Carver Living Center

F-F880

Based on record reviews, observations, and interviews with staff and Medical Director, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents for 1 of 3 residents (Resident #107) observed to have her blood glucose (sugar) level checked. This occurred while there were 18 residents identified with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer potentially exposes residents to the spread of bloodborne infections. Care must also be taken by personnel handling and storing glucometers to protect the glucometers against cross-contamination via contact with other meters or equipment. Also, the facility failed to disinfect individually assigned glucometers stored outside of the residents' rooms in accordance with the instructions provided by the manufacturer of the disinfectant wipes for 2 of 3 residents (Residents #66 and #93) observed to have their blood glucose levels checked.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 1. An interview was conducted on 2/4/25 at 6:17 AM with Nurse #1. When Nurse #1 was asked how long he had worked at the facility, he stated this was his first week. Upon further inquiry, the nurse reported he Level of Harm - Immediate received a short orientation from facility for agency nurses. jeopardy to resident health or safety On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained Residents Affected - Few information on the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); Admission Assessment (indicating

the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations. The orientation packet did not include any information about either the disinfection or storage of glucometers.

During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility.

A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager.

She also noted new staff nurses were assigned a mentor to supplement their orientation.

A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When asked, the Medical Director reported she had been informed of these concerns. She reported this sounded like a training issue and stated, This is the first time I have heard of this happening. The Medical Director reported she thought glucometer disinfection required better learning or training for all staff throughout.

The facility's Administrator and DON were informed of the immediate jeopardy (IJ) on 2/5/25 at 2:00 PM.

The facility provided the following plan for IJ removal:

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance

On 02/04/2025, an agency nurse (Nurse #1) provided care without receiving proper orientation and competency validation regarding glucometer disinfection procedures. The nurse used a glucometer dedicated to Resident #134 for Resident #107 without proper disinfection between residents. When interviewed, the nurse stated they were unaware of facility policies and procedures for glucometer disinfection and did not know which products were approved for disinfection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 All residents requiring blood glucose checks were identified as being at risk. An audit conducted by the Director of Nursing and nursing unit coordinators on 02/04/2025 identified all facility residents requiring blood Level of Harm - Immediate glucose checks and confirmed the presence of residents with blood borne pathogens, creating risk for jeopardy to resident health or cross-contamination. safety

The following immediate actions were taken: Residents Affected - Few - At approximately 7:00 AM on 02/04/2025, upon discovery of the incident, Nurse #1 was immediately removed from resident care duties

- The Director of Nursing contacted Nurse #1 by telephone regarding the requirement to complete comprehensive glucometer competency validation before accepting any future assignments at the facility

Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete

The following systemic changes have been implemented as of 02/05/2025:

1. Comprehensive Glucometer Training and Competency Program:

All licensed nurses (including facility staff and agency staff) must complete the following training and demonstrate competency before performing blood glucose monitoring:

a. Required Equipment and Supplies:

- Gloves

- Glucometer

- Alcohol pads

- Single-use lancet

- Blood glucose testing strips

- Disinfecting wipes

- Paper towels or tissues

b. Complete Glucometer Procedure and Cleaning Steps:

- Obtain needed equipment and supplies

- Perform hand hygiene

- Explain the procedure to the resident

- Provide privacy

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 - [NAME] gloves

Level of Harm - Immediate - Obtain capillary blood glucose sampling jeopardy to resident health or safety - Remove and discard gloves, perform hand hygiene prior to exiting the room

Residents Affected - Few - Retrieve (2) disinfectant wipes from container

- Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of

the glucometer

- After cleaning, disinfect with second wipe, maintaining 3-minute wet contact time. Allow the glucometer to air dry

- Discard disinfectant wipes in waste receptacle

- Perform hand hygiene

- Ensure glucometer is stored in individual plastic bag for each resident to prevent cross contamination

- Place clean dry paper towel or tissue under glucometer before placing on resident table or on top of medication cart to prevent contamination

2. Competency Validation Process:

Direct observation by nurse management of:

- Complete blood glucose monitoring procedure as outlined above

- Proper hand hygiene and glove use at specified steps

- Correct glucometer cleaning and disinfection technique

- Appropriate wet contact time monitoring

- Proper barrier use and storage procedures

- Return demonstration required for all steps

- Documentation of competency verification in employee file

- No blood glucose monitoring permitted until competency validated

3. Ongoing Monitoring:

- The Director of Nursing maintains documentation of all completed competency validations

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 - The staffing coordinator verifies completion of glucometer competency before scheduling

Level of Harm - Immediate Immediate Jeopardy Removal Date: 2/6/2025 jeopardy to resident health or safety The facility's credible allegation of immediate jeopardy removal was validated on 2/7/25. The validation was evidenced by nurse observations and/or interviews conducted on each hallway with regards to the required Residents Affected - Few infection control practices for the disinfection of glucometers. All nurses who were interviewed reported they had received the required in-service training prior to beginning their shift. The education provided stressed

the importance of using individually assigned glucometers for each resident requiring blood glucose monitoring and storing these glucometers in individual, re-sealable plastic bags. The in-service training also included a review of the manufacturer's instructions for the facility's glucometer and disinfectant wipes related to glucometer disinfection, as well as completing a return demonstration of the proper procedures for effective glucometer disinfection. Nurses observed to conduct blood glucose checks and subsequent glucometer disinfection completed the task without difficulty. The nursing practices observed included the proper handling and storage of glucometers to protect the meters from potential cross-contamination via contact with other meters or surfaces. There were no concerns identified during either the interviews or

observations.

The credible allegation was validated, and the immediate jeopardy was removed on 2/6/25.

2. An interview was conducted on 2/4/25 at 12:14 PM with Nurse #2. During the interview, the nurse estimated that she had worked at the facility four times in the last three months. On 2/4/25 at 12:35 PM, a follow-up interview was conducted with the nurse. At that time, Nurse #2 was asked if she received orientation upon starting to work at the facility. She stated, No, I did not. When asked, Nurse #2 reported she did not know how long a glucometer should remain wet (wet contact time) after using a disinfectant wipe to ensure the meter was adequately disinfected.

On 2/4/25, the facility provided a copy of the orientation packet given to agency nurses when they first began working at the facility. A review of the Information Packet for Registry Nurses revealed it contained the following topics: Welcome to [Name of Facility]; Important Guidelines (including dress code, personal devices, medication protocol, supplies, and identification); Admission Assessment (indicating the admission documentation required); Nurse Responsibilities in Admission; Daily Responsibilities; and Documentation Expectations.

During an interview conducted with the facility's Director of Nursing (DON) on 2/5/25 at 8:40 AM, the DON stated the only orientation material the facility provided for agency nurses was the Information Packet for Registry Nurses. She acknowledged the facility did not provide education on glucometer disinfection to agency nurses prior to the nurse working at the facility. The DON stated it was assumed that agency nurses had received training to ensure their overall competency to care for residents prior to being hired and assigned to work in their facility.

A follow-up interview was conducted on 2/7/25 at 8:19 AM with the DON to inquire about the training / orientation provided to newly hired staff nurses. When asked, the DON reported that staff nurses went through an orientation program led by the facility's Staffing Coordinator and Human Resources Manager.

She also noted new staff nurses were assigned a mentor to supplement their orientation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 A telephone interview was conducted with the facility's Medical Director on 2/6/25 at 2:27 PM to discuss the concerns related to glucometer disinfection identified during observations conducted at the facility. When Level of Harm - Immediate asked, the Medical Director reported she had been informed of these concerns. She reported this sounded jeopardy to resident health or like a training issue and stated, This is the first time I have heard of this happening. The Medical Director safety reported she thought glucometer disinfection required better learning or training for all staff throughout.

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32394 potential for actual harm Based on observations, staff interviews, and record reviews, the facility failed to have a medication error rate Residents Affected - Few of less than 5% as evidenced by 2 medication errors out of 25 opportunities, resulting in a medication error rate of 8% for 2 of 5 residents (Residents #85 and #8) observed during the medication administration

observation.

The findings included:

1. Resident #85 was admitted to the facility on [DATE REDACTED].

On 2/4/25 at 11:26 AM, Nurse #2 was observed as she prepared nine (9) medications for administration to Resident #85. The medications included two tablets of a combination medication with each tablet containing 8.6 milligrams (mg) sennosides (a stimulant laxative) / 50 mg docusate (a stool softener) taken from a stock medication bottle stored on the medication (med) cart. The medication was administered to Resident #85 on 2/4/25 at 11:40 AM.

A review of Resident #85's current physician's orders revealed his medication orders included 8.6 mg sennosides (a stimulant laxative) to be given as two tablets by mouth two times a day for constipation (Start Date 7/26/24). Resident #85 did not have a physician's order for docusate.

An interview was conducted with Nurse #2 on 2/4/24 at 12:35 PM related to the medication administration observed on 2/4/25 at 11:26 AM. During the interview, Resident #85's Medication Administration Record (MAR) was reviewed. At that time, Nurse #2 confirmed his physician's order was written for 8.6 mg sennosides (not a combination medication including sennosides and docusate). The stock bottle used for the med administration was also pulled from the med cart and the label of this stock bottle reviewed. At that time, Nurse #2 acknowledged each tablet of the medication contained 8.6 mg sennosides with 50 mg docusate. Upon further review of the stock meds available on the medication cart, the nurse identified a bottle containing 8.6 mg sennosides (as the sole active ingredient) was stored on the med cart and available for administration. During the interview, Nurse #2 acknowledged she administered the wrong medication to Resident #85 during the medication observation conducted earlier that morning. The nurse reported she would alert the nurse supervisor to this error.

An interview was conducted on 2/5/25 at 3:43 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she would expect nursing staff to verify the right medication and right dose

during the med administration process as part of the medication rights (right patient, right drug, right dose, right route, and right time).

2. Resident #8 was admitted to the facility on [DATE REDACTED].

On 2/5/25 at 9:08 AM, Nurse #3 was observed as she prepared thirteen (13) medications for administration to Resident #8. The medications included one tablet of a combination medication containing 600 milligrams (mg) calcium carbonate with 10 micrograms (400 units) of Vitamin D taken from a stock medication bottle stored on the medication (med) cart. A continuous observation was conducted as the medications were administered to Resident #8.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 A review of Resident #8's current physician's orders revealed her medication orders included a combination medication containing 500 mg calcium carbonate with 200 units of Vitamin D to be given as one tablet by Level of Harm - Minimal harm or mouth two times a day for hypocalcemia (low levels of calcium in the blood) with a start date of 4/1/22. The potential for actual harm resident's medication orders also included a current (but separate) order for 2,000 units of Vitamin D to be administered as one tablet by mouth one time a day for supplement (Start Date 2/9/21). Residents Affected - Few

An interview was conducted with Nurse #3 on 2/5/25 at 12:14 PM. During the interview, the discrepancy between the dosage of the calcium / Vitamin D combination medication observed to have been administered to Resident #8 on 2/5/25 at 9:08 AM (versus the dosage ordered by the physician) was discussed. At that time, both the resident's Medication Administration Record (MAR) and label of the stock bottle of the calcium / Vitamin D supplement observed to have been pulled for Resident #8's medication administration were reviewed. During the interview, Nurse #3 insisted she knew Resident #8 was ordered 500 mg calcium with Vitamin D and thought she had pulled the correct medication from the stock bottles. The nurse was informed

the label of the stock bottle handed off for review during Resident #8's medication observation indicated the dosage of the tablet administered to the resident was 600 mg calcium / 400 units Vitamin D (not the 500 mg calcium / 200 units of Vitamin D ordered for her).

An interview was conducted on 2/5/25 at 3:43 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she would expect nursing staff to verify the right medication and right dose

during the med administration process as part of the medication rights (right patient, right drug, right dose, right route, and right time).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38129

Residents Affected - Few Based on record review, resident and staff interviews, the facility failed to maintain accurate medical records

in the areas of medication allergies (Resident #185), failed to document the administration of pain medication (Resident #70), and document discharge to community Against Medical Advice (AMA) (Resident #187) for 3 of 8 residents' records reviewed.

Findings included:

1. Resident #185 was admitted to the facility on [DATE REDACTED] with the diagnosis of chronic atrial fibrillation (irregular heartbeat).

A review of Resident #185's hospital record dated 2/5/24 documented the resident had a medication allergy to aspirin and Compazine (nausea).

A review of Resident #185's facility electronic medical record documented the resident had no known allergies in the medication allergy tab. The Medication Administration Record dated February 2024 documented no known allergies. The resident was not prescribed aspirin and/or Compazine. The resident was discharged on [DATE REDACTED].

On 2/6/24 at 1:42 pm an interview was conducted with the Director of Nursing (DON). The DON stated the resident's medication allergy(s) were required to be listed in their medical record by the admitting nurse.

20906

2. Resident #70 was admitted to the facility on [DATE REDACTED] with the diagnosis of type 2 diabetes mellitus, stage 4 prostate cancer and Lupus.

The quarterly Minimum Data Set(MDS) dated [DATE REDACTED] revealed Resident #70's cognition was intact.

Resident #70 had orders dated 11/4/24 for Methadone HCL oral tablet 5mg by mouth one time a day for pain at 8:00 AM and 1.5 tablet by mouth at bedtime(10:00PM).

An interview on was conducted on 02/03/25 at 1:52 PM with Resident#70 who stated back in November 2024 he requested pain medication and was receiving it very late after the scheduled time. Resident #70 stated he did not understand why staff were so late giving him his medication.

A review of Resident #70's Medication Administration Record for November 2024 revealed there was no documentation the medication was given on 11/4/24 at 10:00 PM. The scheduled 10:00 PM dose was documented as administered on 11/5/24 at 9:59 AM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 345434 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345434 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Carver Living Center 303 East Carver Street Durham, NC 27704

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 An interview was conducted on 2/5/25 at 4:00 PM in conjunction with a record review with the Director of Nursing. She reviewed the Medication Administration Audit report and confirmed the scheduled dose Level of Harm - Minimal harm or Methadone of 1.5mg on 11/4/24 at bedtime was not documented until 11/5/24. The Director of Nursing potential for actual harm stated she had received reports from residents that Nurse #18 was not giving medication as scheduled, when she counseled the Nurse#18 about medication administration, she would state she had given the Residents Affected - Few medication and documented late. She stated Nurse #18 no longer worked for the facility due to a history of not documenting when medications were given or not documenting at all.

A telephone interview was conducted on 2/6/25 at 8:40 AM, the assigned Nurse#18 who stated if the medication was scheduled for 10:00 PM she was pretty sure she had given the medication and may have charted late.

A telephone interview was conducted on 2/7/25 at 10:06 AM, with the Nurse Practitioner #2 who stated Resident #40 had reported pain medications were administered late. The Nurse Practitioner#2 further stated

she reviewed the record and there have been times Resident #70 received the pain medication much later than scheduled and there would be late documentation.

38077

3. Resident #187 was admitted to the facility on [DATE REDACTED].

Review of the discharge return not anticipated Minimum Data set assessment dated [DATE REDACTED] revealed the resident was discharged home/ community.

Review of the medical records revealed no nursing notes or AMA form related to Resident's #187 discharge.

During an interview on 2/5/25 at 11:07 AM, Unit Manager #4 stated the resident had brief stay at the facility.

The resident was admitted to the facility on [DATE REDACTED] at around 6:00 PM and left the facility Against Medical Advice (AMA) on 10/15/24. The resident's family were in the facility on 10/15/24 and hurriedly took Resident #187 home. The Unit Manager #4 stated that any resident who wants to be discharged on AMA, the resident/resident representative had to be signed the AMA form. Unit Manager #4 indicated there was no document in the chart that indicated the resident left the facility AMA. The Unit Manager further indicated she was unsure why there was no documentation about the resident leaving the facility AMA.

The nurse assigned to Resident #187 on 10/15/24 was unavailable to be interviewed.

During an interview on 2/7/25 at 1:43 PM, the Administrator indicated if any resident was leaving the facility Against Medical Advice (AMA), then the AMA form should be signed by the resident and/or resident's family. If the family refuses to sign it, then 2 staff members had to sign it as witnesses. The resident's medical records should be uploaded with the AMA form and a note indicating the circumstances of the discharge.

The Administrator indicated Resident #187 was a PACE ( Program of All-Inclusive Care for the Elderly) resident and was closely followed by PACE for all his medical care and other needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 26 345434