The Villas At The Cedars

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to notify a resident’s provider and family of a significant change in condition following an acute hypoxic event. The resident was newly admitted with intact cognition, chronic lung disease, and orders for CPAP at night and oxygen at 2 L via nasal cannula to maintain O2 saturation above 90%. Baseline assessments documented normal respirations and an oxygen saturation of 96% on room air, with care plan interventions to monitor O2 saturations, watch for cyanosis, administer oxygen as ordered, and keep the physician informed of changes. During combined PT and OT assessments, the resident demonstrated signs of respiratory distress, with therapy documentation noting fluctuating oxygen saturations and lips turning blue. Nursing was notified and the resident was placed on CPAP. Despite these events, progress notes from late morning on one day through the following morning contained no indication that the provider or family were notified of the hypoxic incident. The resident reported that during therapy his oxygen saturation was 66% and that a nurse applied CPAP because there was no oxygen in the room. A family member later learned of the episode directly from the resident and, upon asking staff to recheck, was told the oxygen saturation was 89%, which the family member stated staff had not previously rechecked. Interviews with an LPN, RN, risk manager, NP, and DON confirmed that oxygen saturations of 66% or 89% would be considered low, should have been documented, and should have prompted notification of the provider and family, and that a sudden low oxygen saturation constituted a change in condition. The facility’s Notification of Changes policy required that changes in a resident’s condition be shared with the resident and/or representative and reported to the attending physician, which did not occur in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to follow provider orders and comprehensively assess and monitor a resident with chronic lung disease on admission and after a significant change in condition. The resident’s admission MDS indicated intact cognition, no need for oxygen or respiratory devices, and a diagnosis of chronic lung disease. The baseline care plan identified an alteration in oxygen/gas exchange with interventions to monitor oxygen saturations as ordered and PRN, monitor for cyanosis, document respiratory status, administer oxygen as ordered, and keep the provider informed of changes. Provider orders directed staff to monitor vital signs every four hours for 24 hours after admission, assess pain every shift, chart the resident’s condition in nurse’s notes every shift for seven days, check oxygen saturation levels every shift, and complete Daily Skilled Notes on specified shifts and days. Despite these orders, documentation showed that vital signs and oxygen saturation levels were not obtained and recorded as ordered. Oxygen saturation was recorded at admission and at several subsequent times, but there were gaps, including no oxygen saturation assessments documented for the 3–11 p.m. shift on the day of admission and incomplete vital sign sets at later times. The vital sign records did not show monitoring every four hours for 24 hours as ordered. The January Treatment Administration Record lacked evidence that vital signs were entered at the ordered times and that Daily Skilled Notes were completed on certain shifts. Progress notes between admission and the following morning lacked documentation of additional oxygen saturation assessments, Daily Skilled Notes, and nursing assessments on specific dates. The February TAR also lacked documentation of pain assessments every shift, nurse’s notes every shift for seven days, oxygen saturation checks every shift, and completion of Daily Skilled Notes as ordered. The resident experienced episodes of respiratory distress during PT and OT evaluations, with therapy documentation noting fluctuating oxygen saturations, lips turning blue, and placement on CPAP, but the medical record did not reflect decreased oxygen saturation levels corresponding to these events. The resident reported that during therapy his oxygen saturation was assessed at 66% and CPAP was applied, and a family member reported being told later that his oxygen saturation was 89%, with delays in staff responding to requests to recheck his vital signs and no oxygen equipment in the room until the next day. Facility staff, including an LPN, an RN, the NP, and the DON, acknowledged that the medical record lacked documentation of the hypoxic event, associated nursing interventions, provider notification, family notification, and the increased assessments that should have followed a change in condition, as well as acknowledging that ordered vital sign monitoring, oxygen saturation checks, and daily charting were not completed. Requested policies for assessment, monitoring, and following orders were not provided.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide timely and adequate pain management for a newly admitted resident following cervical spinal fusion surgery. The resident’s admission MDS documented intact cognition, a diagnosis of cervical spinal stenosis, and the need for post-surgical aftercare. The baseline care plan identified pain/comfort issues with a goal of adequate pain relief, including both non-pharmacological interventions and PRN pain medications such as acetaminophen and oxycodone. Provider orders directed staff to monitor pain every shift and to use non-pharmacological interventions, documenting those used. Despite these orders, the January MAR showed no administration of acetaminophen and first documented oxycodone administration more than a day after admission, even though the resident reported severe pain. Documentation inconsistencies were also present, including an incorrect pain rating entry and missing MAR entries for doses noted in progress notes. On the day of admission, the TAR showed the resident’s pain rated as 7/10 during one shift, yet the only non-pharmacological intervention documented was food and drink, and there was no documentation of pain assessments in the progress notes for that day. Subsequent pain assessment logs and progress notes indicated pain ratings of 7/10 and higher, with family members reporting that the resident’s stated pain level understated the true severity. Family interviews described the resident as having constant, severe pain, not wanting to move or eat, and having used the call light for pain medication without receiving it in a timely manner. Staff interviews confirmed that the resident’s ordered oxycodone was not available at the facility upon admission due to a miscommunication about the prescription, and that the resident did not receive narcotic pain medication until the following day. Nursing staff and the NP reported that oxycodone should have been available through the facility’s medication bank and that residents should not have to wait for pain medications when in significant pain. The LPN described the usual admission process of faxing orders to the pharmacy and confirming receipt, and stated she did not know why this resident waited so long for pain medication. An RN acknowledged that with a pain rating of 7/10, she would not rely on non-pharmacological interventions first and stated the resident should have received pain relief on the day of admission. The DON acknowledged a disruption in the process for obtaining pain medications timely for this resident and noted ongoing gaps in nurses following the established process. The facility’s pain management protocol required timely identification and assessment of pain, care planning for pain management, and provider notification with alternative interventions if prescribed medications were not available or delayed, which did not occur as required in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves failures in medication management for two residents, resulting in significant medication errors and delayed pain control. For one resident with intact cognition and diagnoses including heart failure, orthostatic hypotension, and stroke, the facility did not verify and accurately transcribe multiple metoprolol orders from the hospital, cardiology clinic, and pharmacy. The hospital discharge summary prescribed metoprolol succinate 50 mg twice daily, but facility orders initially listed metoprolol succinate ER 50 mg once daily at 8:00 a.m. and once daily at 8:00 p.m., and the MAR showed administration twice daily with one undocumented omitted dose. Later, a cardiology provider note recommended increasing metoprolol succinate to 75 mg daily, while a cardiology order from the same visit directed 75 mg twice daily. Facility orders were entered as metoprolol succinate ER sprinkles 25 mg, 3 tablets twice daily, without documentation that staff clarified the discrepancy between the provider note and the cardiology order or reconciled these with the original hospital order. Subsequently, pharmacy provider orders indicated metoprolol succinate ER 50 mg once daily, but facility orders added metoprolol tartrate 50 mg daily instead of metoprolol succinate, creating duplicate and conflicting orders. The MARs for January and February documented administration of both metoprolol succinate 75 mg twice daily and metoprolol tartrate 50 mg daily over several days, and continued twice-daily dosing of metoprolol succinate despite conflicting once-daily versus twice-daily directions. Nursing progress notes lacked evidence that staff clarified the conflicting and duplicate orders. Interviews with the NP and nursing staff confirmed that duplicate metoprolol orders existed, that metoprolol tartrate was ordered instead of succinate, that the nurse entering the order did not know the difference between the two formulations, and that required second and third verification checks for telephone orders were not completed. The NP and pharmacist stated that the resident received double the prescribed dose of metoprolol, and the resident reported feeling sicker, experiencing dizziness, and being told by both the cardiology provider and NP that she had been receiving the wrong dose. For a second resident admitted after cervical spinal fusion surgery, the facility failed to timely administer prescribed PRN opioid pain medication. Hospital discharge orders and facility provider orders included oxycodone 5 mg every 4 hours PRN for pain and acetaminophen 325 mg, 2 tablets every 4 hours PRN for mild pain. The admission assessment and pain evaluation documented that the resident had occasional pain that affected sleep, therapy, and daily activities, and the baseline care plan identified pain/comfort issues with a goal for adequate pain relief. However, the MAR showed that oxycodone was not administered until the evening after admission, and acetaminophen was not documented as given on the MAR despite a progress note stating it was administered. Progress notes indicated that a family member requested pain medication when the resident rated pain as 7/10, that the nurse had to call a provider to request an oxycodone order, and that oxycodone was then administered twice within a time frame that was too close for the every-4-hours PRN order. Interviews with the resident, family member, NP, LPN, and DON described that the resident arrived in significant pain, that pain medication was not available when he arrived, that he waited over 24 hours for pain relief, and that staff did not follow existing processes to obtain pain medications from the pharmacy or the facility’s medication bank upon admission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that a resident with a seizure disorder consistently received a prescribed anti-seizure medication, Lacosamide 200 mg twice daily, resulting in multiple missed doses over several days. The resident had diagnoses including encephalopathy, seizure disorder, generalized weakness, alcoholic dementia, and metabolic encephalopathy, and the care plan required administration of anti-seizure medication as ordered, positioning to prevent injury during seizure activity, airway management, documentation of seizure characteristics, and monitoring of neurological status after any seizure activity. Physician orders also directed staff to monitor for seizure activity every shift. The January Medication Administration Record showed that the resident did not receive either scheduled dose of Lacosamide on three consecutive days, with six missed doses documented as “medication not available,” and an additional morning dose was not administered on a subsequent day. Three different nurses failed to administer these doses. During this period, there was no documentation that the physician or pharmacy had been notified that the medication was unavailable or that doses were missed, despite the standing order and facility policy requiring medication ordering and reordering when supplies were low. The Treatment Administration Record showed that seizure monitoring tasks were checked off as completed, but the resident’s record and progress notes did not contain documentation of the results of this monitoring or any evidence of increased monitoring after the missed doses. Nursing staff interviews revealed multiple failures in communication and follow-through. One LPN reported caring for the resident on two evenings, finding the medication absent from the cart, and not administering the doses; he did not notify the pharmacy, provider, or nurse manager and did not report the issue to the night nurse. Another LPN stated she received report that the anti-seizure medication was not available, called the pharmacy to reorder it, and was told it would be delivered; she observed that the medication arrived as she was leaving but did not notify the provider or give report to the night nurse, and the dose was not given. A unit manager RN later found 10 tablets of Lacosamide in the medication cart after the resident had been sent to the hospital. A pharmacist confirmed there were no electronic requests for the medication on two of the days in question and that a prescription was already on file to supply the facility upon request. A nurse practitioner reported having no record of any notification from the facility about the medication being unavailable or any refill request, and described being called only when the resident had a change in condition and was found actively seizing, with three seizures observed within seven minutes before EMS transport to the hospital ICU. On the morning the resident was transferred to the hospital, an RN caring for the resident found the resident very sleepy and difficult to arouse and determined it was not safe to administer medications, including the anti-seizure medication, and notified the onsite provider of the change in condition. A progress note documented that the resident was non-responsive and tremoring, and the provider ordered transfer to the hospital. Hospital admission notes indicated the resident was admitted to the ICU with seizure activity and concern for status epilepticus, requiring intubation and ventilator support, and that the resident had been out of Lacosamide for the past three days because it had not been available. A head CT scan identified a thin subdural hemorrhage versus dural thickening along the left cerebral convexity. The DON stated that staff failed to obtain the medication from the pharmacy, resulting in missed doses, did not update the provider when doses were missed, and did not follow medication re-order procedures or complete follow-up to ensure timely delivery of the medication.

Removal Plan

• Suspended LPN-A, LPN-B and LPN-C pending investigation and provided re-education.
• Reviewed the policy and procedure for safe medication and developed a plan to ensure a sufficient supply of medications for residents for timely administration.
• Reassessed all residents with seizure medications to ensure their safety.
• Began re-education and competency testing for nursing staff to ensure compliance with medication administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan in a timely manner following a verbal altercation. The resident had documented diagnoses of severe recurrent major depressive disorder, neurocognitive deficits, PTSD, and major depressive disorder, recurrent episode, moderate. The resident’s ADL care plan identified her as at risk for decreased cognition related to PTSD and MDD, directed staff to monitor for emotional distress or mood and behavior changes, implement safety monitoring as needed, and utilize trauma-informed care. The care plan also identified specific triggers, including unannounced visitors, no male attendees, nightmares, and flashbacks. On the date of the incident, an alleged incident report documented that the resident was involved in a verbal altercation with another resident who became visibly upset, raised his voice, and continued yelling in the hallway, requiring staff intervention. Following this altercation, there was no evidence that the facility reviewed or revised the resident’s comprehensive care plan to address updated triggers, supervision needs, conflict-prevention strategies, or psychosocial follow-up. There was no documentation of a care plan meeting or IDT review after the incident. The resident later reported not feeling safe because people continued entering her room without knocking and stated that the other resident’s behavior triggered her PTSD and caused fear for her safety. The other resident reported a different account of the interaction and continued to knock and open the door slightly after the incident. A nursing assistant reported not recalling recent education on trauma-informed care and was unaware of any recent review of the resident’s care plan. The unit manager RN acknowledged that she did not update the care plan with new interventions after the altercation, and the DON stated the care plan should have been reviewed and revised after such an incident. The facility’s Trauma Informed Care policy required adding goals and interventions to the care plan for residents with a history of trauma and updating the care plan as needed, which was not done in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately support both facility-sponsored and individual activities for two residents who were dependent on staff for activity participation. For one resident, the care plan noted a lack of activity involvement and a preference not to participate in group activities, but did not document any self-guided activities or efforts to encourage the development of the resident's interests, hobbies, or skills. The resident's social history indicated interests in arts and crafts, sports, music, reading, and television, but the activity records primarily reflected participation in smoking, occasional group events, and inconsistent documentation regarding actual engagement. The resident reported to staff that he would participate more if other options were available and specifically requested a television remote, which had not been provided. He also denied having access to a hand-held radio, contrary to what was documented in his assessment. Another resident, who was cognitively intact but dependent on staff for mobility and personal care, also experienced a lack of individualized activity support. Her care plan acknowledged her preference for independent leisure activities and willingness to attend group activities, but did not specify self-guided activities or how her interests would be supported. Activity records for this resident frequently noted her as "not available" for scheduled activities, with inconsistent or unclear documentation about her actual participation. During interviews, the resident expressed feelings of boredom and borderline depression, stating that she was not assisted in time to attend group activities due to her need for mechanical lift transfers. She also indicated a desire for books, puzzles, or games for use in her room, which had not been offered. Staff interviews revealed a lack of awareness regarding the residents' needs and preferences. The activity aide was not aware that either resident wanted more independent activities or that one resident was not being assisted to group activities in a timely manner. The activity director and nursing staff were also unaware of specific barriers, such as the non-functioning television or the need for assistance with transfers. The facility's documentation and communication gaps contributed to the failure to provide meaningful activities tailored to the residents' preferences and abilities.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, physician orders, and the resident’s preferences and goals. The resident, who had a complex medical history including diabetes, chronic kidney disease, and a diabetic foot ulcer, was simultaneously receiving wound care from both an outpatient wound clinic and the facility’s inhouse wound care team. Both providers issued different wound care orders, resulting in inconsistent and conflicting treatments, missed dressing changes, and inaccurate wound assessments. The resident reported that dressing changes were not performed daily as ordered, and sometimes were left for several days, leading to soiled and saturated dressings with visible drainage and active bleeding. Observations and interviews revealed that wound care was not consistently provided as ordered. For example, an LPN performed a dressing change using supplies and techniques not specified in the current orders, including the use of betadine, which was not ordered for the wound. The same soiled ace wrap and tape were reapplied after the dressing change. Documentation showed that wound care orders were frequently not followed, with missed treatments and conflicting orders being carried out on the same day. The facility did not consistently document wound assessments, failed to discontinue outdated orders, and did not ensure that only the most current orders were being followed. There was also a lack of communication and coordination between the inhouse and outpatient wound care providers, resulting in the resident arriving at outpatient appointments with incorrect dressings and supplies. Interviews with facility staff, including the DON, LPNs, RNs, and the inhouse wound nurse, indicated a lack of awareness regarding the resident’s dual wound care providers and the existence of conflicting orders. Staff did not consistently report or resolve order conflicts, and the DON had not audited treatment records to ensure compliance. The outpatient wound care provider and the resident both expressed concerns that the facility was not following the outpatient orders, and the resident’s wound ultimately deteriorated, requiring surgical intervention. Facility policy required regular skin assessments and adherence to wound care protocols, but these were not consistently implemented for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow enhanced barrier precautions (EBP) and proper infection control protocols during wound care for a resident with a diabetic foot ulcer. Observation revealed that the resident had an EBP sign posted, indicating the need for hand hygiene and the use of gloves and gowns during high-contact care activities, including wound care. Despite these instructions, an LPN entered the resident's room, washed her hands, but did not set up a sterile field or bring all necessary dressing supplies before starting the dressing change. The resident's wound was actively bleeding, and the LPN applied pressure with soiled gauze, then wrapped the wound with the same soiled material before leaving the room to gather additional supplies. She did not sanitize her hands after removing her gloves and reused contaminated items, including scissors and bandages, during the dressing change. The soiled dressing supplies were left in the resident's garbage can in the room. The resident involved had a history of Type 2 Diabetes Mellitus with a foot ulcer, non-pressure chronic ulcer, adult failure to thrive, tobacco use, dependence on renal dialysis, and heart failure. The resident required moderate to partial assistance with activities of daily living and used a wheelchair for mobility. The provider's order specified a particular wound care protocol, which was not followed by the LPN, as she used betadine instead of saline and failed to maintain a clean and sterile environment during the dressing change. The LPN also failed to wear a gown and mask as required by EBP guidelines for residents with open wounds. Interviews with facility staff confirmed that the LPN was aware of the EBP requirements but did not adhere to them during the dressing change. The DON later performed the dressing change according to protocol, noting the previous errors, including the use of betadine and the lack of proper PPE and sterile technique. Facility policy and CDC guidelines reviewed in the report emphasized the importance of proper infection prevention measures, including the use of dedicated and clean supplies, hand hygiene, and appropriate PPE during wound care, all of which were not followed during the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to regularly inspect all bed frames, mattresses, and bed rails for safety. Additionally, it was found that not all bed rails and mattresses were safely attached to the bed frames as required. This deficiency was identified through direct observation of the equipment and its attachment to the bed frames.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive care plan and furnish services according to physician orders for one resident. The resident, who had a history of left tibia fracture, diabetes mellitus, hypothyroidism, and morbid obesity, was ordered to receive lymphedema therapy, daily application of personal lotion, and to wear compression stockings or ACE wraps, as well as an abdominal binder. Despite these orders, the resident's care plan did not include the use of compression stockings, ACE wraps, or the abdominal binder. Observations revealed that the resident was not wearing the required compression devices or abdominal binder, and her legs were swollen and red with multiple weeping blisters. Compression stockings and ACE wraps were found in her closet, but had not been applied. Interviews with staff indicated a lack of awareness and follow-through regarding the resident's treatment orders. The resident reported not wearing the abdominal binder for weeks due to it being missing, and staff confirmed they were unable to locate it and had reported this to the nurse manager. Nursing staff were not aware of the current orders for compression stockings or ACE wraps, and the nurse manager was unaware of the missing binder or the absence of compression devices. The Director of Nursing stated that ordered treatments should be provided unless refused or discontinued, but there was no documentation of refusal or discontinuation. The facility's care planning policy requires comprehensive care plans to be updated as resident needs change, which was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary services recommended by physical therapy to maintain or improve a resident's ability to perform activities of daily living. After the resident's physical therapy treatment ended, a functional maintenance program was ordered by physical therapy, but the facility did not initiate the program. The resident's care plan did not include the prescribed exercises, and staff were unaware of the recommendations. The physical therapy assistant stated that a maintenance program was provided to nursing staff, but the form could not be located, and the nurse manager was not aware of any PT recommendations for the resident. The form was later found in a pile waiting to be scanned, indicating a breakdown in communication and implementation of the therapy plan. The resident involved was cognitively intact, dependent on staff for several activities of daily living, and had diagnoses including dementia, renal insufficiency, stroke, and seizure disorder. She expressed concern about her ability to discharge to a facility closer to home, as her discharge goal required her to stand and not use a bariatric mechanical lift. The lack of initiation of the functional maintenance program delayed her progress toward this goal. The facility did not have a designated restorative nurse, and the recommended exercises were not incorporated into the resident's care plan as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The report does not provide additional details about specific residents affected, their medical history, or their condition at the time the deficiency was observed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an allegation of potential abuse involving a resident was reported in a timely manner to both the administrator and the State agency, as required by policy. The incident involved a nursing assistant (NA) who was observed by another NA to have handled a resident roughly and to have been verbally aggressive. The observing NA reported that the alleged perpetrator grabbed the resident's upper arms aggressively and, after the resident attempted to bite, pushed the resident's arm to their mouth and told them to bite themselves. The incident occurred in the presence of a unit manager (RN), but the observing NA did not immediately report the abuse to the RN or complete the required documentation at that time. Instead, the NA attempted to inform an LPN, who did not follow up or ensure the report was escalated, assuming the matter had been addressed. The DON was not informed of the incident until the following afternoon, and the administrator was updated even later. The facility's policy required that all staff report suspected abuse immediately up the chain of command and that the State agency be notified within two hours of suspicion. However, the report to the State agency was not made until nearly a full day after the incident. Interviews with staff confirmed a lack of immediate reporting and confusion about the reporting process, resulting in a significant delay in both internal and external notification of the abuse allegation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an allegation of potential verbal and physical abuse was thoroughly investigated and that protection was provided to a resident after the alleged incident. The incident involved a nursing assistant (NA) who was reported to have handled a resident roughly and made verbally aggressive remarks. The resident, who was severely cognitively impaired, nonverbal, and dependent on staff for activities of daily living, was agitated during care and attempted to bite the NA. In response, the NA reportedly held the resident's arm to his mouth and told him to bite himself. The incident was witnessed by another NA, who documented the rough handling and verbal abuse, but there was a delay in reporting the incident to the director of nursing (DON) and administration. Despite the facility's policy requiring immediate suspension of staff accused of abuse and prompt initiation of an investigation, the alleged perpetrator continued to work with residents after the incident. Documentation and interviews revealed that the incident was not immediately reported to the DON or administrator, and the staff involved were not promptly removed from resident care. Additionally, there was a lack of documentation in the resident's progress notes regarding the alleged abuse, investigation updates, or communication with the resident's representative and provider. Staff interviews indicated that several employees were unaware of the abuse allegation and had not received any recent abuse education related to the incident. The facility's investigation was incomplete, lacking key elements such as incident reports, comprehensive staff and resident interviews, and evidence of education on abuse procedures. The social services designee reported limited involvement in the investigation and was not provided with sufficient information to ensure resident safety and well-being. The administrator and DON acknowledged that the expected interventions, including immediate removal of the alleged perpetrator and timely initiation of the investigation, did not occur as required by facility policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely notification of a physician regarding a resident's elevated blood sugars and significant change in condition. The resident, who had a history of diabetes mellitus and other complex medical issues, was admitted with orders to monitor blood sugars before meals and at bedtime, and to notify the provider if blood sugar was below 75 or above 400. On the day in question, the resident's blood sugar readings were 324 mg/dl in the morning, 400 mg/dl before lunch, and 451 mg/dl before supper. Despite these elevated readings, the provider was not notified promptly as required by the physician's orders and facility policy. Throughout the day, staff observed that the resident was more lethargic than usual, unable to feed himself, and exhibited a decline from his baseline functioning. Multiple staff members, including a trained medication assistant and a nursing assistant, noted these changes and reported them to the registered nurse on duty. However, the nurse did not immediately notify the provider after the first critical blood sugar reading, and a recheck of the blood sugar was not performed within the recommended timeframe. The nurse eventually contacted the provider later in the afternoon, but by that time, the resident's condition had further deteriorated, including hypoxia and altered mental status. Interviews with facility staff, the medical doctor, and the nurse practitioner confirmed that the provider should have been notified earlier about both the elevated blood sugars and the resident's change in condition. The facility's own policy required prompt notification of significant changes, but this was not followed. The delay in notification and assessment contributed to the resident being transferred to the hospital with acute medical issues, including sepsis, respiratory failure, and possible stroke. Documentation and communication lapses were also identified, such as missing provider orders and incomplete assessments.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of stroke and bacterial endocarditis, who was receiving IV antibiotic therapy via a peripherally inserted central catheter (PICC), did not have their PICC line managed according to professional standards and physician orders. During medication administration, an LPN entered the resident's room, disinfected the insertion site, and attached the antibiotic bulb to the PICC line without first checking the line for patency or flushing it with saline as required. The LPN left the room, intending to return later, but did not verify the status of the infusion or disconnect the medication promptly after completion. The antibiotic bulb remained connected to the PICC line for an extended period after the infusion was finished. Further observations and interviews confirmed that the PICC line was not flushed prior to medication administration, contrary to facility policy and standard practice, which require flushing before and after medication administration. The LPN acknowledged the omission, stating they did not want to perform excessive flushing. The facility's policy specifies a vigorous mechanical scrub of the connector and flushing with saline before and after medication administration, but these steps were not followed, resulting in a failure to ensure safe and appropriate administration of IV fluids for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow established infection prevention and control protocols, specifically regarding hand hygiene, use of enhanced barrier precautions (EBP), and disinfection of equipment. Observations revealed that staff did not consistently perform hand hygiene before and after glove use, nor did they always wear required personal protective equipment such as gowns and gloves when providing high-contact care to residents with conditions requiring EBP, such as those with PICC lines or dialysis access sites. In several instances, staff entered and exited resident rooms, assisted with personal care, and handled medical equipment without adhering to proper handwashing or PPE protocols. For one resident with a PICC line and a current infection, staff failed to display appropriate EBP signage and did not provide a container for PPE at the room entrance. Staff, including LPNs and nursing assistants, were observed administering IV medications, assisting with personal care, and handling medical equipment without donning gowns or consistently using gloves. Hand hygiene was often omitted between glove changes and after resident contact. Additionally, the vital sign machine used for this resident was not disinfected after use, contrary to facility policy. Another resident with a visible rash and a third resident requiring EBP for a dialysis access site also experienced lapses in infection control. Staff did not perform hand hygiene after glove removal or between resident contacts, and PPE was not used as required. In one case, a gown was improperly stored and reused. Interviews with staff confirmed gaps in knowledge and practice regarding EBP and hand hygiene, and the facility's own policies outlined expectations that were not met during these observed care activities.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to meet discharge summary requirements for a resident who was discharged against medical advice (AMA). The resident, who had been admitted for rehabilitation, left the facility after an extended leave of absence (LOA) without notifying the facility of the duration of their absence. Upon returning to the facility, the resident collected their belongings and left, but the medical record did not include a recapitulation of the resident's stay or a final summary of their status at discharge. Interviews with the social worker designee and the director of nursing revealed that there was an expectation for a discharge summary to be completed, even for residents discharged AMA. However, the discharge summary was not completed, and the facility's discharge planning policy was found to be incomplete in sections related to the time of discharge and post-discharge procedures. The resident's medical history included non-trauma spinal cord dysfunction, hypertension, hyperlipidemia, anxiety, depression, bipolar disease, and a history of substance abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to monitor and notify the physician following a change in condition for a resident who experienced multiple episodes of vomiting. The resident, who had a history of gastrointestinal issues, began vomiting on the evening of one day and continued through the next morning, ultimately leading to their death. Despite the resident's condition worsening, the nursing staff did not adequately monitor the resident or notify the physician of the change in condition. The resident's medical history included schizoaffective disorder, esophageal varices with bleeding, and a history of traumatic brain injury, among other conditions. The resident's care plan did not reflect their history of gastrointestinal bleeding or vomiting, and the minimum data set did not indicate any issues with vomiting. On the evening of the incident, the resident expressed feeling unwell and had two episodes of vomiting, but the nursing staff did not notify the physician or continue to monitor the resident's condition effectively. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's condition. The licensed practical nurse on duty did not notify the physician, believing that another nurse had already done so. The nurse manager and director of nursing expressed concerns about the lack of monitoring and physician notification. The facility's policy required changes in a resident's condition to be reported to the physician, but this was not followed, contributing to the resident's decline and eventual death.

Removal Plan

• Provided education to the licensed nurses on NA's charting needs to be done prior to the end of their shift.
• Report to the nurse if NA's feel as though there is a change in the resident, and the NA feels as though something is not being addressed by the licensed nurse, to follow up with the NM or DON.
• Education was provided to the licensed nurses indicating nurse's assessments needing to be completed and physician notification needs to be done immediately.
• The audit indicated there was no orders for monitoring, the Physician was notified, a progress note was completed, and resident assessments were completed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report allegations of neglect to the state agency in a timely manner, specifically within the required two-hour window. This deficiency involved a resident who experienced a change in condition that was not properly assessed or monitored by licensed nurses. The resident, who had a primary diagnosis of schizoaffective disorder and additional diagnoses including esophageal varices with bleeding and dysphagia, began vomiting and subsequently died in the facility. The facility's failure to report this incident to the state agency was a significant oversight. The resident's medical records indicated that there were no nursing progress notes for the day prior to the resident's death, and vital signs were taken late in the evening. Despite the resident expressing feeling unwell and experiencing vomiting, the licensed nurses did not notify the physician or continue to monitor the resident's condition adequately. The resident's vomiting episodes were noted, but the nurses did not take appropriate action to address the change in condition, which was outside the resident's baseline. Interviews with facility staff revealed that there was a lack of communication and documentation regarding the resident's condition. The LPNs involved did not notify the physician or document the resident's condition accurately, and the facility's administration did not report the incident to the Minnesota Department of Health, citing it as poor nursing rather than neglect. The facility's policy required reporting of neglect, but the administration and regional staff did not consider the actions of the licensed nurses as neglectful, leading to a failure in reporting the incident as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive care plan for a resident with a history of gastrointestinal bleeds. The resident, who was admitted with a primary diagnosis of schizoaffective disorder, also had additional diagnoses including esophageal varices with bleeding, dysphagia, cognitive communication deficit, schizophrenia, peptic ulcer without hemorrhage or perforation, and a personal history of traumatic brain injury. Despite these conditions, the resident's care plan did not include her history of gastrointestinal bleeding, nor did it outline signs and symptoms to monitor or actions for staff to take in the event of a gastrointestinal bleed. Interviews with facility staff, including a nurse practitioner, nurse manager, director of nursing, and the administrator, confirmed the omission of the resident's gastrointestinal bleeding history from her care plan. The nurse manager and director of nursing acknowledged that the care plan should have included this critical information. Additionally, the facility was unable to provide a care plan policy and procedure when requested, indicating a potential gap in their documentation and procedural protocols.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the use of personal protective equipment (PPE) when sorting dirty laundry, potentially impacting all 82 residents. During an observation and interview, the Environmental Service Director (ESD) indicated that staff were required to wear gowns and gloves when handling dirty laundry. However, it was verified that there were no gowns available on the wall in the dirty laundry room. Interviews with two laundry aides revealed that gowns had not been available for around a month, although gloves were used by one of the aides. The facility's Contaminated Laundry policy, which aligns with the Bloodborne Pathogen Standard 29 CFR 1910.1030(d)(4)(iv)(B), mandates the use of appropriate PPE, including gloves, gowns, face shields, and masks, when handling contaminated laundry.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain resident privacy and dignity for two residents, R46 and R11, as observed during a survey. For R46, the issue arose when a social services designee (SS-A) loudly communicated the resident's need for a check and change in the hallway, compromising the resident's privacy. This was confirmed by a nursing assistant (NA-A) who noted that such communication should be done more discreetly to protect resident dignity. R46 expressed that such incidents would be bothersome, and the Director of Nursing (DON) expected staff to communicate resident needs privately. For R11, the deficiency involved inadequate use of privacy curtains during personal care activities. R11, who was in a persistent vegetative state and dependent on staff for all activities of daily living, was exposed during incontinence care as the privacy curtain was only partially closed. This allowed a clear view from R11 to another resident's side of the room. Nursing assistants involved in R11's care acknowledged the importance of privacy curtains but failed to use them properly due to space constraints. Additionally, there was no clear documentation in R11's care plan regarding dressing preferences, which led to R11 being dressed in a gown throughout the day, contrary to family expectations. The facility did not have a policy related to resident dignity, which contributed to the lack of consistent practices in maintaining resident privacy and dignity. The DON reviewed R11's care plan and noted the absence of specific interventions regarding dressing preferences, emphasizing the expectation for residents to be dressed in day clothes unless otherwise care planned. This lack of policy and clear documentation contributed to the deficiencies observed in maintaining resident dignity.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident, identified as R30, to safely administer their own non-oral medications. R30, who was cognitively intact and had multiple diagnoses including paraplegia, cataracts, diabetes mellitus, hypertension, and renal failure, was independent in some activities of daily living and desired to self-administer certain medications. The care plan directed staff to perform a self-administration assessment to evaluate R30's ability to self-administer medications. However, the SAM assessment did not include non-oral medications such as eye drops, nasal spray, and topical treatments, which R30 was using independently. During observations and interviews, it was noted that R30 had medications like fluticasone nasal spray, Clear Eyes Triple Relief eye drops, and Biofreeze gel in their room, which they used without a proper assessment or physician's order for self-administration. The licensed practical nurse (LPN) and registered nurse (RN) confirmed the presence of these medications in R30's room and acknowledged the lack of appropriate orders and assessments. The Director of Nursing (DON) verified that the SAM assessment did not cover non-oral medications and expressed concern about the risk of improper use without a proper assessment.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate the needs and preferences of a resident, identified as R62, who required assistance with toileting due to the use of a wheelchair and limb prosthesis. R62's care plan indicated the need for supervision during non-weight bearing transfers and assistance with adjusting clothes and wiping during toilet use. Despite this, R62 was using a bathroom down the hall instead of the shared bathroom connected to his room because the shared bathroom had a tube draining into the toilet, which R62 found unpleasant. R62 had previously communicated this issue to the staff, but was told it was only body fluids. Observations and interviews revealed that the shared bathroom was used for peritoneal dialysis drainage for another resident, and the staff were unaware of R62's preference to use a different bathroom. The Director of Nursing (DON) was not informed of R62's concerns and stated that dialysis contents could be drained into the toilet or into drain bags when multiple residents used the bathroom. The facility did not provide a policy regarding this issue, and staff members, including nursing assistants and an LPN, were either unaware of the situation or had not communicated R62's concerns to the appropriate personnel.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a clean and sanitary environment for a resident who was dependent on tube feeding. The resident, who was in a persistent vegetative state and had diagnoses of quadriplegia and epilepsy, relied on a feeding tube for more than 50% of their nutrition. Observations revealed that the enteral feeding pump, tube feeding pole, and supporting legs were not cleaned and had visible splatters and a dusky appearance. Despite a previous directive for nightly cleaning, there was no documentation of cleaning from mid-July to September. Staff interviews indicated a lack of awareness of a cleaning schedule or documentation process, and the Director of Nursing acknowledged the importance of regular cleaning for infection control. The facility also failed to maintain cleanliness in shared spaces and resident rooms. Observations noted an unclean exhaust fan in a shared bathroom and a wall vent and ceiling tiles with grayish particles and brown streaks in a resident's room. The facility's maintenance records did not include requests to clean these areas, and interviews with maintenance staff confirmed the need for cleaning. The facility's policies on daily and deep cleaning procedures did not specifically address the cleaning of these areas, leading to their neglect. Additionally, the facility did not ensure that furniture was kept in good condition. A resident reported a loose lining on an extended table from a dresser in their room, which had not been addressed. Maintenance staff were unaware of the issue, and there was no policy in place for maintaining or fixing resident room items and furniture. The lack of a structured process for reporting and addressing maintenance issues contributed to the oversight.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive and individualized care plan for a resident reviewed for constipation. The resident, who was cognitively intact and independent with most activities of daily living, had a history of end-stage renal disease and diabetes mellitus. Despite being occasionally incontinent of bladder and frequently incontinent of bowel, the resident's care plan lacked information about bowel and bladder incontinence, toileting, or constipation. This omission was significant as the resident had previously called an ambulance twice due to stomach pain and constipation, resulting in hospital visits. Interviews with facility staff, including a nursing assistant, an LPN, and the DON, revealed that staff relied on care plans to understand the assistance required by residents. The DON acknowledged the resident's history of constipation and hospitalizations related to abdominal pain and confirmed that the care plan did not address these issues. The facility's policies indicated that care plans should be based on comprehensive assessments and updated as residents' conditions and care needs changed, which was not adhered to in this case.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comprehensively assess and monitor non-pressure related skin conditions for a resident, identified as R49, who was reviewed for skin concerns. R49 was cognitively intact, had end-stage renal disease, diabetes mellitus, and was occasionally incontinent of bladder and frequently incontinent of bowel. The resident had a diabetic foot ulcer and was receiving treatment for papular eczema with triamcinolone acetonide cream. However, the care plan lacked information about papular eczema, rashes, and itching or scratching, and there was insufficient documentation on the application of the cream and the resident's skin condition. The Medication Administration Record (MAR) indicated that the cream was applied 22 times, refused twice, and was not applied during three hospitalizations. There were instances where staff noted to see progress notes, but these notes lacked further description of whether the cream was applied. Weekly skin inspections showed that the resident often refused skin assessments, and there was no documentation of improvement or deterioration of the skin condition. Interviews with staff revealed that they were aware of the skin condition but did not consistently document or follow up on the resident's skin issues. The Director of Nursing (DON) confirmed that there was no documentation on whether the resident's skin was improving, and no dermatology appointment had been set up. The facility's policy on skin assessment and wound management required staff to notify the provider, update care plans, and document skin conditions, but these actions were not adequately followed. The lack of comprehensive assessment and monitoring of the resident's skin condition led to the deficiency identified in the report.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide routine range of motion (ROM) exercises for a resident in a persistent vegetative state with quadriplegia and contractures. Despite the care plan directing staff to perform passive ROM daily, there was a lack of documentation in the medication and treatment administration records, progress notes, and nursing assistant charting. Observations revealed that nursing assistants did not perform ROM during morning care, and there was a lack of communication between therapy and nursing staff regarding the resident's need for ROM exercises. Additionally, the facility did not implement a walking program for a resident with intact cognition and bilateral leg prosthetics. The care plan lacked information on walking or ambulation, and the resident reported inconsistent assistance with walking. Documentation showed infrequent ambulation, and interviews with staff indicated a lack of awareness of the resident's walking program. The director of rehab confirmed the resident had a walking program but preferred certain nursing assistants, and the director of nursing found no walking program description in the care plan or tasks. The facility's policy on Activities of Daily Living (ADLs) directed staff to maintain or improve residents' abilities with ADLs, such as ambulation, but did not address range of motion. The lack of adherence to care plans and communication between departments contributed to the deficiencies in providing necessary ROM and walking programs for the residents.

Penalty

Fine: $22,205

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was offered the current pneumococcal vaccination, despite having received written consent from the resident's family. The resident, who was admitted with diagnoses including metabolic encephalopathy and dementia, had a consent form signed by the family on March 4, 2024, authorizing the pneumococcal vaccine per the primary care provider's order and CDC guidelines. However, the medical record lacked evidence that the vaccine was offered or administered. During an interview, the Director of Nursing confirmed that no orders were received from the physician, despite the signed consent, and acknowledged the oversight in the vaccination process.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate documentation of medications and treatments for two residents, R1 and R3, when they were hospitalized. R1's medication administration record (MAR) for June showed omissions in documenting the administration of Hydromorphone Hydrochloride, a narcotic pain medication, and Acticoat, a silver dressing for wound care. Additionally, daily weight records for R1 were left blank on specific dates. R1 was cognitively intact and required assistance for transferring and toileting, with diagnoses including peripheral vascular disease and type II diabetes. For R3, who was severely cognitively impaired and had diagnoses of dementia and rheumatoid arthritis, the MAR indicated that medications and treatments were documented as administered even after R3 had been hospitalized. This included medications such as Melatonin, Seroquel, and Depakote, as well as treatments like barrier cream application and catheter maintenance. The documentation errors occurred on the evening shifts, with LPNs marking the treatments as completed despite R3's absence from the facility. Interviews with facility staff revealed a lack of awareness and oversight regarding these documentation errors. The Director of Nursing (DON) and other nursing staff were unaware of the omissions and incorrect documentation. The DON stated that a number should be documented in the MAR when a medication is not administered, and a nurse's note should explain the reason. However, this procedure was not followed, leading to inaccurate records. The facility's policy on medication error procedures emphasizes the need for evaluation and documentation of medication usage, but these guidelines were not adhered to in these cases.