Primrose Retirement Community of Lancaster

Based on employee record review and staff interview the facility failed to ensure first aide training was completed by a new employee within sixty days of hire. This had the potential to affect all 48 residents residing in the facility.

Findings include:

Review of Resident Assistant (RA) #136's employee file revealed a hire date of 08/21/23. RA #136 did not complete her first aide training until December of 2023. Her sixtieth day of employment was 11/13/23.

In an interview on 07/03/24 at 10:00 A.M. the Director of Nursing verified that RA #136's first aide training was not completed within sixty days of hire.

Based on review of employee records, review of facility tuberculosis control plan, and staff interview the facility failed to obtain the second step of tuberculosis testing on five employees after hire. This had the potential to affect all 48 residents residing in the facility.

Findings include:

Review of the facility tuberculosis control policy revealed that all newly hired employees are to have two step tuberculosis testing completed after hire.

Review of employee records revealed that the second step of the two step tuberculosis testing was not completed for Resident Assistant #136, Resident Assistant #137, Resident Assistant #141, Licensed Practical Nurse #124 and Cook #101.

In an interview on 07/03/24 at 10:00 A.M. the Director of Nursing verified that the second step of the two step tuberculosis testing was not completed for Resident Assistant #136, Resident Assistant #137, Resident Assistant #141, Licensed Practical Nurse #124 and Cook #101.

Based on observation of the kitchen and staff interview the facility failed to store all food in a manner that protects it against contamination and spoilage. This had the potential to affect all 48 residents residing in the facility.

Findings include:

During an observation tour of the kitchen on 07/02/24 at 11:00 A.M. the following spices, stored on a rack in the dry storage area, were noted to be open and undated. An 18 ounce container of black pepper with one eighth of the container remaining, a 0.16 ounce container of Turkish bay leaves with six leaves remaining, and a 16 ounce container of whole celery seed with three fourths of the container remaining. Further observation of the dry storage area revealed an open bag of angel hair pasta approximately half full stored in a zip-lock style bag that was dated but not closed and an open and undated 34.5 ounce container of peanuts with approximately an eighth of the container remaining. Observation of the reach in freezer revealed the floor inside the freezer to be covered with crumbs and food derbies.

In an interview on 07/02/24 at 11:20 A.M. Dietary Manager #157 verified the black pepper, Turkish bay leaves and celery seed were open and undated, the open bag of angel hair pasta stored in a zip-lock style bag was dated but not closed, the peanuts were open and undated and the presence of crumbs and food derbies on the floor of the reach in freezer.

This violation is a recite to the annual survey completed 03/29/23.

Based on review of fire drill records and staff interview the facility failed to perform one exit fire drill on each shift every three months and failed to evacuate residents capable of self evacuation twice a year on each shift. This had the potential to affect all 48 residents residing in the facility.

Findings include:

Review of the facility fire drill reports revealed no day shift drill was conducted in October, November or December of 2023 and no evening shift drill was conducted in April, May or June of 2024. Evacuation of residents capable of self evacuation only occurred with the 11/21/23 evening shift fire drill.

In an interview on 07/02/24 at 4:30 P.M. Maintenance Director #126 verified that no day shift drill was conducted in October, November or December of 2023 and no evening shift drill was conducted in April, May or June of 2024 and that evacuation of residents capable of self evacuation only occurred with the 11/21/23 evening shift fire drill.

This violation is a recite to the annual survey completed 03/29/23.

Based on review of records and staff interview the facility failed provide proof that the facility central heating system was checked every two years by a heating contractor. This had the potential to affect all 48 residents residing in the facility.

Findings include:

Review of facility records revealed no inspection report for the central heating system with in the last two years.

In an interview on 07/03/24 at 10:00 A.M. the Executive Director verified there was not a current report for the inspection of the central heating and cooling system.

Based on observation, medical record review, elopement investigation review, Weather Underground weather report review, review of facility policies and interview, the facility failed to provide a safe environment and adequate supervision to prevent Resident #8 from eloping from the facility. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injury and/or death on 06/18/24 at around 6:00 P.M. when Resident #8, who had dementia and history of unsafe wandering in the community, exited the main entrance of the facility, unsupervised and without staff knowledge, and was found approximately 0.3 miles from the facility, walking along a two-lane road with a speed limit of 25 miles per hour (mph), by Resident Assistant #113 and #125. The facility did not know Resident #8 had exited the building until another resident (Resident #10) alerted staff that Resident #8 had exited the front door. Facility staff returned the resident to the facility on 06/18/24 at around 6:30 P.M. Following Resident #8's elopement the facility failed to assess the resident upon her return despite the outdoor temperature of 89 degrees Fahrenheit (F). This affected one resident (#8) of five sampled residents. The facility census was 48.

On 07/03/24 at 5:25 P.M. the Executive Director (ED) was notified Real and Present Danger began on 06/18/24 when the facility failed to ensure Resident #8 was provided a safe environment and adequate supervision to prevent elopement. On 06/18/24 at approximately 6:00 P.M. Resident #8 exited the facility unsupervised and without staff knowledge and was brought back to the facility after Resident #10 alerted staff she (Resident #8) walked out of the facility. The facility failed to implement effective systems to ensure the safety of Resident #8 and all residents following the incident and failed to implement proper interventions to prevent elopement, assess residents for risk of elopement, and thoroughly investigate the incident of elopement.

The Real and Present was abated on 07/05/24 when the facility implemented the following corrective actions:

On 07/05/24 on or before 5:30 P.M. Resident #8 was moved to the memory care facility with family assistance.

On 07/05/24, 07/06/24, and 07/07/24, 35 of 39 facility staff were educated on the door access control policy. The four remaining staff members were to be educated prior to their next scheduled shift. Education would then occur annually after 07/07/24. The facility implemented a plan for the ED and Director of Nursing (DON) to review all (resident) changes in condition during one-on-one meetings. This was to be an on-going process, and any residents identified at risk were to be reviewed.

On 07/05/24, 07/06/24, and 07/07/24, 35 of 39 facility staff were educated by the ED on the missing resident policy and missing resident checklist. The four remaining staff members were to be educated prior to their next scheduled shift.

On 07/07/24 (elopement) drills were completed on all three shifts requiring a missing resident checklist to be completed by staff. Missing resident drills would be completed quarterly and results would be reported during monthly quality assurance (QA).

On 07/05/24, 07/06/24 and 07/07/24, 35 of 39 staff were educated by the ED on resident change in condition. The four remaining staff members were to be educated prior to their next shift. The DON or designee and charge nurse would review the daily nursing report for any change of conditions every day.

On 07/05/24, 07/06/24 and 07/07/24, 35 of 39 staff watched a Relias Dementia 101 training video provided by the ED or DON. Ongoing Dementia training would continue to be part of the staffs annual training. The ED or DON would monitor Relias completion monthly and report any noncompliant staff at monthly QA.

On 07/06/24 Regional Nurse Manager #175 educated the DON on The Move in Process policy and the Initial Resident Nursing Assessments policy. Beginning 07/06/24 all new admissions would be reviewed for compliance with the policy. Audits of 10% of non-admission assessments would be completed monthly for four months by the DON or Assistant Director of Nursing #120.

On 07/06/24 34 of 48 residents were reviewed for a dementia diagnosis, five residents (#5, #13, #19, #28, #33) were identified to have a dementia diagnosis and an elopement risk assessment was completed by the Director of Nursing (DON).

On 07/08/24 15 of 48 residents were reviewed for a dementia diagnosis, one resident (#63) was identified to have a dementia diagnosis and an elopement risk assessment was completed by the DON. The facility implemented a plan for all residents to be evaluated for elopement risk with a change of condition and every six months. Audits of 10% of medical records would be completed monthly for four months by the DON and results would be reported during monthly Quality Assurance (QA) meetings.

Although the Real and Present Danger was abated on 07/05/24, the violation remains as the facility was in the process of implementing their corrective action plan and monitoring to ensure ongoing compliance.

Findings include:

Review of Resident #8's history and physical completed prior to admission on 05/01/24 by Physician #200 revealed Resident #8 had been found walking about a mile from her home on 04/30/24. Further review revealed the resident was not taking her medication regularly and there were concerns about her cognitive decline and home safety.

Review of a pre-move in evaluation dated 05/31/24 authored by the Director of Nursing (DON) reflected Resident #8 had a diagnosis of dementia. A Brief Interview for Mental Status (BIMS) score revealed a score of five out of ten indicating the resident had severe cognitive impairment.

The pre-move in evaluation did not include information related to the resident being found walking a mile from home on 04/30/24 or evidence the resident's safety and/or elopement risk were assessed/evaluated prior to move in.

Review of Resident #8's medical record revealed an admission date of 06/17/24 with diagnoses of moderate late onset Alzheimer's dementia, with anxiety, mixed action and resting tremors, hypertension, and macular degeneration of the left eye. The resident was admitted from her privately owned condo located in the same community as the facility.

Review of the move in evaluation dated 06/17/24 authored by the DON reflected Resident #8 had a diagnosis of dementia. The move in evaluation did not include information related to the resident being found walking a mile from home on 04/30/24 or evidence the resident's safety and/or elopement risk were assessed/evaluated prior to move in. A BIMS score dated 06/17/24 revealed the resident continued to score a five out of ten indicating severe cognitive impairment.

Record review revealed Resident #8's risk for elopement was not assessed and there was not a service plan related to the resident's diagnosis of dementia/severe cognitive impairment, safety needs and/or elopement risk upon admission.

Review of the admission nursing progress note dated 06/17/24 at 12:50 P.M. authored by Assistant Director of Nursing (ADON) #120 revealed Resident #8 arrived at the facility at around 9:30 A.M. with her daughter-in-law. Further review revealed the resident was alert and pleasant and that the nursing staff would administer the resident's medications and provide stand-by assistance with the resident's showers.

Review of a nursing evaluation dated 06/17/24 at 9:00 A.M. authored by ADON #120 revealed Resident #8 was independent with ambulation and transfers.

Review of a nursing progress note dated 06/18/24 at 6:27 P.M. authored by ADON #120 revealed the staff were notified by Resident #10 that she (Resident #10) had observed Resident #8 exiting the front door of the community. Staff went outside to the resident and assisted her back to the community. The resident indicated to staff she was going to return to her home, down the road from the facility. She additionally reported she planned to go golfing. Facility staff reminded the resident that she was not golfing until the next morning with friends. Resident #8's son was notified, and he indicated somebody would be in to sit with her.

Review of an incident report dated 06/18/24 authored by ADON #120 revealed Resident #8 was observed going out the front door by Resident #10. Resident Assistant (RA) #113 went out and caught up to the resident and asked where she was going. Resident #8 indicated to RA #113 that she was returning to her home (which was just down the street from the facility) to get her golf clubs. RA #113 reminded the resident that her golf clubs were in her closet at the facility. Resident #8 verbalized understanding and returned to the facility.

Review of an undated facility investigation (author unknown) revealed Resident #8 was observed going out the front door by Resident #10. Resident Assistant (RA) #113 went out and caught up to the resident and asked where she was going. Resident #8 indicated to RA #113 that she was returning to her home (which was just down the street from the facility) to get her golf clubs. RA #113 reminded the resident that her golf clubs were in her closet at the facility. Resident #8 verbalized understanding and returned to the facility. Further review revealed ADON #120 immediately notified the ED and DON as well as the resident's power of attorney (POA). The resident's family came to the facility and spent the night with the resident. A care conference was scheduled with the resident's family. No root cause for the incident was noted on the investigation. In addition, the facility did not include individual staff statements in their investigation.

Review of the facility Pendant Call Log revealed Resident #10 pressed here call pendant on 06/18/24 at 5:56 P.M. from the main dining room. The pendant activation was not cleared for 11 minutes. Further review revealed two exit door alert notifications were sent around the same time at 5:59 P.M. listed as the fireside lounge exit door on the call log and one at 6:03 P.M. listed as the independent living (IL) 109 stairwell exit door on the call log when staff exited the facility to go after Resident #8. Door alert notifications were sent to the facility staff phones. The door notification for the fireside lounge exit door was acknowledged and cleared 14 minutes after it was sent. The door notification for the IL 109 stairwell exit door was acknowledged and cleared 11 minutes after it was sent.

Review of Resident #8's medical record revealed no physical or skin assessment was documented as being completed for Resident #8 once the resident was returned to the facility. Further review revealed no elopement risk assessment was completed following this incident after Resident #8 exited the building without staff knowledge or supervision.

Review of the weather report for 06/18/24 on Weather Underground.com revealed the temperature was 89 degrees Fahrenheit with no precipitation.

Review of a nursing progress note dated 06/19/24 at 10:11 A.M. authored by ADON #120 revealed family had stayed with Resident #8 during the night and the family reported no difficulties during the night.

Review of a nursing progress note dated 06/20/24 at 10:55 A.M. authored by ADON #120 revealed family was staying with Resident #8 at all times to help her settle in.

Review of a nursing progress note dated 06/23/24 at 8:54 P.M. authored by Licensed Practical Nurse (LPN) #112 revealed the family was no longer staying with Resident #8, the facility placed the resident on every 30-minute checks and utilized the door tab (a plastic tab that was on the resident's apartment door that would move to a different position if the door was opened) on the resident's door.

Review of a nursing progress note dated 06/24/24 at 2:00 P.M. authored by the DON revealed a care meeting was held with Resident #8's family and the 30-minute checks and use of the door tab were stopped at this time. Wellness checks and meal reminders were added to the resident's service plan, as well as a white board being placed on the resident's apartment door so that the date and days activities could be written on it for the resident to see easily.

Review of Resident #8's service plan/care plan dated 06/24/24 authored by the DON revealed wellness checks were to be completed at 12:00 A.M., 3:00 A.M., 6:00 A.M., 10:00 A.M., 2:00 P.M., and 8:00 P.M.

Review of Resident #8's medical record revealed no service plan/care plan was developed for the resident prior to the above plan dated 06/24/24 authored by the DON.

Review of a nursing progress note dated 06/27/24 at 7:58 P.M. authored by LPN #112 revealed Resident #8 was in her apartment, she had a steady gait and was pleasantly confused. Further review revealed the resident's sliding door (leading to a patio area enclosed by a porch railing) was shut and locked with the blinds pulled closed.

Review of a nursing progress note dated 06/28/24 at 3:21 P.M. authored by LPN #124 revealed Resident #8 had been pleasant most of the shift. However, Resident #8 had been a little agitated thinking she was supposed to leave and meet someone. The resident was redirected and went to the facility pub with another resident.

Review of a nursing progress note dated 06/29/24 at 5:47 A.M. authored by LPN #127 revealed Resident #8 was up most of the night and had been agitated and trying to get out of the patio door to leave. Resident #8 had also been observed walking naked in the hallway.

Review of a nursing progress note dated 06/30/24 at 7:09 P.M. authored by LPN #123 revealed Resident #8 was disoriented and continued to exit seek. Record review revealed no evidence of any new safety interventions being initiated at this time.

Review of a nursing progress note dated 07/01/24 at 9:56 A.M. authored by the DON revealed Physician #200 was notified of staff concerns with Resident #8's anxiety and dementia.

Review of a nursing progress note dated 07/01/24 at 9:56 A.M. authored by the DON revealed new orders were received from Physician #200 for the antipsychotic medication, Seroquel 25 milligrams one half of a tablet, to be given by mouth, at bedtime, as needed for agitation.

Review of Resident # 8's medical record revealed the resident was transferred to a memory care unit on 07/05/24.

Interview on 07/03/24 at 9:40 A.M. with ADON #120 verified Resident #8 went out the front door on 06/18/24 at around 6:00 P.M. (without staff knowledge) and was subsequently found by RA #113 and #125 on the road in front of the facility 0.3 miles from the facility near the entrance of her previous condo complex. ADON #120 revealed she thought it might have taken RA #113 and #125 about five minutes to get to the resident after they were alerted that she left the building. During the interview, ADON #120 revealed she had admitted the resident on 06/17/24 and did not observe any exit seeking behaviors from the resident prior to her leaving the facility the next day (on 06/18/24).

Interview on 07/03/24 at 11:44 A.M. with RA #113 revealed the first time she had worked with Resident #8 was on 06/18/24. She reported she had not seen any exit seeking behavior from the resident but was on alert because she had been told there was a possibility Resident #8 could be exit-seeking. RA #113 did not recall who told her about the possibility Resident #8 could be exit seeking. The RA revealed she was passing out dinner trays to residents who chose to eat in their rooms when Resident #10 pushed her pendant and notified staff that Resident #8 had gone out the front door after stating she was going home. RA #113 stated she and RA #125 immediately went out the front door after Resident # 8. When they got to her, she was walking on the road in front of the facility, in the middle of the road, almost to the entrance of her previous condo complex. She told them she was going home to find her golf clubs. The resident was confused and became agitated when they tried to redirect her to the sidewalk out of the way of a passing car. RA #113 further stated Resident #8 was wearing long sleeves and long pants as well as a sweater type vest and she remembered it was very hot outside that day. She described the resident as being slightly sweaty. RA #113 revealed she did not feel the resident was aware of traffic safety. The RA indicated she had last seen Resident #8 between 5:15 P.M. and 5:30 P.M. RA #113 felt it took herself and RA #125 about 10 minutes to get to the resident after Resident #10 set off her pendant as they were on the second floor when they received notification that Resident #10 had pressed her pendant. She stated she did not clear the alert on Resident #10's pendant or the doors that she and RA #125 exited to go after Resident #8 until after they had reached Resident #8 and had her on her way back to the facility.

Interview on 07/03/24 at 12:00 P.M. with the ED and DON verified Resident #8 was outside of the facility on 06/18/24 at around 6:00 P.M. and that facility staff were not aware that she had exited the building until they were notified by Resident #10. The ED and DON verified they had not implemented any elopement or wandering interventions for the resident prior to her exiting the building without staff knowledge. They were aware of the resident's history and physical completed (prior to admission) on 05/01/24 by Physician #200 that revealed Resident #8 had been found walking about a mile from her home on 04/30/24. However, they stated they did not feel this was a problem because Resident #8's son, who was POA felt Physician #200 did not understand Resident #8 was very active and liked to walk. The ED and DON revealed the facility did not complete a comprehensive investigation to determine the root cause of Resident #8's elopement. They revealed their normal process was for the DON to speak with the staff involved in the incident and write a synopsis of the incident.

Interview on 07/03/24 at 12:30 P.M. with the DON verified Resident #8's elopement risk was not reassessed after she exited the building on 06/18/24.

On 07/03/24 at 1:00 P.M. an attempt to reach Physician #200 by phone was unsuccessful as the physician's office was closed at that time.

Interview on 07/03/24 at 1:15 P.M. with Resident #10 revealed on 06/18/24 Resident #8 was talking about going home at dinner. Resident #10 stated she was concerned about Resident #8, so she was keeping an eye on her when she saw her walk out the front door. Resident #10 stated she immediately pushed the button on her call pendant to alert staff and started yelling for the kitchen staff. She stated facility staff came right away, and the kitchen staff were calling the nurse's station at the same time. Resident #10 further stated she felt Resident #8 was very confused and she was not safe to be in the facility because it was too easy for her to get out.

On 07/03/24 at 1:20 P.M. during an attempted interview with Resident #8, the resident had trouble completing sentences and could not verbalize the day of the week or the current date. She stated she thought it was September. Resident #8 then stated she was visiting the facility and needed to return to her condo on (road and city provided). At the time of the interview, Resident #8 was observed dressed in two short sleeved shirts, a lightweight wind breaker style jacket, a skirt and golf shoes.

Interview on 07/03/24 at 1:45 P.M. with the ED and DON revealed the facility does not have cameras or a wander guard system. They further stated all exit doors except the front and rear entrances were always alarmed. When these doors were opened an alert goes to the phones, the facility staff carry for communication and notification when they are working. An audible alarm does not sound. The facility staff were to check the doors before they clear the notification of the door opening. The front and rear entrances were alarmed from 7:00 P.M. until 7:00 A.M. with notifications of opening going to the staff phones during those hours. They stated the facility staff completed frequent checks on Resident #8, on 06/18/24 once she returned to the facility, until her family arrived to be with her.

Interview with Resident #8's son/POA on 07/03/24 at 2:00 P.M. revealed he described her as always confused. He stated he comes in and gets her ready for the day and takes her to the dining room for breakfast. The facility staff makes sure she gets to activities and to meals the rest of the day. He stated Resident #8 had attempted to walk downtown to a hair appointment about two weeks before she moved into the facility. This was not normal behavior for her, and the facility was made aware of the incident on the day that she moved in.

Interview on 07/03/24 at 4:20 P.M. with RA #125 revealed around 6:00 P.M. Resident #10 pressed the button on her call pendant and let them know that Resident #8 had gone out the front door. RA #125 stated that when they caught up to Resident #8, she was walking at a good pace in the center of the right lane of the road 0.3 miles from the facility near the entrance to her previous condo complex. RA #125 stated a car passed them while they were still in the road and Resident #8 made no effort to get out of the road as the car passed. RA #125 stated the resident was dressed in long pants, a long-sleeved shirt, and sweater type vest. She stated the resident's hands and forehead were sweaty but not overly so. RA #125 stated she had not personally seen exit seeking behavior prior to the resident leaving the facility on 06/18/24.

Interview on 07/05/24 at 11:20 A.M. with Medical Assistant #201, who worked with Physician #200 in his office, revealed she sees Resident #8 when she is in the office. Medical Assistant #201 stated the resident knows she is at the doctor's office when she is there but does not usually know the date or time. Medical Assistant #201 further stated the resident had been found walking about a mile from her home on 04/30/24, before she was admitted to the facility, and a neighbor saw her and took her home. Medical Assistant #201 verified Physician #200 was notified that Resident #8 had exited the facility without staff knowledge or supervision on 06/18/24.

Interview on 07/05/24 at 11:30 A.M. with RA #136 revealed she worked with Resident #8 on the morning of 06/18/24. RA #136 stated that the resident's son came in that morning and helped her get ready for the day and then took her to the dining room for breakfast. RA #136 stated she did not recall Resident #8 talking about leaving or going home. RA #136 further revealed she does not remember what day, but knows that it was after 06/18/24, she came downstairs at lunch time and found Resident #8 at the front door looking for her car.

Interview on 07/05/24 at 11:45 A.M. with the ED revealed there was not a written shift report for the RAs and verified the front and rear entrances only sent alerts to the facility staff's phones between the hours of 7:00 P.M. and 7:00 A.M. The ED stated the alert is sent to the phones unless the person exiting was in procession of a key fob that could be used to exit the building at the front and rear entrances without an alert being sent. The ED revealed Resident #8 was issued a key fob and had it in her possession from the time of her move into the facility.

Interview on 07/05/24 at 12:00 P.M. with the ED revealed Resident #8 was no longer in possession of a key fob.

On 07/05/24 at 1:20 P.M. Resident #8 was observed ambulating past the private dining room in wing B between rooms 114 and 116. Further observation revealed no one from the facility was in the hallway with her or in a position where the resident would be visible to them even though the facility had indicated the resident was supposed to be receiving one on one care at that time.

Interview on 07/05/24 at 1:20 P.M. with the ED and DON verified Resident #8 was to always be under one-on-one supervision.

Interview on 07/05/24 at 1:20 P.M. with RA #129 revealed she had directed Resident #8 to the restroom by the garden café and did not have the resident in her line of site, while she finished a conversation with another resident's family.

Review of the facility policy titled Door Access Control Policy effective 05/11/22 revealed the facility controlled access to all buildings by limiting and controlling the use and function of both access cards and key fobs issued. Further review revealed the ED had the final authority on the issuance of all key fobs issued and that training would be provided when key fobs were issued that included being mindful when coming and going that others do not come in or out of the community. When an individual no longer needed door access control the ED was to retrieve and inactivate the key fob.

Review of the policy titled Missing Resident/Elopement effective 01/01/15/revised 05/31/23 revealed that a resident's risk related to wandering and elopement were to be evaluated as a part of the pre-admission evaluation and upon any resident changes in cognition of functionality. A service plan with specific interventions to maintain the resident's safety was to be established and was to include the amount and type of supervision provided. Further review revealed that any incident of wandering outside of the facility, or a missing resident should be documented in an incident report and in the resident's medical record. The service plan should be revised to include interventions. The responsible party, primary care/physician provider should be informed as appropriate. The Missing Resident Checklist should be completed for all incidents of a missing resident.

Based on observation and interview, the facility failed to store refrigerated food safely and label opened foods in the kitchen. This had the potential to affect all 41 residents in the facility.

Findings include:

1. Observation of the kitchen on 03/29/23 at 11:00 A.M. revealed the reach in cooler contained nine shelves. All nine shelves had white plastic coating chipped off the ends of the shelves and rust covering the exposed metal on the shelves.

Interview with the Dining Service Director (DSD) #37 on 03/29/23 at 12:20 P.M. verified the chipped coating and the rust on the shelves of the reach in cooler and the shelves needed to be replaced.

2. Observation of the dry food storage on 03/29/23 at 11:10 A.M. revealed: an opened 10 pound bag of uncooked fettuccini noodles almost empty and not resealed, gallon jugs of white vinegar (1/2 full), amber honey (1/2 full), vanilla extract (1/4 full) and maple syrup (3/4 full) with sticky dried syrup down the side of the jug. The gallon jugs were not dated when opened.

An interview with DSD #37 at the time of the observation verified the noodles were open and exposed to air but should have been closed and the maple syrup jug had dried, sticky syrup down the side which should have been cleaned from the jug and not permitted to dry. DSD #37 also verified the gallon jugs were to be dated when opened and the facility was using a label maker to label the items when opened but the labels didn't always stick and fall off.

3. Directly outside of the dry food storage was a shelf containing spices. The shelf had opened and undated spices of 16-ounce containers of: Spanish paprika (1/4 full), whole celery seed (1/2 full), two containers of cummin (3/4 full), lemon pepper (3/4 full), black pepper (1/2 full), Hungarian paprika (1/4 full), granulated onions (1/2 full), cinnamon (1/2 full each), dill weed (1/4 full), and three baking sodas (all 1/4 full). Also on the shelf were: one 1.38 ounce Thyme (1/2 full), a 0.5 pound seasoned salt (1/2 full) and 28 ounces of garlic powder (1/8 full) parsley (1/2 full), and Italian seasoning (1/4 full) that were also not dated.

Interview with Cook #25 on 03/29/23 at 12:15 P.M. verified that the spices should be dated when opened.

Interview with DSD #37 on 03/29/23 at 3:14 P.M. verified the listed spices were not labeled and should be labeled when they are opened. The DSD stated the current system of using the label maker was ineffective and she planned to provide education to the staff about using permanent marker instead.

Based on record review and interview, the facility failed to complete twelve fire drills a year, evacuate residents twice a year per shift and verify transmission of alarms. This had the potential to affect all 41 residents residing in the facility.

Findings include:

1. Review of the fire drills from March 2022 to February 2023 revealed there was no evidence fire drills between July 2022 to November 2022 were completed.

Interview on 03/29/23 at 4:10 P.M. with the Maintenance Director (MD) #23 revealed he was hired in October 2022 and he did not complete fire drills until December 2022.

Interview on 03/29/23 at 4:47 P.M. with the Executive Director (ED) verified she was unable to locate evidence the fire drills were completed from July through November 2022.

2. Review of the fire drills conducted March 2022 to February 2023 revealed there were no alarm confirmations for the following fire drills: 03/29/22, 04/28/22, 05/27/22, 06/30/22, 12/16/22, and 02/27/23.

Interview with the MD #23 on 03/29/23 at 4:15 P.M. verified he conducted the fire drills in December 2022 and February 2023. He verified there was no evidence of alarm confirmation for either drill. Further interview revealed the February 2023 drill was a silent drill and he got busy and forgot to confirm the alarm receipt with the alarm company within 12 hours of the drill and when he remembered, it was outside of the allotted time frame.

Interview with the Executive Director on 03/29/23 at 4:59 P.M. verified the fire drills for 03/29/22, 04/28/22, 05/27/22, and 06/30/22 were completed by the previous Maintenance Director and the possibly the Maintenance Regional Manager and she was not sure why the alarms were not confirmed.

3. Record review of the fire drills conducted by the facility that were documented from March 2022 to February 2023 revealed there were no evacuation of residents during the drills conducted 12/06/22, 01/18/23 and 02/27/23.

Interview with the Maintenance Director on 03/29/23 at 4:17 P.M. revealed that he conducted the fire drills listed and had not completed any resident evacuations. The MD stated he planned to start doing evacuation next month and improve the fire drills in the facility.

Based on record review and interview, the facility failed to conduct monthly fire safety inspections. This had the potential to affect all 41 residents residing in the facility.

Findings include:

Record review of the monthly fire safety- self inspection forms for the facility dated from 03/29/22 to 03/03/23 revealed the months of June to October of 2022 were not completed.

Interview on 03/29/23 at 4:12 P.M. with Maintenance Director (MD) #23 verified the Fire Safety Self Inspection Form was not completed June 2022 through October 2022

Interview with the Executive Director on 03/29/23 at 4:45 P.M. verified there was no evidence the monthly fire inspections were completed June 2022 through October 2022.

Based on observation and interview, the facility failed to have a copy of the most recent licensure survey results easily accessible to the residents. This had the potential to affect all 41 residents residing in the facility.

Findings include:

Initial tour of the facility on 03/29/23 at 9:00 A.M. revealed no evidence of the state survey agency most recent investigation/survey results available to the residents.

Observation on 03/29/23 at 12:30 P.M. revealed a 4 x 6 frame was displayed on a small table at the entrance of the facility. The frame contained a note stating the survey results were at the nurses station at the back of the building. There were no survey results observed at the nurses' station.

On 03/29/23 at 12:35 P.M. interview with Licensed Practical Nurse #4, who was at the nurses' station located at the back of the building, revealed she did not know where to locate the results of the last state agency survey.

On 03/29/23 at 2:06 P.M. interview with Resident #9 revealed she didn't know how to locate the most recent state agency survey results.

Interview with Executive Director at 2:15 P.M. revealed the framed note was to alert the residents of the location of the most recent survey results. The ED provided a black binder with no labeling on the binder to indicate the contents which was located behind the nurses' station. The binder contained the most recent state agency survey results.

Interview with the ED on 03/29/23 at 4:25 P.M. verified the survey results were not easily identifiable/accessible to the residents being in an unlabeled binder at the nurses' station especially if residents and staff do not know the location.

Based on review of medical records, staff and resident interviews, review of staffing schedules and staff timecards, review of the resident council minutes, and facility policy review, the facility failed to ensure medications were administered per physician orders and within the allowed time parameters and failed to ensure qualified staff was on duty to administer the medications. This resulted in Real and Present Danger and the potential for serious life-threatening harm, injury and/or ultimate death when residents where not provided essential medications and assessments as ordered. This affected 34 residents (#10, #13, #14, #15, #18, #19, #20, #21, #22, #23, #24, #27, #28, #30, #32, #34, #35, #36, #37, #40, #41, #43, #44, #46, #47, #49, #50, #53, #56, #57, #58, #59, #80, and #82) of 36 residents who depended on the nurse to administer medications and assessments. The facility census was 66.

On 09/22/22 at 4:14 P.M., the Director of Nursing (DON) and Executive Nurse Manager #360, were notified Real and Present Danger began on 09/07/22 at 7:32 A.M., when the facility failed to ensure nursing staff was available on 09/07/22 from 7:32 A.M. through 6:30 P.M. to provide necessary care and treatment including medication administration to residents and provide supersvision of staff.

The Real and Present Danger was abated on 09/27/22 when the facility provided the following corrective action plan:

On 09/07/22 at 6:32 P.M. through 09/08/22, all 34 residents affected on 09/07/22 were assessed by Licensed Practical Nurse (LPN) #301 and LPN #302. No residents were found to require medical intervention.

On 09/07/22, the Former Executive Director completed an incident report when the residents didn't receive medications as physician ordered.

On 09/19/22, the DON was hired to ensure all shifts have adequate coverage to fulfill the care needs of residents, including medication administration.

Beginning on 09/19/22, the DON will be monitoring the schedule daily to ensure adequate coverage. Agency will be used in the absence of facility staff. The facility had two agency contracts. The Director of Nursing will consult the Executive Nurse Manager #360 for any assistance with schedule and staffing. There will be no audits as this is an ongoing leadership role of the DON.

On 09/23/22, all resident's physicians were notified of the missed medications and the lack of nursing coverage on 09/07/22 by the DON and Designee.

On 09/26/22, the DON resigned effective immediately.

On 09/27/22, Executive Nurse Manager #360 will be monitoring the schedule daily to ensure adequate coverage and provide nursing coverage as needed while the facility recruits a new DON.

On 10/03/22, LPN #365 and LPN #366 will start employment with the facility and assist with working a routine nursing schedule at the facility.

On 10/10/22, an Assistant Director of Nursing (ADON) will start on employment with the facility and will assist with monitoring the nursing schedule to ensure staffing coverage.

In October 2022, the facility will hold Quality Assurance (QA) meeting and will discuss staffing and nursing coverage.

Training for the DON and ADON will be completed by the Executive Nurse Manager #360 within 90 days of hire.

Although the Real and Present Danger was abated, the facility remains out of compliance as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.

Findings include:

1. Review of the medical record for Resident #10 revealed an admission date of 05/28/20. Diagnoses included atrial fibrillation, hypertension (HTN), sleep apnea, dementia, and bilateral knee replacement.

Review of the physician orders and medication administration record (MAR) for Resident #10 revealed orders for diltiazem 180 milligrams (mg) once daily due at 8:00 A.M. for HTN, furosemide 40 mg daily due at 8:00 A.M. for edema, sotalol 80 mg twice daily for atrial fibrillation due at 8:00 A.M., and acetaminophen 325 mg every eight hours for pain due at 7:00 A.M. and 3:00 P.M. Review of the September 2022 MAR revealed Resident #10 did not receive diltiazem, furosemide, sotalol and acetaminophen as scheduled on 09/07/22.

2. Review of the medical record for Resident #13 revealed an admission date of 08/08/19. Diagnoses included coronary artery disease (CAD), depression, narcolepsy, gastrointestinal reflux disease (GERD), chronic kidney disease (CKD) and HTN.

Review of the physician orders and MAR for Resident #13 revealed orders for Plavix 75 mg due at 8:00 A.M. for high cholesterol, Cymbalta 30 mg due at 8:00 A.M. for depression, and isosorbide extended release (ER) 30 mg at 8:00 A.M. to prevent chest pain. Review of the September 2022 MAR revealed Resident #13 did not receive Plavix, Cymbalta, and isosorbide ER as scheduled on 09/07/22.

3. Review of the medical record for Resident #14 revealed an admission date of 07/28/21. Diagnoses included heart failure, atrial fibrillation, high cholesterol, pacemaker, and pulmonary HTN.

Review of the physician orders and MAR for Resident #14 included memantine extended release 14 mg due between 8:00 A.M. and 11:00 A.M. for dementia, metoprolol 50 mg due between 8:00 A.M. and 11:00 A.M. for high blood pressure, Xarelto 20 mg due between 8:00 A.M. and 11:00 A.M. for high cholesterol, and Lasix 40 mg twice daily for atrial fibrillation due at 8:00 A.M. Review of the September 2022 MAR revealed Resident #14 did not receive memantine, metoprolol, Lasix, or Xarelto as scheduled on 09/07/22.

4. Review of the medical record for Resident #15 revealed an admission date of 05/28/20. Diagnoses included atrial fibrillation, hematuria, hydrocele, and falls.

Review of the physician orders and MAR for Resident #15 revealed orders for Furosemide 20 mg once on Monday, Wednesday and Friday due at 8:00 A.M., memantine 10 mg twice daily due at 8:00 A.M., and Donepezil 20 mg daily due at 8:00 A.M. for cognition. Review of the September 2022 MAR revealed Resident #15 did not receive the donepezil, memantine or furosemide as scheduled on 09/07/22.

5. Review of the medical record for Resident #18 revealed an admission date of 03/29/19. Diagnoses included atrial fibrillation, insomnia, asthma, hyperlipidemia, and HTN.

Review of the physician orders and MAR for Resident #18 revealed orders for Lasix 20 mg due at 8:00 A.M., metoprolol tartrate 25 mg due at 8:00 A.M., Tambocor 50 mg twice daily to treat atrial fibrillation due at 8:00 A.M., and Symbicort 160-4.6 mcg inhale two puffs, twice daily for asthma due at 8:00 A.M. Review of the MAR for September 2022 revealed Resident #18 did not receive Lasix, metoprolol, Tambocor, and Symbicort as scheduled on 09/07/22.

6. Review of the medical record for Resident #19 revealed an admission date of 07/14/22. Diagnoses included end stage renal disease, Parkinson's disease, and hyperlipemia.

Review of the physician orders and MAR for Resident #19 revealed orders for metoprolol succinate delayed release (DR) 25 mg once daily at 8:00 A.M. for high blood pressure, and carbidopa-levodopa 25-100 mg take twice daily due at 8:00 A.M. and 6:00 P.M. for Parkinson's disease. Review of the MAR for September 2022 revealed Resident #19 did not receive metoprolol and carbidopa-levodopa as scheduled on 09/07/22.

7. Review of the medical record for Resident #20 revealed an admission date of 08/10/16. Diagnoses included dementia, osteoarthritis, history of urinary tract infections, and mastodynia.

Review of the physician orders and MAR for Resident #20 revealed orders for acetaminophen 325 mg two tablets, twice daily due at 8:00 A.M. and 6:00 P.M. and Zoloft 25 mg once daily between 8:00 A.M. and 11:00 A.M. for mood. Review of the MAR for September 2022 revealed Resident #20 did not receive acetaminophen or Zoloft as scheduled on 09/07/22.

8. Review of the medical record for Resident #21 revealed an admission date of 04/13/22. Diagnoses included low back and leg pain, edema and myalgia.

Review of the physician orders and MAR for Resident #21 revealed orders for gabapentin 300 mg once daily at 12:00 P.M. for pain, and Buspar 5.0 mg three times per day for anxiety due at 12:00 P.M. Review of the MAR for September 2022 revealed Resident #21 did not receive gabapentin and Buspar as scheduled on 09/07/22.

9. Review of the medical record for Resident #22 revealed an admission date of 02/18/22. Diagnoses included HTN, coronary artery disease, spinal stenosis of lumbar region, acute kidney failure, and chronic pain.

Review of the physician orders and MAR for Resident #22 revealed orders for Norvasc 10 mg once daily due at 6:00 P.M. for coronary artery disease, hydrodiuril 25 mg once daily due at 8:00 A.M. for high blood pressure, Imdur ER 30 mg once daily due at 8:00 A.M. for high blood pressure, lisinopril 20 mg once daily due at 8:00 A.M. for high blood pressure, potassium chloride ER 10 milliequivalent (meq) once daily due at 8:00 A.M. for high blood pressure, and Coreg 6.25 mg twice daily due at 8:00 A.M. and 6:00 P.M. Review of the MAR for September 2022 revealed Resident #22 did not receive Norvasc, hydrodiuril, Imdur, lisinopril, potassium, and Coreg as scheduled on 09/07/22.

10. Review of the medical record for Resident #23 revealed an admission date of 02/18/22. Diagnoses included dementia, major depressive disorder, generalized anxiety disorder, CKD, osteoarthritis in multiple joints, and HTN.

Review of the physician orders and MAR for Resident #23 revealed orders for Seroquel 25 mg take one half tablet once a day at 12:00 P.M. for mood, Seroquel 25 mg once daily at 6:00 P.M. for mood, Aricept 23 mg once daily due at 8:00 A.M for dementia, duloxetine 40 mg once daily for depression due at 8:00 A.M., melatonin 3.0 mg once in the evening for sleep due at 6:00 P.M., metoprolol 25 mg twice per day due at 8:00 A.M. and 6:00 P.M., and Tylenol 650 mg four times daily due at 8:00 A.M., 12:00 P.M., and 4:00 P.M. Review of the MAR for September 2022 revealed Resident #23 did not receive Seroquel, Aricept, duloxetine, melatonin, metoprolol, and Tylenol as scheduled on 09/07/22.

11. Review of the medical record for Resident #24 revealed an admission date of 12/01/28. Diagnoses included colon cancer, CAD, depression, anxiety, Alzheimer's disease, and chronic pain.

Review of the physician orders and MAR for Resident #24 revealed orders for losartan potassium 25 mg daily due at 8:00 A.M. for HTN hold for systolic blood pressure less than 100, venlafaxine ER 150 mg daily for depression due at 8:00 A.M. and alprazolam 0.25 twice per day for anxiety due at 8:00 A.M. Review of the September 2022 MAR revealed Resident #24 did not receive losartan, a blood pressure assessment, venlafaxine, or alprazolam as scheduled on 09/07/22.

12. Review of the medical record for Resident #27 revealed an admission date of 03/08/21. Diagnoses included HTN, mixed hyperlipidemia, and dementia.

Review of the physician orders and MAR for Resident #27 revealed orders for Lexapro 10 mg once daily due at 8:00 A.M. for mood, Lasix 20 mg once daily due at 8:00 A.M., candesartan one twice per day due at 8:00 A.M to treat high blood pressure, and carvedilol 3.125 mg take twice per day to treat heart failure. Review of the MAR for September 2022 revealed Resident #27 did not receive Lasix, Lexapro, candesartan, and carvedilol as scheduled on 09/07/22.

13. Review of the medical record for Resident #28 revealed an admission date of 03/28/22. Diagnoses included HTN, osteoarthritis, CKD, and bilateral knee replacement.

Review of the physician orders and MAR for Resident #28 revealed orders for amlodipine 10 mg daily for hypertension due at 8:00 A.M., duloxetine 60 mg once daily for depression due at 8:00 A.M., hydrochlorothiazide (HCTZ) 25 mg once daily due at 8:00 A.M., carvedilol 25 mg twice per day due at 8:00 A.M. and 6:00 P.M., and hydralazine 10 mg three times per day for HTN due at 8:00 A.M., 2:00 P.M. and 6:00 P.M. Review of the MAR for September 2022 revealed Resident #28 did not receive amlodipine, duloxetine, HCTZ, carvedilol, or hydralazine as scheduled on 09/07/22.

14. Review of the medical record for Resident #30 revealed an admission date of 02/08/19. Diagnoses included osteoporosis, atrial fibrillation, arthritis, cataracts, and HTN.

Review of the physician orders and MAR for Resident #30 revealed orders for Lasix 40 mg once every other day due at 8:00 A.M., gabapentin 300 mg once daily at 6:00 P.M., metoprolol 25 mg once daily due at 8:00 A.M., and Eliquis 2.5 mg twice per day for atrial fibrillation due at 8:00 A.M. and 6:00 P.M. Review of the MAR for September 2022 revealed Resident #30 did not receive Lasix, gabapentin, metoprolol or Eliquis as scheduled on 09/07/22.

15. Review of the medical record for Resident #32 revealed an admission date of 06/11/15. Diagnoses included early dementia, osteoporosis, glaucoma, HTN, and chronic pain.

Review of the physician orders and MAR for Resident #32 revealed orders for prednisone 5.0 mg once every other day due at 8:00 A.M., acetaminophen 500 mg two tablets three times per day due at 8:00 A.M. and 12:00 P.M., and tramadol 50 mg take one- and one-half tablet four times per day for pain due at 8:00 A.M., 12:00 P.M. and 4:00 P.M. Review of the MAR for September 2022 revealed Resident #32 did not receive prednisone, acetaminophen, and tramadol as scheduled on 09/07/22.

16. Review of the medical record for Resident #34 revealed an admission date of 03/29/18. Diagnoses included CKD, HTN, and congestive heart failure.

Review of the physician orders and MAR for Resident #34 revealed orders for blood pressure check once daily as need and notify physician if higher than 140/90, cinacalcet 90 mg once every other day for renal disease due at 9:00 A.M., lisinopril 5.0 mg one daily due at 8:00 A.M., acetaminophen 325 mg take two tablets twice daily due at 9:00 A.M., amlodipine 5.0 mg twice daily due at 8:00 A.M., Coreg 3.125 mg twice daily due at 8:00 A.M., and penicillin 500 mg one every six hours due at 7:00 A.M. and 11:00 A.M. Review of the MAR for September 2022 revealed Resident #34 did not receive a blood pressure check, cinacalcet, lisinopril, acetaminophen, amlodipine, penicillin, or Coreg as scheduled on 09/07/22

17. Review of the medical record for Resident #35 revealed an admission date of 01/26/19. Diagnoses included back pain, diabetes mellitus (DM), osteoporosis, HTN, and memory impairment.

Review of the physician orders and MAR for Resident #35 revealed orders for amlodipine 10 mg daily due at 8:00 A.M, losartan/HCTZ 100-25 mg once daily for HTN due at 8:00 A.M., metoprolol 50 mg once per day due at 8:00 A.M., and tradjenta 5.0 mg once per day at 8:00 A.M. for DM. Review of the MAR for September 2022 revealed Resident #35 did not receive amlodipine, losartan/HCTZ, metoprolol, or tradjenta as scheduled on 09/07/22.

18. Review of the medical record for Resident #36 revealed an admission date of 04/18/21. Diagnoses included anxiety, spinal stenosis, CKD, and major depression disorder.

Review of the physician orders and MAR for Resident #36 revealed orders for sertraline 100 mg twice per day due at 8:00 A.M. for depression. Review of the MAR for September 2022 revealed Resident #36 did not receive the 8:00 A.M. dose of sertraline as scheduled on 09/07/22.

19. Review of the medical record for Resident #37 revealed an admission date of 05/18/22. Diagnoses included hyperlipidemia, GERD, osteoporosis, and atherosclerosis.

Review of the physician orders and MAR for Resident #37 revealed orders for amlodipine 10 mg once daily due at 8:00 A.M., and bupropion 150 mg twice daily due at 8:00 A.M. and 2:00 P.M. for mood. Review of the MAR for September 2022 revealed Resident #37 did not receive amlodipine and bupropion as scheduled on 09/07/22.

20. Review of the medical record for Resident #40 revealed an admission date of 03/16/17. Diagnoses included CAD, HTN, and anxiety.

Review of the physician orders and MAR for Resident #40 revealed orders for bupropion 150 mg once daily at 10:00 A.M., Lexapro 10 mg once daily due at 8:00 A.M. for mood, and Eliquis 2.5 mg twice daily due at 10:00 A.M. Review of the MAR for September 2022 revealed Resident #40 did not receive bupropion, Lexapro or Eliquis as scheduled on 09/07/22.

21. Review of the medical record for Resident #41 revealed an admission date of 03/16/21. Diagnoses included HTN, DM, cataracts, cervical cancer, and memory loss.

Review of the physician orders and MAR for Resident #41 revealed orders for amlodipine 5.0 mg once daily due at 8:00 A.M., metformin 500 mg twice daily for DM due at 8:00 A.M., and sertraline 25 mg once daily for mood due between 8:00 A.M. and 11:00 A.M. Review of the MAR for September 2022 revealed Resident #41 did not receive amlodipine, metformin, or sertraline as scheduled on 09/07/22.

22. Review of the medical record for Resident #43 revealed an admission date of 01/13/22. Diagnoses included benign prostatic hyperplasia, HTN, and GERD.

Review of the physician orders and MAR for Resident #43 revealed orders for Lasix 20 mg twice daily due at 8:00 A.M. and 2:00 P.M. Review of the MAR for September 2022 revealed Resident #43 did not receive Lasix as scheduled on 09/07/22.

23. Review of the medical record for Resident #44 revealed an admission date of 02/22/21. Diagnoses included DM, HTN, depression, colon cancer, chronic obstructive pulmonary disease (COPD), and arthritis.

Review of the physician orders and MAR for Resident #44 revealed orders for an accu-check (blood glucose check) twice per day for DM due at 4:00 P.M., check blood pressure twice per day due between 8:00 A.M. and 11:00 A.M. for HTN, bupropion 200 mg once daily at 8:00 A.M., Paxil 40 mg once daily for depression due at 8:00 A.M., carvedilol 6.25 mg twice per day due at 8:00 A.M., and Janumet 50-1,000 mg twice per day due at 8:00 A.M. for DM. Review of the MAR for September 2022 revealed Resident #44 did not receive a blood glucose check, blood pressure checks, bupropion, carvedilol, and Janumet as scheduled on 09/07/22.

24. Review of the medical record for Resident #46 revealed an admission date of 08/30/13. Diagnoses included HTN, dizziness, fatigue, and other long-term drug therapy.

Review of the physician orders and MAR for Resident #46 revealed orders carbidopa-levodopa 25-100 mg three times daily due at 11:00 A.M., and 2:00 P.M., sertraline 100 mg daily due at 8:00 A.M. and midodrine 2.5 mg twice daily at 8:00 A.M. and 5:00 P.M., and document blood pressure. Review of the MAR for September 2022 revealed Resident #46 did not receive carbidopa-levodopa, sertraline, midodrine, or a blood pressure check as scheduled on 09/07/22.

25. Review of the medical record for Resident #47 revealed an admission date of 03/15/22. Diagnoses included atrial fibrillation and HTN.

Review of the physician orders and MAR for Resident #47 revealed orders for metoprolol 25 mg take half tablet daily due at 8:00 A.M. and Eliquis 5.0 mg take twice per day due at 8:00 A.M. Review of the MAR for September 2022 revealed Resident #47 did not receive metoprolol and Eliquis as scheduled on 09/07/22.

26. Review of the medical record for Resident #49 revealed an admission date of 03/29/22. Diagnoses included DM, dementia, and HTN.

Review of the physician orders and MAR for Resident #49 revealed orders for amlodipine 5.0 mg once per day due at 8:00 A.M. hold for blood pressure (BP) less than 100/60, lisinopril 20 mg once daily at 8:00 A.M., metoprolol 25 mg take half tablet once daily due at 8:00 A.M. hold for BP less than 100/60, buspirone 5.0 mg twice daily due at 8:00 A.M., metformin 500 mg take twice daily due at 8:00 A.M., and accu-check two times a day due at 4:00 P.M. Review of the MAR for September 2022 revealed Resident #49 did not receive amlodipine, lisinopril, metoprolol, buspirone, accu-checks, or metformin as scheduled on 09/07/22.

27. Review of the medical record for Resident #50 revealed an admission date of 01/02/19. Diagnoses included asthma, CKD, and peripheral venous insufficiency.

Review of the physician orders and MAR for Resident #50 revealed orders for amlodipine 10-20 mg once daily due between 8:00 A.M. and 11:00 A.M. Review of the MAR for September 2022 revealed Resident #50 did not receive amlodipine as scheduled on 09/07/22.

28. Review of the medical record for Resident #53 revealed an admission date of 09/17/21. Diagnoses included dementia, DM, and depression.

Review of the physician orders and MAR for Resident #53 revealed orders for glimepiride 2.0 mg once per day for DM due at 8:00 A.M., Janumet 50 - 1,000 mg once daily at 5:00 P.M. for DM, memantine 28 mg once daily due at 8:00 A.M., and Eliquis 2.5 mg twice per day due at 8:00 A.M. Review of the MAR for September 2022 revealed Resident #53 did not receive glimepiride, Janumet, memantine, and Eliquis as scheduled on 09/07/22.

29. Review of the medical record for Resident #56 revealed an admission date of 09/17/21. Diagnoses included depression, anxiety, and atrophy of vulva.

Review of the physician orders and MAR for Resident #56 revealed orders for lisinopril 10 mg once daily due at 8:00 A.M., Lexapro 20 mg once daily due at 8:00 A.M., and Mobic 15 mg once a day for arthritis and fibromyalgia pain. Review of the MAR for September 2022 revealed Resident #56 did not receive of Lexapro, Mobic, and lisinopril as scheduled on 09/07/22.

30. Review of the medical record for Resident #57 revealed an admission date of 12/01/21. Diagnoses included arrythmia, arthritis, atrial fibrillation, coronary artery disease, HTN, stroke, and dementia.

Review of the physician orders and MAR for Resident #57 revealed orders for Eliquis 5.0 mg twice per day due at 8:00 A.M. and 6:00 P.M. and citalopram 20 mg once daily due at 6:00 P.M. for mood. Review of the MAR for September 2022 revealed Resident #57 did not receive Eliquis and citalopram as scheduled on 09/07/22.

31. Review of the medical record for Resident #58 revealed an admission date of 08/05/22. Diagnoses included atrial fibrillation, congestive heart failure, COPD, pulmonary edema, osteoarthrosis, and pain.

Review of the physician orders and MAR for Resident #58 revealed orders for diltiazem 120 mg once daily for HTN due at 8:00 A.M., metoprolol 100 mg take half once daily due at 8:00 A.M., sacubitril/valsartan 97/103 mg take twice daily due at 8:00 A.M. for heart disease, furosemide 40 mg twice daily due at 8:00 A.M., Eliquis 5.0 mg twice daily due at 8:00 A.M., Respimat two puffs orally twice per day due at 8:00 A.M. for COPD, terbinafine 250 mg once daily due at 8:00 A.M. for fungal infection, and Bactrim twice per day for infection due at 8:00 A.M. Review of the MAR for September 2022 revealed Resident #58 did not receive diltiazem, metoprolol, sacubitril/valsartan, furosemide, Eliquis, terbinafine, and Bactrim as scheduled on 09/07/22.

32. Review of the medical record for Resident #59 revealed an admission date of 08/29/22. Diagnoses included blood clots and HTN.

Review of the physician orders and MAR for Resident #59 revealed orders for baclofen 10 mg once daily due at 8:00 A.M. for pain, gabapentin 400 mg take three times daily due at 8:00 A.M. and 12:00 P.M., metoprolol tartrate 25 mg twice daily due at 8:00 A.M., and lovenox 0.4 ml injection once in the morning due at 8:00 A.M to prevent blood clots. Review of the MAR for September 2022 revealed Resident #59 did not receive baclofen, gabapentin, metoprolol, and lovenox as scheduled on 09/07/22.

33. Review of the medical record for Resident #80 revealed an admission date of 03/29/18. Diagnoses included HTN, moderate/major neurocognitive disorder due to probable Alzheimer ' s disease, CAD, recurrent major depressive disorder, and dementia.

Review of the physician orders and MAR for Resident #80 revealed orders for Lexapro 20 mg once daily due at 8:00 A.M., metoprolol 25 mg once daily due at 8:00 A.M., and memantine 10 mg twice daily due at 9:00 A.M. Review of the MAR for September 2022 revealed Resident #80 did not receive Lexapro, metoprolol, and memantine as scheduled on 09/07/22.

34. Review of the medical record for Resident #82 revealed an admission date of 10/16/21. Diagnoses included DM, HTN, and falls.

Review of the physician orders and MAR for Resident #82 revealed orders to check blood sugar once a day in the morning due at 8:00 A.M., check blood sugar per freestyle libre sensor between 2:00 P.M. and 6:00 P.M. for DM, Humalog inject 22 units once per day 15 minutes before breakfast due at 8:00 A.M. for DM, Humalog nine units prior to lunch due at 12:00 P.M. for DM, Humalog three units prior to supper for DM, HCTZ 12.5 mg once daily for HTN due at 8:00 A.M., and metoprolol 25 mg once per day due at 8:00 A.M. Review of the MAR for September 2022 revealed Resident #82 did not receive her blood sugar checks, Humalog insulin, HCTZ, or metoprolol as scheduled on 09/07/22.

Interview on 09/22/22 at 8:08 A.M with LPN #336 revealed she worked from 7:00 A.M. to 7:00 P.M. in the sister (Memory Care) facility nearby the facility on 09/07/22. LPN #336 recalled there was not a nurse to work in the Assisted Living (AL) facility that day. LPN #336 stated she was asked to cover and work in both the AL facility and the Memory Care facility by the Former Executive Director (FED) on the morning of 09/07/22 when she arrived to work. LPN #336 stated that because the two buildings were in two different physical locations (approximately 10-minute walk) and she would be the sole nurse caring for approximately 72 residents in two different buildings, she did not feel comfortable, and she refused to do so. LPN #336 stated at around 4:00 P.M., she went over and administered pain medication for Resident #21 who was in pain.

Interview on 09/22/22 at 8:49 A.M. with the DON revealed he had worked at the facility for four days, since 09/19/22, and the FED quit and walked out of the facility on 09/21/22. The DON revealed he was informed by the FED (before he resigned) that the facility went without a nurse one day earlier in the month (wasn't sure of the exact date) and residents did not get their medications that day.

Interview on 09/22/22 at 9:55 A.M. with Resident #15 revealed the nurse was very late getting his medication to him once or twice recently but he could not remember the dates. Resident #15 shared he wasn't sure why the medications were late but stated the facility needs help.

Interview on 09/22/22 at 10:30 A.M. with State Tested Nurse Aide (STNA) #312 revealed she worked on 09/07/22 and there was no day shift nurse in the facility. STNA #312 revealed the residents were upset and asked how they would get their medications. STNA #321 stated she didn't know what to tell them. STNA #312 revealed the FED was getting medications out of the medication cart and giving them to residents' families to administer.

Telephone interview on 09/22/22 at 12:02 P.M. with the FED revealed he resigned on 09/21/22. The FED revealed he does not have a license or certification to pass medications and he did not administer any medications to residents on 09/07/22. The FED revealed he had an agency nurse scheduled to provide coverage on 09/07/22, who called off at 4:00 A.M. that morning. The FED further revealed he immediately posted the listing on two agencies webpages, but no one picked up the shift for that day. The FED further reported trying to find coverage through facility staff with no success. The FED revealed he called the corporate office who told him to give medications to residents' families to administer. The FED also reported Hospice Nurse #375 was there and administered medications to one or two hospice residents. The FED also revealed he was able to get LPN #336 to come over to give controlled pain medication to Resident #21 around 4:00 P.M. after she had gone the whole day without her pain medication. The FED stated that most residents did not get their medications that day.

Review of the staff schedules for September 2022 revealed on 09/07/22, there was no nursing staff scheduled.

Review of the timecard for 09/07/22 revealed the facility had no nurse coverage on 09/07/22 from 7:32 A.M. through 6:30 P.M.

Interview on 09/22/22 at 12:27 P.M. with LPN #304 revealed she was scheduled to work the night shift from 09/05/22 at 7:00 P.M. to 09/06/22 at 7:00 A.M., and again on 09/06/22 from 7:00 P.M. to 09/07/22 at 7:00 A.M. LPN #304 shared that she also picked up and worked part of the day shift on 09/06/22 due to the facility not having nursing coverage. LPN #304 stated that by 09/07/22 at 7:00 A.M. she had only had five hours of sleep due to picking up the day shift and working the two-night shifts prior and she could not safely work any longer. LPN #304 further shared she worked the day shift on 09/08/22. LPN #304 stated the residents shared with her, how unhappy they were, with not getting their medications the day before.

Interview on 09/22/22 at 12:38 P.M. with LPN #302 revealed she worked 09/08/22 day shift and heard there was not a nurse in the facility the day before. LPN #302 shared those residents were upset about not getting their medications the day before. LPN #302 revealed the residents' pill packs from 09/07/22 were still in the medication cart on 09/08/22. LPN #302 revealed Resident #82's blood sugar was over 400 on the morning of 09/08/22. LPN #302 notified the physician to obtain additional insulin coverage for Resident #82. LPN #302 also recalled Resident #21 was very upset about going all day without her pain medication.

Interview on 09/22/22 at 4:25 P.M. with Executive Nurse Manager #360 confirmed she was aware the facility did not have nursing coverage on 09/07/22 and residents went without medications. Executive Nurse Manager #360 confirmed there were sister facilities in the central area of the state that could have been called to assist with nursing coverage.

Interview on 09/23/22 at 9:00 A.M. with Hospice Nurse #375 revealed she was at the facility on 09/07/22 at around 10:30 A.M. Residents started coming out of their rooms and asking where their medications were. Hospice Nurse #375 revealed she was able to obtain and administer medications for Resident #10 who was on hospice. Hospice Nurse #375 stated she called the families of the palliative care residents to inform them of the lack of nursing coverage.

Interview on 09/26/22 at 5:46 P.M. with Resident #21 revealed she has gone without medications for a whole day, twice now since living in the facility. Resident #21 stated she was scheduled pain medication three times a day and she didn't get the first two doses and was in a lot of pain by the time she got the medication, late in the day. Resident #21 couldn't remember the dates she went without the medications but stated it makes her feel very anxious about whether she will have a nurse to give her mediations.

Interview on 09/26/22 at 5:56 P.M. with Resident #25 revealed she remembered not getting her medication on 09/07/22. Resident #25 revealed there were not enough staff at the facility, and she doesn't know why she was paying for help she doesn't get.

Interview on 09/27/22 at 10:13 A.M. with LPN #301 revealed she was the night shift nurse on 09/07/22 and she arrived to work at 6:30 P.M. LPN #301 stated the FED called her and asked her to come in early. LPN #301 shared that she administered 6:00 P.M. medications to those residents she could who were not ordered the same medication again, so they would not be getting a double dose of the same medication. LPN #301 shared the residents were very scared there would not be a nurse and they were very glad to see her. LPN #301 shared that she assessed all residents who were due for medications and those that were upset and wanted to talk. LPN #301 further shared that she did not obtain any blood glucose levels for any residents until those who were ordered on the morning of 09/08/22.

Interview on 09/28/22 at 9:40 A.M with Nurse Practitioner (NP) #361 revealed it was important for residents to have scheduled medications on time, without missed doses. NP #361 stated the antihypertensives need to be taken regularly to avoid risks of uncontrolled HTN that can lead to cardiovascular events such as a stroke.

Interview on 09/28/22 at 4:37 P.M. with Pharmacist #376 revealed Humalog was a fast-acting insulin and was given after meals and at bedtime. Pharmacist #376 revealed if blood sugar was high and a resident didn't receive Humalog, they could become hyperglycemic (excessive amount of sugar in the blood that the body cannot process). If gabapentin was prescribed for neuropathy pain, missed doses could cause an increased pain level, but if it prescribed for seizures, it would have more dire consequences such as a seizure. Cymbalta or Effexor could lower the levels of the drug in the blood and the resident may have had a headache. If metoprolol was given without a blood pressure assessment, it could decrease the blood pressure, and if the dose was missed, it would lead to increased blood pressure.

Review of the Resident Council Meeting Minutes for September 2022 revealed under the Questions and Concerns header, the residents expressed a concern with medications being administered late. The facility responded there should always be a nurse on duty for all shifts.

Review of the facility's policy titled Administration of Medication-General Guidelines revised 12/31/18, revealed medications are administered, as prescribed, only by staff member authorized to administer medications. The policy further revealed medications are administered within one hour of the scheduled time (one hour before and one hour after). Obtain and record any vital signs, as ordered by the physician/prescriber, prior to medication administration. Additionally, the policy revealed medication administration is documented on the residents MAR at the time the mediation is given, by the person who administers the medication.

This violation substantiates Master Complaint Number OH00135711 and Complaint Numbers OH00135700, OH00135687, OH00135686, and OH00135683.