin Aspart) flex pen Injection Solution 100 unit/milliliter (ml), to inject 12 units subcutaneously with meals for diabetes. Observation of the medication administration on 11/21/24 at 12:09 P.M., revealed Licensed Practical Nurse (LPN) #20 did not prime the insulin pen FIASP prior to administering 12 units into Resident #01's right lower quadrant of abdomen. Interview on 11/21/24 at 12:15 P.M. with LPN #20, verified she did not prime the insulin pen prior to administering 12 units to Resident #01. Review of manufacture instructions from FIASP revealed to prime the FIASP flex pen by turning the dose selector to two units, hold the pen with the needle pointing up, tap the top of the pen gently a few times to let any air bubbles rise to the top, and press and hold the doe button until the dose counter shows zero. A drop of insulin should be seen at the needle tip. If you do not see insulin, repeat steps no more than six times. https://www.novomedlink.com/diabetes/patient-support/product-education/library.html 2) Review of the medical record for Resident #12, revealed an admission date of 09/03/24 with a discharge date of 10/11/24. Diagnoses included spina bifida, paraplegia, bipolar disorder, and generalized anxiety disorder (GAD). Review of the Admission Assessment dated 09/03/24, revealed Resident #12 was alert and oriented to person, time, and place. Resident #12 was dependent on staff for medication administration. Review of the physician orders dated 09/04/24, revealed Resident #12 was ordered Buspar 15 milligrams (mg), give one tablet by mouth three times a day for anxiety and Flexeril 10 mg, give one tablet by mouth three times a day for muscle spasms. Review of the September 2024 medication administration record (MAR) revealed Resident #12 had missing documentation on the following days for Buspar and Flexeril. a) 09/04/24 for the 10:00 P.M. dose. b) 09/05/24 through 09/08/24 for the 6:00 A.M. doses. c) 09/10/24 through 09/14/24 for the 6:00 A.M. doses. ) 09/15/24 for the 10:00 P.M. dose. e) 09/16/24 for the 6:00 A.M. dose. f) 09/17/24 and 09/18/24 for the 10:00 P.M. doses. g) 09/18/24 and 09/19/24 for the 6:00 A.M. doses. h) 09/21/24 for the 6:00 A.M. and 10:00 P.M. doses. i) 09/22/24 through 09/24/24 for the 6:00 A.M., 2:00 P.M. and 10:00 P.M. doses. j) 09/25/24 and 09/26/24 for the 6:00 A.M. dose. k) 09/28/24 and 09/29/24 for the 6:00 A.M. dose. Review of the October 2024 MAR, revealed Resident #12 had missing documentation on the following days for Buspar and Flexeril: a) 10/01/24 through 10/06/24 for the 6:00 A.M. doses. b) 10/08/24 through 10/10/24 for the 6:00 A.M. doses. Interview on 11/26/24 at 8:42 A.M. with LPN #23, verified Resident #12's missing doses for September and October for Buspar and Flexeril. Interview on 11/27/24 at 9:32 A.M. with interim Director of Nursing (DON), verified staff were not signing off MAR's accurately including Resident #12. Interim DON reported that when we find missing documentation, we call staff in to complete documentation. 3) Review of the medical record for Resident #16, revealed an admission date of 09/18/24 with a readmission date of 11/18/24. Diagnoses included dementia, schizophrenia, type two diabetes mellitus (DM II), and hypertension. Review of the Admission Assessment dated 11/18/24, revealed Resident #16 was alert and oriented to person and place but disoriented to time. Resident #16 was dependent on staff for medication administration. Review of the physician order dated 09/19/24, revealed Resident #16 was ordered Clozapine 200 mg, give one tablet by mouth in the morning for schizophrenia. Review of the progress note dated 10/18/24, revealed Resident #16 did not receive his Clozapine 200 milligrams (mg) because it was on order with the pharmacy. Review of the progress note dated 10/19/24, revealed Resident #16 was sent to the hospital due to homicidal ideations and threats towards staff. Review of the hospital paperwork dated 10/19/24, revealed Resident #16 was admitted to the hospital for acute psychosis possibly related to medication withdrawal (clozapine). Resident #16 presented from nursing home for acute behavior changes and agitation over the past three days. Review of the medication administration record (MAR) dated October 2024 revealed Resident #16 did not receive Clozapine on 10/18/24. Interview on 11/21/24 at 4:16 p.m. with Pharmacy Representative (PR) #50, revealed the pharmacy reached out to the facility on 10/18/24 because of needing absolute neutrophil laboratory (lab) count (ANC) in order to fill the Clozapine. PR #50 reported a delivery of ten pills went to the facility around 8:30 P.M. Interview on 11/25/24 at 10:59 A.M. with interim Director of Nursing (DON), verified Resident #16 did not receive a dose on 10/18/24. Interview on 11/25/24 at 11:33 A.M. with LPN #22, revealed she sent Resident #16 out on 10/19/24 because he made threats about self-harm and others. LPN #22 reported he made a comment about slicing someone's neck to another staff member. LPN #22 spoke to the physician and received orders to send Resident #16 out by emergency services to be evaluated at the hospital. The family was notified. Interview on 11/25/24 at 4:20 P.M. with Social Services (SS) #80, revealed she had a care conference on 10/18/24 with Resident #16 and his sister. SS #80 stated LPN #21 reported he ran out of his medication because it wasn't filled yet and also reported some behavior changes. SS #80 reported she instructed LPN #21 to call pharmacy and find out what was going on with the medications. SS #80 stated the pharmacy needed an updated lab sent to them before they would fill the medication. SS #80 reported her findings to the interim DON and LPN #23. Review of the facility policy titled, Medication AdministrationBased on review of the medical record, interviews, observations, and policy review, the facility failed to administer medications according to physician orders. This affected three (#01, #12, and #60) of the three residents reviewed for medication administration. The facility census was 27.

Findings include:

1) Review of the medical record for Resident #01 revealed an admission date of 08/16/24. Diagnoses included type two diabetes mellitus (DM II), cerebrovascular disease, and hypertension.

Review of the Admission Assessment dated 08/16/24, revealed Resident #01 was alert and oriented to person, time, and place. Resident #01 was dependent on staff for medication administration.

Review of a physician order dated 08/18/24, revealed Resident #01 was ordered FIASP (Insulin Aspart) flex pen Injection Solution 100 unit/milliliter (ml), to inject 12 units subcutaneously with meals for diabetes.

Observation of the medication administration on 11/21/24 at 12:09 P.M., revealed Licensed Practical Nurse (LPN) #20 did not prime the insulin pen FIASP prior to administering 12 units into Resident #01's right lower quadrant of abdomen.

Interview on 11/21/24 at 12:15 P.M. with LPN #20, verified she did not prime the insulin pen prior to administering 12 units to Resident #01.

Review of manufacture instructions from FIASP revealed to prime the FIASP flex pen by turning the dose selector to two units, hold the pen with the needle pointing up, tap the top of the pen gently a few times to let any air bubbles rise to the top, and press and hold the doe button until the dose counter shows zero. A drop of insulin should be seen at the needle tip. If you do not see insulin, repeat steps no more than six times. https://www.novomedlink.com/diabetes/patient-support/product-education/library.html

2) Review of the medical record for Resident #12, revealed an admission date of 09/03/24 with a discharge date of 10/11/24. Diagnoses included spina bifida, paraplegia, bipolar disorder, and generalized anxiety disorder (GAD).

Review of the Admission Assessment dated 09/03/24, revealed Resident #12 was alert and oriented to person, time, and place. Resident #12 was dependent on staff for medication administration.

Review of the physician orders dated 09/04/24, revealed Resident #12 was ordered Buspar 15 milligrams (mg), give one tablet by mouth three times a day for anxiety and Flexeril 10 mg, give one tablet by mouth three times a day for muscle spasms.

Review of the September 2024 medication administration record (MAR) revealed Resident #12 had missing documentation on the following days for Buspar and Flexeril.

a) 09/04/24 for the 10:00 P.M. dose.

b) 09/05/24 through 09/08/24 for the 6:00 A.M. doses.

c) 09/10/24 through 09/14/24 for the 6:00 A.M. doses. ) 09/15/24 for the 10:00 P.M. dose.

e) 09/16/24 for the 6:00 A.M. dose.

f) 09/17/24 and 09/18/24 for the 10:00 P.M. doses.

g) 09/18/24 and 09/19/24 for the 6:00 A.M. doses.

h) 09/21/24 for the 6:00 A.M. and 10:00 P.M. doses.

i) 09/22/24 through 09/24/24 for the 6:00 A.M., 2:00 P.M. and 10:00 P.M. doses.

j) 09/25/24 and 09/26/24 for the 6:00 A.M. dose.

k) 09/28/24 and 09/29/24 for the 6:00 A.M. dose.

Review of the October 2024 MAR, revealed Resident #12 had missing documentation on the following days for Buspar and Flexeril:

a) 10/01/24 through 10/06/24 for the 6:00 A.M. doses.

b) 10/08/24 through 10/10/24 for the 6:00 A.M. doses.

Interview on 11/26/24 at 8:42 A.M. with LPN #23, verified Resident #12's missing doses for September and October for Buspar and Flexeril.

Interview on 11/27/24 at 9:32 A.M. with interim Director of Nursing (DON), verified staff were not signing off MAR's accurately including Resident #12. Interim DON reported that when we find missing documentation, we call staff in to complete documentation.

3) Review of the medical record for Resident #16, revealed an admission date of 09/18/24 with a readmission date of 11/18/24. Diagnoses included dementia, schizophrenia, type two diabetes mellitus (DM II), and hypertension.

Review of the Admission Assessment dated 11/18/24, revealed Resident #16 was alert and oriented to person and place but disoriented to time. Resident #16 was dependent on staff for medication administration.

Review of the physician order dated 09/19/24, revealed Resident #16 was ordered Clozapine 200 mg, give one tablet by mouth in the morning for schizophrenia.

Review of the progress note dated 10/18/24, revealed Resident #16 did not receive his Clozapine 200 milligrams (mg) because it was on order with the pharmacy.

Review of the progress note dated 10/19/24, revealed Resident #16 was sent to the hospital due to homicidal ideations and threats towards staff.

Review of the hospital paperwork dated 10/19/24, revealed Resident #16 was admitted to the hospital for acute psychosis possibly related to medication withdrawal (clozapine). Resident #16 presented from nursing home for acute behavior changes and agitation over the past three days.

Review of the medication administration record (MAR) dated October 2024 revealed Resident #16 did not receive Clozapine on 10/18/24.

Interview on 11/21/24 at 4:16 p.m. with Pharmacy Representative (PR) #50, revealed the pharmacy reached out to the facility on 10/18/24 because of needing absolute neutrophil laboratory (lab) count (ANC) in order to fill the Clozapine. PR #50 reported a delivery of ten pills went to the facility around 8:30 P.M.

Interview on 11/25/24 at 10:59 A.M. with interim Director of Nursing (DON), verified Resident #16 did not receive a dose on 10/18/24.

Interview on 11/25/24 at 11:33 A.M. with LPN #22, revealed she sent Resident #16 out on 10/19/24 because he made threats about self-harm and others. LPN #22 reported he made a comment about slicing someone's neck to another staff member. LPN #22 spoke to the physician and received orders to send Resident #16 out by emergency services to be evaluated at the hospital. The family was notified.

Interview on 11/25/24 at 4:20 P.M. with Social Services (SS) #80, revealed she had a care conference on 10/18/24 with Resident #16 and his sister. SS #80 stated LPN #21 reported he ran out of his medication because it wasn't filled yet and also reported some behavior changes. SS #80 reported she instructed LPN #21 to call pharmacy and find out what was going on with the medications. SS #80 stated the pharmacy needed an updated lab sent to them before they would fill the medication. SS #80 reported her findings to the interim DON and LPN #23.

Review of the facility policy titled, Medication Administration