Wabash Senior Living & Rehab

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to maintain equipment that was present on the crash cart and available for use for 1 of 3 residents (R1) reviewed for emergency events in a sample of 36. This failure has the potential to effect 32 residents (R4-R36) residing in the facility with active orders to attempt resuscitation/CPR (Cardiopulmonary Resuscitation). The findings include:R1's admission Record documents an admission date of [DATE] and includes diagnoses of Acute and Chronic Respiratory Failure with Hypercapnia and Hypoxia, Nonrheumatic Tricuspid Insufficiency, Obstructive Sleep Apnea, Atelectasis, Oxygen Dependent, Pulmonary Hypertension, Peripheral Vascular Disease, and Chronic Kidney Disease. R1'S MDS Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 is cognitively intact. Section GG documents R1 is dependent on staff for hygiene, bathing, and dressing. Transfers were not attempted due to medical condition. R1's Practitioner Order Form Life-Sustaining Treatment (POLST) form documents R1's signature dated [DATE] and documents V14's (Physician) signature on [DATE]. In Section A, a checkmark is documented for Yes CPR (Cardiopulmonary Resuscitation): attempt CPR, utilize all indicated modalities per standard medical protocol. In Section B, a check mark is documented for Full Treatment: goal is to attempt to prevent cardiac arrest by using all indicated treatments. Utilize intubation, mechanical ventilation, cardioversion, and all other treatments as indicated.R1's Progress Notes authored by V9 (Licensed Practical Nurse) dated [DATE] at 5:05PM documents (name) PT (Physical Therapist) came to get this nurse at 4:30pm r/t (related to) res (resident) being unresponsive, upon entering room this nurse observed resident not breathing, no pulse found. CPR initiated at 4:34pm, 911 called at that time. Paramedic came at 4:40PM, he called ER (Emergency Room) Medical Director, given at 4:47 to stop CPR, resident pronounced dead at 4:47pm. This nurse called responsible party, notified of death. Coroner notified of death, arriving at 5:00 and will discuss arrangements with family.On [DATE] at 1:30PM, V9 (Licensed Practical Nurse/LPN) stated that on [DATE] she was notified by a physical therapist that R1 was nonresponsive. V9 stated she went directly to R1's room and started CPR. V9 stated she was assisted by V11 (LPN) and V11 went and retrieved the crash cart. V9 stated when V11 was preparing to hookup the AED (Automated External Defibrillator) there were no pads in the crash cart and the battery was showing low battery. V9 stated they continued chest compressions until EMS (Emergency Medical Services) arrived. V9 stated she has worked at this facility for the last 6 years. V9 stated she was not sure who checked the crash cart, but she had never checked it. V9 stated she was aware that there was an AED machine on the cart, and she has had training to use the AED machine. On [DATE] at 6:52PM, V11 stated she has worked at the facility for 2 years. V11 stated there has always been an AED machine on the crash cart but she has never had to attempt to use it before [DATE] when R1 was found unresponsive. V11 stated she was summoned to the room immediately when R1 was found unresponsive. V11 stated she ran and got the crash cart while V9 was starting compressions. V11 stated when she returned to the room with the crash cart, she unlocked it and grabbed the Ambu bag (bag valve mask) and gave it to one of the other staff members in the room and she grabbed the AED machine. V11 stated she started searching for pads and could not find any pads anywhere on the cart, V11 stated she opened the AED machine, and it automatically turns on, the AED started saying low battery, low battery. V11 stated she finally closed the door on the AED because she could not do anything without the pads and the machine was still saying low battery. V11 stated EMS arrived and time of death was called at 4:47PM. V11 stated she has had training on AED's through her CPR class. V11 stated she was taught in CPR training that if you have an AED available to use it and that is what she tried to do. V11 stated she notified V2 (Director of Nursing/DON) immediately and told her there were no pads and it was saying low battery. V11 stated another nurse, V12 (Registered Nurse/RN), told her she had used the last set of pads on a code on [DATE] and had reported it to V6 (Assistant Director of Nursing/ADON) that there were no more pads. V11 stated she felt like she wasted time looking for pads and trying to get R1 hooked to the AED.On [DATE] at 10:04AM, V6 stated there is only one crash cart for the whole facility. V6 stated she is in charge of checking the crash cart monthly. V6 stated they did have an AED (Automated External Defibrillator) on the crash cart, but it has been removed recently as of Monday [DATE]. V6 stated the last time the AED was used, it did work she thinks but the battery was low. V6 stated V1 (Administrator) is in charge of ordering new pads for the AED. V6 stated the AED is in the administrator's office at this time until they get a new battery. V6 was asked if there is a check list of the items checked on the crash cart and V6 provided a document titled Crash Cart Checklist. The list did not include a check for an AED machine. The last documented check was on [DATE]. V3 stated the cart must be checked monthly. V6 stated she was not aware of the AED not being used while the AED was present on the cart. V6 stated all the staff get training about every 6 months on CPR and includes the use of an AED. On [DATE] at 1:07PM, V6 stated when she checked the crash cart monthly, she stated she would turn on the AED machine every time. V6 stated battery low would display every time for the last 4 months (since [DATE]). V6 stated we talked to (V13 Facility Owner) and he stated we didn't need one (battery) but he did just finally approve the purchase of a battery I believe. V6 said the pads to the AED were used on the last code on [DATE] and she believes pads have been ordered. V6 stated she also would check for pads when she checked the AED, and she said there were always 2 sets of pads on the cart. V6 stated the pads were used when they had codes in between the monthly checks evidently so there were no pads when the last resident coded on [DATE]. V6 stated the nursing staff have all been CPR trained and this includes the use of an AED.On [DATE] at 11:24AM, V1 (Administrator) was asked if he receives work orders from maintenance or whoever orders supplies for equipment. V1 stated he does receive request for supplies that need to be ordered. V1 was asked if he was notified that the battery was low on the AED machine, V1 stated yes, he has known for a while and has sent up request and it is a process we have to go through to get approvals for items that need to be ordered. V1 stated I believe we have permission now. V1 was asked if the battery and the pads have been ordered yet and he stated no, not yet. V1 stated the AED machine has been pulled from the crash cart and is in his office until the battery and pads have been ordered and received and at that time the AED machine will be returned to the crash cart.On [DATE] at 12:08PM, V8 (Regional Director of Operations) stated he was unaware that there was an AED in the facility, and it must have been in the facility when the company bought the facility. V8 stated it is not a regulation to have an AED until 2030 and he doesn't see the problem. V8 was informed that the AED had been present on the crash cart but not checked or maintained.On [DATE] at 12:34PM, V2 (Director of Nursing) stated she was aware that there was an AED on the crash cart. V2 stated V6 checks the crash cart monthly and includes AED checks. V2 stated they had known the battery was low for a while but thought that it still functioned even though it said low battery. V2 stated the AED was used on another resident in December but showed a non-shockable rhythm. V2 stated I guess that is when the last set of pads were used because when they had another resident to code on [DATE], there were no adult pads available, and the battery was low. V2 stated the nurses are expected to use the AED machine when it is available. V2 stated the battery has been low for a couple of months and that is as far back as she knows because she has only worked here a couple of months. V2 stated she does not have documentation to prove the AED was checked monthly as it is not on the crash cart checklist. V2 stated the supplies are ordered by Medical Records/supplies personnel.On [DATE] at 9:12AM spoke with V6 in regard to checking of the AED. V6 stated she checked it monthly, and she would open it up and make sure it came on and then closed it. V6 stated she does not remember any lights on the machine she just remembers that it would voice prompt low battery. V6 stated she would then close it back down. On [DATE] at 10:15AM, V13 (Facility Owner) stated he was aware that the battery was low on the AED machine. V13 stated the AED was still functioning even with a low battery. V13 stated they (nurses) didn't need to use the AED on R1 the last code. When V13 was asked to clarify, V13 replied she was dead and they started CPR, they continued CPR until the EMS arrived and they then called the code. V13 stated you know when someone is really dead, and you still have to do CPR. V13 stated as soon as the facility was made aware that they were out of pads, the pads were ordered for the AED machine. V13 was asked if he expected the staff to keep documentation of the checks on the AED machine and V13 stated I refuse to answer that question. On [DATE] at 12:25PM, the AED machine was observed with V1 present. The AED Machine was opened up and automatically was flashing red lights and had an activated voice prompt of Low Battery, Low Battery repeatedly for 35 seconds. On [DATE] at 3:00PM, V15 (Regional Community Liaison) provided the invoices for the AED battery and pads. The invoice documents that Adult Pads were ordered on [DATE], with order confirmation date of [DATE]. The invoice for the AED battery documents the order was placed on [DATE].On [DATE] at 2:14PM, V17 (Sales Representative) with the medical supply company that the order for the AED pads were placed, confirmed the order number documented on the invoice provided by V15 and stated that the order date was [DATE] and not [DATE] as documented on the invoice provided by V15. V17 provided the invoice with the documented order date of [DATE].On [DATE] at 1:50PM, V16 (Sales Representative) with the medical supply company that the AED battery was placed, confirmed the order number of the invoice provided by V15 and stated that the order was placed late on [DATE] and that there were no other orders placed by this the facility for an AED battery before [DATE]. V16 stated their invoice documents and order date of [DATE] because order was placed late in the evening, so date fell to the next business day. V16 provided this invoice with the order date of [DATE].The Owners Manual for the AED documents under the section titles Schedule Maintenance documents daily maintenance: Check the Status Indicator to ensure that it is green. When the light is Green, the AED is ready for rescue. If the indicator is RED, refer to troubleshooting table on page 5-3. Indicator troubleshooting table documents for battery: the last battery indicator (LED) is red and flashing. Solution: The battery is low. Replace with a new battery. Monthly maintenance: Open the AED lid, wait for the AED to indicate status. Observe the change of the status indicator or RED. After 5 seconds, verify that the Status Indicator returns to GREEN. Check that the battery has adequate charge. If the battery indicator is red, replace the battery.The facility policy titled Policy for Emergency Cart (E-Cart) with a revision date of [DATE] documents Purpose: To organize and maintain the emergency cart (E-Cart) to ensure adequate needed equipment for CPR procedures. Under the section titled Policy documents The E-Cart will be inventoried and restocked after each use and checked at least monthly and documented.The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation with a revision date of February 2018 documents under Preparation for Cardiopulmonary Resuscitation 2. Maintain equipment and supplies necessary for CPR/BLS (Basic Life Support) in the facility at all times.An Order Listing Report dated [DATE] documents active orders for life sustaining treatment or all residents residing in the facility. There are 32 residents (R4-R36) on this report with active orders to attempt resuscitation/CPR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received the correct medications in accordance with their physician's orders for 2 (R83, R92) of 7 residents reviewed for significant medication errors in the sample of 45.
This past noncompliance occurred between 3/17/2024 and 4/1/2025.
Findings include:
1. R83's admission Record documented an admission date of 3/13/2024 and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood, anxiety disorder, unspecified, and unspecified atrial fibrillation.
R83's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5, which indicates severe cognitive impairment.
R83's Physician Order Summary documented divalproex (seizure and/or mood stabilization treatment) oral tablet delayed release 500mg (milligrams) -1 tablet by mouth twice a day, acetaminophen (pain reliever) oral tablet 500mg-give 2 tablets by mouth two times a day and apixaban (blood thinner) 5mg tablet-take 1 tablet by mouth twice a day.
R83's Progress Note dated 3/17/2025 by V3 (Registered Nurse/RN) documented that she was passing medications and took R83 and R92 back to their shared room. V3 documented that she heard a conflict up the hall that made her accidentally mix up the unlabeled medication cups. V3 documented R83 was given R92's medications including donepezil (dementia treatment) 5mg.
2. R92's admission Record documented an admission date of 8/8/2024 and included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance mood, altered mental status and muscle weakness.
R92's MDS dated [DATE] documented a BIMS score of 3, which indicates severe cognitive impairment.
R92's Physician Order Summary documented donepezil hydrochloride (dementia treatment) 5mg-1 tablet by mouth at bedtime and memantine (dementia treatment) 10mg tablet, take 1 tablet by mouth twice a day.
R92's Progress Note dated 3/17/2025 by V3 (RN) documented that she was passing medications and took R92 and R83 back to their shared room. V3 documented that she heard a conflict up the hall and accidentally swapped the medication cups. V3 documented R92 was given R83's medications including acetaminophen 1000mg, valproate 500mg and apixaban 5mg.
On 04/24/25 at 10:00 AM, V1 (Administrator) stated, he had been notified by V3 (RN) that she administered the wrong medications to R83 and R92. V1 stated, he advised V3 to contact V2 (Director of Nursing/DON) and then he immediately started working on the plan of correction that included education and observation of medication administration by nursing staff.
On 04/24/25 at 10:36 AM, V2 (DON) stated, she was notified via phone by V3 (RN) that she had given R83 and R92 the wrong medications. V2 stated V5 (Physician) was contacted, vitals were obtained on R83 and R92 with monitoring scheduled for every 2 hours for the next 24 hours. V2 stated V1 immediately started a plan of correction that included education and auditing of the nursing staff being observed during medication administration on 10 residents.
The facility policy Adverse Consequences and Medications Error (revised April 2014) documented under Policy The interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and mediation-related problems such as adverse drug reactions (ADRs) and side effects. Adverse consequences shall be reported to the Attending Physician and Pharmacist, and to federal agencies as appropriate. Under Policy, 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professionals' standards and principles of the professional(s) providing services.
Prior to the survey date, the facility took the following actions to correct the non-compliance:
1. Incident Investigation of 2 residents on one wing had received the wrong medication during the bedtime medication pass.
2. Per review of the Interdisciplinary team, it is felt that there is potential for other residents.
3. Staff member had been offered education regarding 5 rights of medication administration. Completed by 4/1/2025. Mediation Administration rate at 0% during survey.
4. All nursing staff to be educated regarding 5 rights of medication administration. Completed by 4/1/2025, Medication Administration rate at 0% during survey.
5. The Administrator/Director of Nursing and/or designee will observe return demonstration of medication on each nurse with 10 residents med passes being observed. V2 completed audits by 4/1/2025 with V1 and V2 in attendance.
6. QAPI (Quality Assurance Performance Improvement) meeting held - any issue identified will be immediately corrected and re-education will be offered and reviewed during QAPI meeting. This was also completed by 4/1/25.

Based on interview and record review, the facility failed to timely transmit Minimum Data Set (MDS) Assessments for 2 (R20 & R25) of 2 residents reviewed for timely MDS submission in the sample of 45.
The findings include:
1. R20's Face Sheet documented an admission date of 11/20/2024 and included diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. This same document listed a discharge date of 12/5/24.
R20's last transmitted MDS was an admission assessment and was completed on 11/27/24.
2. R25's Face Sheet documented an admission date of 10/29/2024 and included diagnoses of repeated falls, anemia, type 2 diabetes, and muscle weakness. This same document listed a discharge date of 11/26/24.
R20's last transmitted MDS was an admission assessment and was completed on 11/5/24.
On 4/23/25 at 11:00 AM, V4 (MDS Coordinator) stated that she just took over this job in March of 2025 and recognizes that R20 and R25's assessments are showing up as overdue quarterly assessments, however a discharge assessment should have been completed and transmitted with a due date of 12/5/24 for R20, and a discharge assessment should have been completed and transmitted with a due date of 11/26/25 for R25.
On 4/24/25 at 11:30 AM, V4 stated that she had completed and transmitted the discharge MDS's for R20 and R25.
Review of the final validation report documents that R20's discharge assessment target date was 12/05/2024, but was not transmitted as complete until 4/24/25 and documents a message that the completion date is more than 14 days after the assessment reference target date. This same report documents that R25's discharge assessment target date was 11/26/24, but was not transmitted as complete until 4/24/25 and documents the same message that the completion date is more than 14 days after the assessment reference target date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transfer a resident safely for 1 (R1) of 3 residents reviewed for accidents in the sample of 6.
This past non-compliance occurred between 12/01/2024 to 12/13/2024.
The findings include:
R1's admission Record documents R1 was admitted to the facility on [DATE] and includes diagnoses of cerebral aneurysm, non-ruptured, contracture of muscle, multiple sites, adult failure to thrive, altered mental status, delusional disorder, generalized anxiety disorder, and Paroxysmal Atrial Fibrillation.
R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 01, indicating R1 has severe cognitive impairment. The same MDS documents that R1 has impairment on both upper and lower extremities, is dependent for showers, bed to chair transfers, and getting in and out of shower.
R1's Care Plan documents that R1 has an ADL (Activities of Daily Living) self-care performance deficit. Documented interventions include that R1 requires extensive assist with bathing/dressing/hygiene and R1 requires two assist with full body mechanical lift for all transfers.
R1's [NAME] documents for Toilet Use: R1 requires two assist with full body mechanical lift for all transfers and R1 requires two assist with full body lift for all transfers or two assists with transfers.
R1's Physician's Orders dated as of 11/1/2024 document an order for Eliquis tablet 2.5mg (milligrams) two times a day for AFib (Atrial Fibrillation).
R1's Progress Note dated 12/2/24 at 12:51 PM by V12 (Licensed Practical Nurse) documents (R1) noted to have a large bruise to right forearm. (R1) reported that staff transferred her to shower without using hoyer (mechanical) lift yesterday afternoon. MD (physician) and POA (Power of Attorney) notified.
R1's Nurse's Progress Note dated 12/2/24 at 3:21pm by V1 documents I spoke with (R1) today regarding a bruise that occurred the night before during a transfer prior to her shower. (R1) stated that the aides in no way intentionally set out to harm her in any way. She thanked me for talking with her and had no other concerns at this time.
On 12/10/24 at 2:00pm, V2 (Assistant Administrator) said there was an incident on 12/1/24 involving R1 that occurred on 12/1/24. V2 said that there were 2 Certified Nurse's Aides (CNA), that do not usually work that hall, that gave R1 a shower. V2 said that instead of using the mechanical lift, they lifted R1 under her arms. V2 said that both staff told her that R1 never screamed or yelled or even told them they needed to use the lift. V2 said that the incident was brought to her attention on 12/2/24 (Monday) that R1 had a large bruise on her right forearm from not being transferred with the mechanical lift. V2 said that V15 (Certified Nurse's Aide/CNA) said that there were no issues with the mechanical lifts, they just didn't use it and lifted her without it. V2 said that they should have used the mechanical lift, but didn't. V2 also said that R1 is on Eliquis which is a blood thinner and does bruise easily.
On 12/10/24 at 11:30am, R1 was sitting in her recliner in her room. R1 said she did not want to talk about it and she had told the story a million times and was not going to say it again. R1 would not let this surveyor look at her arm. R1 was alert and answered questions appropriately at this time.
On 12/12/24 at 11:25 AM, R1 was asked about the incident on 12/1/24 and R1 said they didn't use the lift and those girls were never going to shower her again. R1 said they are not allowed in her room again. R1 said she did not tell them to stop or to use the lift when they transferred her. R1 said that she is ok and that that will not happen again. R1 said they made this big bruise on her arm. R1 was asked to see the bruise and R1 would not let this surveyor look at the bruise. R1 was observed to have contractures in both hands and unable to use them. The lower part of the bruising towards her wrist was visible and it was reddish pink in color. R1 was alert and answered questions appropriately at this time.
On 12/12/24 at 3:15 PM, V15 (CNA) said she worked on 12/1/24 and said she was told that R1 needed a shower and no one told her that she needed a mechanical lift. V15 said she was not aware of looking at the [NAME] and has been employed at the facility for maybe 9-10 weeks. V15 said that they transferred R1 under her arms and held the seat of her pants. V15 said that facing R1 she put her arm under R1's arms in the arm pit area and R1's arm pit area was in the bend of her arm. V15 said she also had ahold of the seat of R1's pants. V15 said that R1 did not scream or yell and all that R1 said they were never giving her a shower again. V15 said they used the shower in the 800 hall that was closed since the showers on the 500 hall were being used. V15 said that R1 never told them to stop and they should use the lift or they would have used it. V15 said to her knowledge, the lifts were not broken. V15 said there was bruising on R1's right arm before they showered her. V15 said after R1's shower, they lifted her back in bed. V15 said they did not use the lift putting her in bed. V15 also said she did not use a gait belt.
On 12/10/24 at 3:24pm, V16 (CNA) said she was not aware that R1 required a mechanical lift for transfers. V16 said she was being trained and had only worked a couple of days. V16 said that on 12/1/24 she transferred R1 with V15. V16 said she was on the opposite side of V15 and placed her arm under R1's arm with R1's weight resting in the bend of her arm and used her other hand to hold the seat of R1's pants. V16 also said she did not use a gait belt. V16 said R1 never told them they needed to use the lift. V16 said they took R1 to the 800 hall to shower since the shower on the 500 hall was being used. V1 6 said that no one could have heard R1 screaming and yelling since she did not yell or scream at all. V16 said that R1 kept saying you will never give me a shower again and that was it. V16 said they showered her without any issues and then put her back in bed again not using the lift.
On 12/11/24 at 10:00am, V12 (Licensed Practical Nurse/LPN) said she came in on Monday (12/2/24) and saw bruising on R1's right arm. V12 said that R1 told her that the CNA's couldn't get the lift to work and lifted her under her arms and that is where the bruise came from yesterday (12/1/24) V12 said R1 also told her that they were transferring her to a chair. V12 said she took a picture of the bruise and reported it to administration on 12/2/24 and also called the physician and R1's POA (Power of Attorney).
On 12/11/24 at 10:50am, V14 (Registered Nurse/RN/Infection Preventionist/wound nurse) said that she is aware of the incident. V14 said she was not aware of any bruising present on R1's right arm prior to the incident on 12/1/24.
The facility policy titles Safe Lifting and Movement of Residents (revised July 2021) documents Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. A resident that requires a mechanical lift may also be a two person assist with the use of proper equipment i.e (in example) gait/transfer belts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered for 1 (R77) of 10 residents reviewed for medication administration in the sample of 38. This failure resulted in R77 experiencing a significant medication error in which 5 additional doses of diuretic medication were administered resulting in dizziness, abnormal lab values, Intravenous Fluid administration, supplemental Potassium medication, and a hospital admission for an Acute Kidney Injury.
This past non-compliance occurred between 3/14/24 and 3/19/24.
Findings Include:
R77's admission Record documented R77 was [AGE] years old with an admission date to the facility of 03/08/2023. Diagnoses listed in their entirety on this document are: Alzheimer's Disease with late onset; Essential Hypertension; Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
R77's Progress Note dated 3/8/2024 with a time of 1:48 P.M. documented V12 (Physician) was here for rounds in which he reviewed medications, labs, vitals and weights. Received new order to start Duo nebs BID (twice daily) x 7 days and Zaroxolyn 5mg (milligrams) daily for 5 days.
R77's Progress Note dated 03/18/2024 with a time of 2:23 P.M. documented R77 was complaining of dizziness, reported to V12. New orders were received for a CBC (Complete Blood Count), CMP (Complete Metabolic Panel), UA (Urinalysis Analysis) and orthostatic B/P (blood pressure).
R77's Progress Note dated 03/19/2024 with a time of 12:44 A.M. documented R77 is currently receiving 2 diuretics, Furosemide 40 mg two times a day and Zaroxolyn 5 mg in the morning. R77 was noted to be experiencing dizziness, dry mouth, and urinating less this shift. Had to ambulate to the bathroom with one assist. A Progress Note dated 03/19/2024 with a time of 1:31 P.M. documented R77 was prescribed Zaroxolyn on 03/08/2024 intended for 5 days. Medication was ordered in the system for an indefinite end date therefore R77 has been receiving Zaroxolyn since 03/09/2024. Held this AM (03/19/2024) due to symptoms. V12 notified to discontinue medication and V13 (Nurse Practitioner/NP) will see R77 today.
R77's Medication Administration Record documented Zaroxolyn was administered daily from 03/09/2024 - 03/18/2024 and held on 03/19/2024.
R77's Progress Note dated 03/19/2024 with a time of 1:31 P.M. documented new orders for Potassium 40 meq (milliequivalent) by mouth three times a day and a 500 milliliters intravenous (IV) bolus. R77 was then to have an additional 100 milliliters per hour times two hours, along with a BMP daily for 3 days, and close monitoring for fluid overload. Additionally, R77's Furosemide was to be decreased to 20mg BID for 3 days. A document labeled CBC/CMP dated 03/19/2024 documents the following: BUN (blood urea nitrogen) 96 (high) normal value 7-25, Creatinine 2.8 (high) normal value 0.6-1.3, Sodium 134 (low) normal 136-145, Potassium 2.3 (Low) normal 3.5-5.1, and GFR 14 (low) normal >90. R77's Medication Administration Record dated March 2024 documented the bolus and intravenous fluids ordered to be given were Normal Saline Solution 0.9% with administration completed as ordered.
R77's Progress Note dated 03/19/2024 with a time of 6:20 P.M. documented that the certified nurse assistant reported R77 pulled IV out. R77's Progress Note dated 03/19/2024 with a time of 7:15 P.M. documents that IV attempts were made with no success. R77 was refusing additional attempts. R77's Progress Notes further document that on 03/20/2024 at 3:27 A.M., R77 was reapproached and explained the need to restart the IV. R77 tolerated the restart well, and voiced no concerns. IV of Normal Saline was hung at 100 ml / hr (hour). On 03/20/2024 at 05:15 A.M., a note documented that lab was here to draw the BMP at this time. A nurses note dated 03/20/2024 with a time of 10:13 A.M. documented V13 was notified of a BUN critical at 100--new order received to give bolus of 500mL NS (Normal then back to 100mL per hour at previous dosage). A nurses note dated 3/20/2024 with a time of 10:40 A.M. documented an IV of 500mL bolus NS infused and hung new bag, set rate at 100mL per hour. IV site patent at this time and no redness, no edema noted. A nurse note dated 03/20/2024 with a time of 12:06 P.M. documents R77 pulled out IV line. R77 does not comprehend what IV is or what it is for. A nurse note dated 3/20/2024 with a time of 2:40 P.M, documented received order from V13 to send to (name of local hospital) for direct admit.
The local hospital Discharge summary dated [DATE] documented R77 had an admission date to the hospital of 03/20/2024 with a diagnosis of Acute Kidney Injury. This same document noted R77 was having worsening edema in the long term care facility and more aggressive diuretics were ordered however, the length of treatment was extended beyond what was initially ordered. R77 experienced a decline in renal function. R77 had received IV fluids at the facility however, R77 continued to remove the IV. During R77's hospitalization R77 was treated with IV fluids for the Acute Kidney Injury, and diuretics were held. R77 initially had a creatine of 2.9 (No reference range given although lab results indicated high), creatine down to 1.7 (no reference [NAME], although a high but improving level is noted).
A Progress Note dated 03/20/2024 with a time of 2:20 P.M. documented R77 admitted back to facility around 12:30 PM.
On 04/19/2024 at 8:53 A.M., V3 (Director of Nursing/DON) stated she was made aware of the medication error by V14 (Licensed Practical Nurse). After reviewing the incident, it was discovered that when V10 (LPN) placed the order in the Electronic Medical Record (EMR) system with no end date. The EMR system places an end date of indefinite on each order unless a different date is selected. R77 was assessed by medical staff at the time of the medication error discovery and new orders were received for treatment that same day. R77 was treated in the facility until she wouldn't keep her IV in. V3 started a QAPI (Quality Assurance Performance Improvement) plan on the medication error. V3 checks the physician orders daily to ensure that the orders were written correctly. V3 stated that moving forward, all new orders will be matched against the nurses note. V3 educated all nursing staff on properly placing an order with an end date.
On 04/19/2024 at 9:18 A.M. V10 (LPN) stated that she received the order for Zaroxolyn and that she was the nurse who placed the order for R77 Zaroxolyn in the computer. V10 stated that she did not place an end date on the order. V10 stated that she had been educated since the incident to ensure if the order contains an end date to make sure it is on the order in the EMR.
On 04/18/2024 at 12:35 P.M., V12 stated that the expectation is that the facility follow physician orders. V12 stated that the extra doses of Zaroxolyn was a medication error. The extra doses of the medication lead to admission to a local hospital with diagnosis of Acute Kidney Injury. V12 stated that there was timely notification of the medication error and the hospitalization was a direct result of the medication error.
A document titled Med Error, dated 3/19/24 documented R77 was prescribed Zaroxolyn 5mg daily times 5 days starting on 03/09/2024. When the order was placed there was no end date, so the order was indefinite. R77 has been receiving metolazone (Zaroxolyn) from 03/09/2024 - 03/18/2024 due to medication being held 03/19/2024 due to R77 having symptoms of dizziness. R77 was unable to give description. Action taken documents V13 saw R77 on rounds. Labs were ordered and done on R77. New order for IV fluids for 2 days, Oral Potassium 40 meq three times a day, decrease Furosemide to 20 mg for 3 days then return to 40 mg dose. Monitor for fluid overload. Do BMP daily times three days.
A note dated focus area in R77's Plan of Care documented R77 receives diuretic therapy related to edema of bilateral lower legs and feet. The goal listed for this focus area is that R77 will be free of any discomfort or adverse side effects of diuretic therapy through the review date.
The policy titled Administering Medications with a revised date of April 2019 documented, Medications are administered in a safe and timely manner. The same policy goes on to state .4. Medications are administered in accordance with prescriber orders, including any required time frame.
Prior to the survey date, the facility took the following actions to correct the deficient practice:
1. A Quality Assurance and Performance Improvement (QAPI) meeting was held on 3/20/24. The incident was reviewed and identification of others at risk was discussed. In attendance - V1 (Administrator), V3 (DON) and V12 (Medical Director).
2. Interventions put into place to reduce risk of recurrence: Nursing staff educated regarding double checking orders for end dates upon entry. All nursing staff education was completed by 3/20/24.
3. Monitoring/Effectiveness: Administrator (V1), DON (V3) or designee will monitor order entries for end dates, 2 new orders will be monitored 5 days per week for 4 weeks. Any issue identified will be immediately corrected and re-education will be offerred and reviewed during QAPI Meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a window alarm was in working order for a resident at a high risk for elopement for 1of 3 residents (R1) reviewed for elopement in the sample of three.
This past non-compliance occurred between 11/9/23 and 11/16/23.
Findings include:
R1's Face Sheet documented an admission Date of 5/19/23 and listed diagnoses including Unspecified Dementia, Severe, with Anxiety, Chronic Obstructive Pulmonary Disease, Depression, and Hypertension.
Elopement Risk Assessments for R1 were completed on 10/5/23 and 11/10/23. The Elopement Risk Assessments document the following: Residents are at a high risk for elopement when yes is answered to both questions in section A or a score of 5 or greater. R1's Elopement Risk assessment dated [DATE] documents a score of 19.5 and R1's Elopement Risk assessment dated [DATE] documents a score of 18.5, indicating R1 is a high risk for elopement. Both questions in section A of the Elopement Risk Assessments completed on 10/5/23 and 11/10/23 have a documented answer of yes.
R1's Care Plan dated 11/10/23 documented a problem area, (R1) is an elopement risk/wanderer related to a Dementia diagnosis.
A Nursing Progress Note dated 11/9/23 at 5:40pm , authored by V1, Administrator, documented, I spoke to (V3, Certified Nursing Assistant) who was working on Wing 7 and she saw someone at the Wing 7 door, and went to assist them in. As she got closer to the door she realized it was (R1) so she approached her calmly and slowly and assisted her back to her room on Wing 6. Investigation revealed her window was closed, but the screen was up and clothing (was) outside her window. A string of personal items were along the sidewalk to the Wing 7 entrance.
A Summary of Incident dated 11/9/23 documented,Summary of investigation: (R1) is a [AGE] year old female admitted [DATE] and resides on our lockdown Memory Care Unit. (R1) is independent with transfers/ambulation throughout (the unit). It appears (R1) exited her room through her window and walked to the next wing and entered the building through those doors. (R1) was last seen in the dining room at 4:45pm by staff and went toward her room. At 5:15pm, (V3) assisted (R1) as she was trying to enter the building through the Wing 7 entrance. The screen to (R1's) window in room was open and clothes were scattered outside on the ground leading to the path she took. Prior to 11/9/23, (R1) wasn't observed exit seeking out a window.
An Elopement Details Report dated 11/9/23 documented, Time resident went missing: 11/9/23 at 5:15pm. Time resident found: 11/9/23 at 5:15pm, at Wing 7 entrance, found by (V3, Certified Nurses Assistant). Conclusion: Root Cause: Resident had an appointment outside the facility earlier in the day. Resident stated (to V3) that she 'needed a break from everything.' Resident also thought she saw her husband outside. Head to toe assessment: No injuries noted. (Personal perimeter alarm) in place and functioning. Window alarms assessed for function and batteries were checked. (Initiated) Frequent checks for 72 hours.
A Smart Action Plan documented a problem,Resident eloped through a window on the Memory Care Unit, with a corresponding goal, No resident will leave the premises or a safe area without authorization or necessary supervision, and corresponding action items, Head to toe body assessment, frequent checks for 72 hours, replace batteries in window alarm, assess (personal perimeter bracelet alarm), husband to decrease frequency of visits as visits increase behaviors. Target completion date 11/10/23. Audit all Elopement Assessments to ensure any resident at risk is identified. Target completion date 11/10/23. Audit care plans of residents who are at risk of elopement. Target completion date 11/10/23. Test window alarms weekly. Target date 11/10/23 and ongoing. Re-inservice staff on Elopement Policy. Target date 11/13/23.
On 11/28/23 at 11:10am, V5, Memory Care Unit Coordinator, stated R1's cognition varies widely according to the day, and her exit seeking behavior seems to be exacerbated by her husband visiting. V5 stated on 11/9/23 at about 5:15pm, after V5 had left for the day, R1 was observed by staff to be standing outside the Wing 7 entrance doors. V5 stated it was determined by investigation that R1 had exited the building via the window of her room. V5 stated the investigation determined the battery in the window alarm was dead, resulting in the alarm not sounding when the window was raised. V5 stated there was a trail of clothing and personal care items outside the building leading from underneath the window to the Wing 7 entrance door. V5 stated R1's personal perimeter alarm was in place and was working, but is only triggered if one of the doors to the outside is breached, therefore it did not sound when R1 crawled out the window. V5 stated V4, Maintenance Director, was supposed to be checking the window alarm batteries. V5 stated she is now responsible for checking them weekly.
On 11/28/23 at 11:30am, R1 was alert and oriented to herself only. R1 stated she did not remember anything about having crawled out her window to exit the building. R1 stated her memory is bad and she often forgets things.
On 11/28/23 at 11:40am, V4 stated after the elopement he checked all the window alarms in the building, all of which are located on the Memory Care Unit (Wing 6) which were all working with the exception of R1's room, due to the battery being dead. V4 stated he immediately replaced the battery, which he estimates, Should last about a year. V4 stated he checked the batteries in all the window alarms approximately 2 months prior to the incident, and stated this is not documented. V4 stated he doesn't think there is any policy about when to check the batteries.
On 11/28/23 at 11:50am, V2, Assistant Administrator, stated there is no policy as to when the batteries in the window alarms should be checked, but the action plan that was developed after the elopement specifies that V5 will now be checking the batteries weekly and documenting.
On 11/28/23 at 12:20pm, V3 stated she works the 2pm to 10pm shift, and on 11/9/23 she was working on Wing 7. At about 5:15pm, she saw somebody standing outside in front of the Wing 7 entrance door. V3 stated it was R1, wearing a T-shirt, jacket, sweatpants and shoes. V3 stated R1 seemed confused and anxious, which she usually does. V 3 stated when she opened the door for R1, her personal perimeter bracelet alarm set off the door alarm so it was obviously working. V3 stated she asked R1 what she was doing and how she got outside and R1 said 'she was taking a break from everything'. V3 stated there were no signs of injuries. V3 stated the temperature outside was in the 50s, it had been sunny that day, there was no rain, and it was around sunset but it wasn't completely dark out yet. V3 stated she took R1 back to Wing 6, where staff were not aware she had gotten out.
On 11/28/23 at 2:05pm, V2 stated on 11/9/23, R1 was last seen in the Wing 6 Dining Room at 4:45pm headed back to her room after eating supper. V2 stated R1 would have been outside for a maximum period of 15 to 30 minutes. V2 stated a full body assessment was immediately performed and R1 had no injuries. V2 stated frequent checks for a 72 hour period were immediately implemented. V2 stated R1's window alarm battery was found to be dead and was replaced. V2 stated all other window alarms were checked and found to be operational. V2 stated V5 is now doing weekly window alarm battery checks for all Wing 6 windows. V2 stated R1's husband has agreed to do fewer visits, and to not knock on windows or doors when he is leaving, as he sometimes does. V2 stated all Elopement Risk Assessments in the facility, including R1's, were updated to make sure any at risk residents had been identified. V2 stated all staff were re educated on the Elopement Policy, and R1's Care Plan was also updated. V2 stated all members of the Quality Assurance Committee, including the Medical Director, have discussed the incident and approved the resulting action plan. V2 stated R1 had an doctors appointment and a visit from her husband the day before the incident, and staff feel this led to an increase in exit seeking behavior.
An Elopement Prevention and Response Policy dated 2/19/21 documented,The community provides a safe environment for all residents. Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so.
Prior to the survey date, the facility took the following actions to correct the non-compliance:
1. On 11/10/23, members of the Quality Assurance Committee met to discuss the elopement and team members reviewed the Smart Action Plan and the Elopement Policy.
2. On 11/10/23, all staff members were re-inserviced on the facility's Elopement Policy.
3. On 11/9/23, the batteries in R1's window alarm were replaced, and the batteries in all the window alarms on the Memory Care Unit were tested and found to be working.
4. On 11/16/23, V5 initiated weekly testing of all the window alarms on the Memory Care Unit, with documentation on the 'Wing 6 Window Alarms flow sheet.
5. On 11/10/23, R1's husband agreed to reduce the frequency of his visits in order to minimize R1's exit seeking behavior following his visits.
6. On 11/10/23, R1's Elopement Risk Assessment and Care Plan were updated, and all Elopement Risk Assessments in the facility were audited.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide written documentation which stated the reason the facility could not meet the resident's needs for 1 (R1) of 3 residents reviewed for discharge procedure in the sample of 3.
Findings include:
1. R1's face sheet documented R1 was admitted to the facility on [DATE] with diagnoses including: pneumonitis due to inhalation of food and vomit, dysphagia, unspecified intellectual disorders, autistic disorder, insomnia. R1's care plan documented R1 had several physical behaviors such as hitting, pinching, and biting staff. R1's 6/22/23 Minimum Data Set (MDS) documented R1 was severely cognitively impaired.
On 8/24/23 at 10:11 AM, V1 (Administrator) said R1 was admitted after a hospital stay due to aspiration pneumonia. V1 said R1 was going to work with speech therapy and be discharged back to the group home R1 was residing prior to hospital stay.
On 8/24/23 at 12:29 PM, V2 (R1's Legal Guardian) said R1 was living in a group home and was transferred to the hospital due to aspiration problems. V2 said the hospital had recommended placing a feeding tube in R1 but V2 felt that was unnecessary and wanted a second opinion. V2 said R1 was transferred to another hospital for a second opinion and declined a feeding tube be placed again. V2 said R1 is not verbal and would not have been able to maintain a feeding tube. V2 said he chose R1 to be placed on palliative care if R1's only other option was having a feeding tube placed. V2 said R1 was transferred to the facility with the intention of end of life care.
On 8/24/23 at 2:37 PM, V3 (Social Services Assistant) said R1 was admitted to the facility with the expectation R1 would be receiving services of hospice. V3 said when R1 arrived to the facility it was clear R1 was not going to be a candidate for hospice services. V3 said when R1 arrived to the facility he was very mobile and did have some aggressive behaviors with staff such as bending staff's finger back, twisting staff's wrists, attempting to bite staff, and pounding on doors trying to get out of the building. V3 said he did not recall R1 having any aggressive behaviors towards other residents. V3 said R1 was transferred to an acute psychiatric facility for evaluation of his behaviors. V3 was asked why the facility could not meet R1's needs V3 said it was mainly nursing not being able to be one on one with R1. V3 said R1 required constant supervision due to exit seeking and wandering. V3 stated we (the facility) can't have a single staff follow a resident around the building all day.
On 8/24/23 at 10:11 AM, V1 (Administrator) said R1 had been transferred to an acute psychiatric hospital for behaviors. V1 said the hospital had notified the facility they were R1's base line behaviors and R1 would be discharged back to the facility. V1 said the facility had completed an emergency involuntary discharge after being notified there was no improvement to R1's behaviors.
R1's Electronic Medical Record (EMR) documented several progress notes documenting the facility's attempts to find placement in group homes like the group home R1 had previously resided in.
R1's EMR documented a 6/26/23 at 3:00 PM progress note .(Acute psychiatric hospital) called. They can accept (R1). They would like for him to be sent with 3 outfits and night clothes if he wears them . sent current medications . Transportation notified that (R1) has been accepted .
R1's EMR documented a 7/3/23 at 12:17 PM progress note .(Acute psychiatric hospital) called and requested (R1) to be picked up from their facility this Friday at 1100. Transportation Supervisor is aware and will make arrangements for transportation. (Acute psychiatric hospital) reported that (R1) is still pinching and exit seeking but can be easily redirected .
R1's EMR documented a 7/6/23 at 11:13 AM progress note .called with an update on (R1) today from (Acute psychiatric hospital). (R1) is eating and sleeping well, he is exit seeking, pinching, getting physical today when being redirected. Doctor has said this is his baseline behavior and they don't feel they can do anymore with him. They do feel like he has more behaviors with male staff and advise if we can avoid this it may be helpful, he prefers female staff. I did ask if they can keep him a bit longer to try and help with the behaviors as we feel it will put our other guests at risk. She said she understands and does feel like he would be in a better setting like his previous home but they're unable to do anything further as doctor said it's his baseline behavior .
R1's EMR documented a 7/6/23 at 4:59 PM progress note . Phone call made this afternoon to (R1's) guardian, (V2), letting him know that the facility would be doing an involuntary/ emergency discharge at this time .
R1's 7/6/23 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents documented an emergency transfer or discharge from the facility citing . your welfare and needs cannot be met in the facility, as documented in your clinical records by your physician . and .the safety of individuals in this facility is endangered The facility was not able to produce any documentation R1 was a danger to other residents or documentation from R1's physician why R1's needs could not be met in the facility. R1's 7/6/23 Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents also documented . on the date of transfer or discharge, you will be relocated to: Facility/ Person: (V3/ R1's Legal Guardian) . R1 was discharged to an acute psychiatric hospital.
On 8/24/23 at 12:29 PM, V2 (R1's Legal Guardian) said the facility had called him to inform him R1 would not be allowed to be readmitted to the facility after his stay in the acute psychiatric hospital because the facility could not handle R1's behaviors. V2 stated he was unsure why they were unable to find R1 placement in a group home after his return from the hospital. V3 said R1 was still at the acute psychiatric hospital at the time of this investigation. V3 said he was told there was an appeal process but V3 did not know what he was supposed to do or who to talk to about that.
On 8/24/23 at 1:44 PM, V5 (Chief Nursing Officer at the Acute Psychiatric Hospital) said R1 had been in the Acute Psychiatric Hospital for almost 2 months and had only had approximately 5 days with aggressive behaviors and was doing well.
On 8/29/23 at 9:45 AM, V1 (Administrator) was asked why an emergency involuntary discharge was performed when R1 had been at the acute psychiatric hospital for 10 days and responded R1 was initially sent to the acute psychiatric hospital for behaviors and when they called back and told us his behaviors were his base line that is when we initiated the emergency involuntary discharge. V1 said she felt like the acute psychiatric hospital was better equipped to care for R1's behavioral needs. V1 verified there was no documentation from R1's physician documenting why the facility could not meet R1's needs, what interventions had been put in place, and why the receiving facility was better equipped to care for R1.
The facility's 9/1/09 Transfer/ Discharge policy documented .1. When a resident is transferred or discharged , the resident's chart will be documented by a physician. 2. Each resident is allowed to request or agree to relocate within the community or transfer to another facility, and to participate in the transfer or discharge . 4. Notification of transfer or discharge will follow the regulations of the State in which (the facility) is licensed and will be made at least 30 days in advance unless the individual qualifies for a State- defined emergency relocation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide two staff members to carry out a mechanical lift transfer for one of one resident (R13) reviewed for mechanical lift transfers in the sample of forty two.
Findings include:
On 01/17/23 at 10:55am, the surveyor entered the room of R13 . V2, Certified Nursing Assistant (CNA), was observed performing a mechanical lift transfer of R13 from the bed into the wheelchair. V2 was unassisted by other staff. V5, R13's family member, was also present during this transfer. V2 completed the procedure and left the room. V5, and R13, who was alert and oriented to person, place, and time, both stated this was not the first time only one staff member had performed a mechanical lift transfer for R13 .
R13's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status Score of 12, indicating R13 has minimal deficits in cognitive function. The same MDS documented that R13 requires extensive assistance from at least two staff members for transfers.
On 1/18/23 at 9:52am, V1, Administrator, stated V2 had approached V1 and V2 reported to V1 that V2 had done R13's transfer by herself. V1 confirmed there should always be at least two staff members present when performing mechanical lift transfers. V1 stated she told V2 that V2 would be disciplined when V2 came back from lunch. V1 stated V2 did not return after lunch, thereby terminating V2's employment. V1 stated staff were immediately re-educated about safe mechanical lift transfers.
On 1/19/23 at 9:45am, V3 CNA, confirmed there should always be at least two staff present during mechanical lift transfers. V3 stated in the past few days, staff were re-educated about safe transfers.
A Mechanical Lift Transfers Policy dated 01/30/20 documented, Guidelines: #5: Two nursing or therapy associates are required when using a mechanical lift.