Every finding on record at Asistencia Villa Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure the call light system (a communication device linking patients/residents to staff, allowing them to request assistance via a button or pull cord, alerting a central station for timely help) and shower equipment were maintained in safe and working condition for resident use when:1. One wall mounted call light located in one of two facility showers, did not have a pull cord accessible for resident use.This failure resulted in the inability for residents or staff to have a call light readily available in the shower to summon staff assistance in case of an emergency.2. One of two shower beds (used by residents for bathing and for transport to and from their room) had two non-functioning side rails due to missing locking pins. The absence of the pins rendered the side rails unsecured and unable to be locked in an upright position.This failure resulted in increased risk of residents' injury due to the inability for staff to properly use the shower bedside rails during bathing and transportation in order to help prevent falls and potential injury.1. During an observation on December 16, 2025, at 12:05 PM, in one of two facility shower rooms (Shower room A), there were two separate shower stalls. One of the two shower stalls had a call light on the wall but could not be activated because there was no pull cord connected to it and there was no button to press or activate.During a concurrent observation and interview on December 16, 2025, at 12:10 PM, with the Facility Maintenance Director (FMD), the FMD stated residents, and staff were supposed to be able to call for assistance by using a pull cord to activate the call system. The FMD further stated the call system was supposed to be available for every shower and toilet area. The FMD acknowledged one of two shower stalls did not have a pull cord and there was no way to manually activate the call system without a pull cord. The FMD stated he did not know why there was no pull cord and that he had not been made previously aware the pull cord was missing.During an interview on December 17, 2025, at 2:12 PM, with the Administrator (ADMIN), the ADMIN stated every shower and every restroom in the facility should have a pull cord to activate the call system.During an interview on December 18, 2025, at 10:27 AM, with the Director of Nursing (DON), the DON stated the pull cords for the call system should present on all call lights and in operating condition. The DON further stated it was important to ensure the call light system was maintained properly to ensure residents can get help if they fall and to ensure the residents can get ahold of staff in a timely manner, if needed.During a review of the facility's policy and procedure (P&P) titled, Nurse's Call System, (undated), the P&P indicated, It is the policy of this facility to maintain building systems in good working order, inspecting them at intervals which comply with state, federal and company standards as to repair as necessary. 2. Replace immediately defective light bulbs or buzzers and chords.3. Check to see that call systems in toilets, bathrooms and shower are properly grounded and working.2. During an interview on December 16, 2025, at 10:01 AM, with Resident 62, Resident 62 stated the facility had a shower bed which had non-functioning side rails and that it had been that way for a couple months.During a concurrent observation and interview on December 18, 2025, at 2:25 PM, inside Resident 56's room, CNA 3 was in Resident 56's room with the shower bed and had just finished transporting Resident 56 from the shower room to the residents' room and assisted with transferring the resident to her bed. The shower bed which was used to shower Resident 56 and transport her back to her room, had two side rails which were down and were unable to be kept in an upright position because there was a missing pin on each side of the bed which was used to keep the bed rails up. CNA 3 stated she just finished showering Resident 56 and brought her back to her bed in the shower bed. CNA 3 stated the siderails usually swing upward and then a pin is placed in a hole on both sides of the bed to hold up the siderails but both pins were missing and were supposed to be attached to the bed. CNA 3 stated she did not use the bed rails and instead transferred the resident in the shower bed with the side rails down since there were no pins to keep the side rails up. CNA 3 stated sometimes if she needs the side rails to stay up, she will find a plastic spoon and stick the handle of the spoon in the pin hole on each side of the bed to keep the side rail upright.During a concurrent observation and interview on December 18, 2025, at 2:27 PM, CNA 4, CNA 4 was assisting to remove the shower bed from Resident 56's room and stated the shower bed had not had pins to keep the side rails up for approximately one month. CNA 4 stated she sometimes would jam a spoon handle in the hole to keep the side rails up. CNA 4 stated she was not sure if the maintenance department was aware of the issue or not.During an interview on December 18, 2025, at 2:57 PM, with the Facility Maintenance Director (FMD), the FMD stated he was made aware a few days ago that the pins were missing for the side rails on the shower bed. The FMD further stated he had not fixed the bed yet because he was waiting to see where he could find the correct pin size for the side rails. The FMD stated he was now going to install temporary pins on the bed which could be used to keep the side rails up.During an interview on December 18, 2025, at 4:45 PM, with the Director of Nursing (DON), the DON stated the side rails for the shower bed were supposed to be up anytime any resident was being transported in the shower bed due to safety concerns. The DON further stated he was not aware one of the shower beds did not have the required pins to keep the side rails functional.During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, (undated), the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes.and a facility-wide commitment to safety at all levels of the organization. 4. Employees shall be trained and inserviced on potential accident hazards and how to identify and report accident hazards, and try to prevent avoidable accidents.

Based on observations, interviews and record review, the facility failed to establish and maintain effective infection prevention and control practices for nine of ten sampled residents (Residents 2, 11, 33, 36,59, 79, 81, 97, and 103) when: 1. For Resident (81), the oxygen tubing (a flexible plastic tube to deliver oxygen from the oxygen concentrator to the resident) was resting on top of the oxygen concentrator (a medical device that pulls in room air and concentrates oxygen to supplemental oxygen to the resident), open to air and not stored inside a respiratory equipment bag, on December 15, 2025.2. Two urinary catheter bags (a medical bag used for collecting urine) were touching the floor for Residents 2 and 59 on December 15, 2025.3. One Certified Nursing Assistant 3 (CNA 3) did not wear a gown while performing high contact resident care activities (transferring, dressing, and assisting with toileting) for Resident 11 who was on enhanced barrier precautions (infection control measures used in healthcare settings to prevent the spread of multidrug-resistant organisms)4. One Licensed Vocational Nurse 4 (LVN 4) did not sanitize and disinfect the glucometer (device used to check blood sugar) between uses on five residents (Residents 33, 36,79, 97, and 103) on December 17, 2025.These failures had the potential to result in cross-contamination (when germs are spread from one person, surface, or object to another, making it easier for infections to spread) and infection due to improper storage of respiratory equipment, failure to follow enhanced barrier precautions, improper placement of urinary drainage systems, and failure to disinfect shared medical equipment between residents. 1. During a review of Resident 81's Administration Record (Contains demographic and medical information), it indicated Resident 81 was admitted to the facility on [DATE], with the diagnoses that included acute respiratory failure (when lungs suddenly cannot get enough oxygen in to the body) respiratory failure with hypoxia (when the lungs cannot give the body enough oxygen to breath Properly), chronic obstructive pulmonary disease ( a long term lung disease that makes it had to breath because the airway are damage or blocked). During a concurrent observation and interview with CNA 1 on December 15, 2025, at 10:40 AM, in Resident 81's room, an oxygen concentrator was observed positioned in the middle of the room. The oxygen tubing was observed coiled and resting on top of the oxygen concentrator open to air and not stored inside a respiratory equipment bag. At the time of the observation, the tubing was not connected to the resident. CNA 1 stated the oxygen equipment belongs to Resident 81 and the oxygen tubing should be stored inside a respiratory equipment bag when not in use for infection control purposes. CNA 1further stated leaving the tubing open to air could result in contamination. During a review of Resident 81's Physician Orders, dated November 25, 2025, it indicated Resident 81 had an order for Oxygen at 2 L per min via n/c (oxygen delivered through a nose tube at a steady flow of 2 liters per every minute), every shift. During a concurrent interview and record review on December 18, 2025, at 4:26 PM, with the Director of Nursing (DON), the facility's policy and procedure titled Departmental (Respiratory – Therapy) - Prevention of infection, revised September 2025, was reviewed. The Policy indicated, Purpose. the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment., Infection Control Considerations Related to Oxygen Administration., 6. Keep the oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use. The DON confirmed that staff did not followed the policy. 2a. During a review of Resident 2's clinical records, the admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease, stage 5 (condition where damaged kidneys lose their ability to filter waste and urine), other neuromuscular dysfunction of bladder (condition affecting the bladder due to inactivity of the brain), and surgical amputation of left leg (removal of damaged body part). During a concurrent observation and interview, on December 15, 2025, at 11:08 AM, with the Registered Nurse (RN 1), in Resident 2's room. Resident 2 was lying in his bed. His urinary catheter bag was hanging off the bed frame on the resident's right side of the bed resting on the floor. The RN 1 stated it is not supposed to be on the floor for infection control purposes. 2b.During a review of Resident 59's clinical records, the admission Record, indicated Resident 59 was admitted to the facility on [DATE], with diagnoses that included obstructive and reflux uropathy (a blockage that causes the urine to flow backward), neuromuscular dysfunction of bladder (a condition affecting the bladder due to inactivity of the brain), and cystitis, unspecified without hematuria (an inflammation of the bladder). During a concurrent observation and interview, on December 15, 2025, at 11:10 AM, with the RN 1, in Resident 59's room. Resident 59 was lying in his bed. His urinary catheter bag was hanging off the bed frame on the resident's right side of the bed resting on the floor. The RN 1 stated it is not supposed to be on the floor for infection control purposes. During a concurrent interview and record review with the Case Manager/Infection Prevention Nurse (CM/IPN) on December 17, 2025, at 2:40 PM, the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, revised September 2025, was reviewed. The P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection control. 2. Be sure the catheter tubing and drainage bag are kept off the floor. The CM/IPN stated the P&P was not followed and should have been to prevent bacteria from re-entering the urinary bag. 3. During a review of Resident 11's admission Record, it indicated Resident 11 was admitted to the facility on [DATE], with diagnoses which included fracture of lateral malleolus of left fibula (a type of ankle fracture), hypothyroidism (also called underactive thyroid, is when the thyroid gland does not make enough hormones), and abnormalities of gait (walking) and mobility. During an observation on December 16, 2025, at 9:29 AM, outside Resident 11's room, there was a sign posted outside the residents doorway which indicated, Enhanced Barrier Precautions. gown and gloves must be used during high contact resident care activities. dressing. transferring. or assisting with toileting.[room and bed number of Resident 11]. CNA 3 was then observed to enter Resident 11's room without wearing a gown and assisted Resident 11 by dressing the resident, emptying Resident 11's urinal drainage bag (a bag which is attached to a urinary catheter and contains and holds urine) and dumped the urine into the toilet, and assisting the resident to transfer from the bed to a wheelchair. CNA 3 never wore a gown during her interaction with the resident. During a concurrent observation and interview on December 16, 2025, at 9:41 AM, CNA 3 exited Resident 11's room and stated she had just assisted Resident 11 by emptying the resident's urine drainage bag, put on the residents' pants, shoes and bra, and then transferred the resident to a wheelchair. CNA 3 stated she was not aware Resident 11 was on enhanced barrier precautions because she did not see the sign posted outside the resident's doorway. CNA 3 then observed the sign Enhanced Barrier Precautions posted outside the resident's door and acknowledged the sign indicated the room and bed of Resident 11. During a review of Resident 11's physician's orders, an order dated November 10, 2025, indicated, Foley Catheter [a flexible tube inserted through the urethra into the bladder to drain urine] . RT [related to] urinary retention [the inability to completely empty the bladder of urine]. During a review of Resident 11's physician's orders, an order dated November 11, 2025, indicated, Enhanced Barrier Precautions: Foley. During a review of Resident 11's care plan (an individualized plan for the medical care of a resident) titled, The resident has Indwelling catheter d/t [due to] urinary retention, had a listed goal which indicated, The resident will show no s/sx [signs and symptoms] of urinary infection. The care plan included the following interventions, .monitor/record/report to MD for s/sx [signs and symptoms] UTI [Urinary Tract Infection. During an interview on December 18, 2025, at 10:23 AM, with the Director of Nursing (DON), the DON stated Enhanced Barrier Precautions were developed to help protect the residents by preventing the spread of infection. The DON further stated staff assisting residents on enhanced barrier precautions were supposed to wear a gown and gloves during transferring, changing, and assisting with toileting or other high contact care activities. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, (undated), the P&P indicated, 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity.3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing.c. transferring.f. changing briefs or assisting with toileting.g. device care or use (central line, urinary catheter.5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. 6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.10. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE [personal protective equipment like gloves, gowns etc.] . 4. During medication administration observation on December 17, 2025, at 5:47 AM, in station 1, with Licensed Vocational Nurse 4 (LVN 4), LVN 4 was observed at Station 1 preparing to perform blood sugar level (BSL) checks. LVN 4 entered Resident 33's room and performed a BSL check using a shared glucometer. Upon completion, LVN 4 did not clean or disinfect the glucometer. LVN 4 immediately proceeded to Resident 103's room and utilized the same glucometer to perform a BSL check. LVN 4 continued to perform BSL checks for Resident 79, 97, and 36 using the same device. During the entire sequence, LVN 4 failed to sanitize or disinfect the glucometer between residents. During an interview on December 17, 2025, at 7:06 AM with LVN 4, LVN 4 acknowledged and stated she did not sanitize glucometer after use for Resident's 33, 103, 79, 97, and 36. LVN 1 further stated the glucometer should have been sanitized after each use. During a concurrent interview and record review with the Case Manager/Infection Prevention Nurse (CM/IPN), on December 17, 2025, at 2:36 PM, the facility's policy and procedure (P&P) titled Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2025, was reviewed. The P&P indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA bloodborne pathogen standard. 5. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment. The CM/IPN stated the P&P was not followed and should have been to prevent blood-borne pathogen through contamination (spread of infection).

Based on observation, interviews, and record review, the facility failed to ensure medication storage was secured and IV (intravenous, a small tube that gives fluids into a vein) fluid was properly labeled when: 1. An IV fluid bag for Resident (63) was observed without a documented date, time, medication name, rate, or staff initials on the label.2. One of two treatment carts (Cart in 400 hall - a mobile cabinet on wheels, used all the bandages, syringes, meds, etc. needed to treat patients right at their bedside) was found unlocked and unattended by staff.3. One of 15 medication carts (Station 1's medication cart - a cart used by licensed nurses to transport medication to resident rooms) was found unlocked and unattended by a licensed nurse. These failures had the potential to be accessed and dispensed by an unauthorized person, and placing the health of 93 residents at risk for harm. 1. During a review of Resident 63's admission Record (contains demographic and medical information), the admission Record indicated Resident 63 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with diabetic chronic kidney disease (a condition where the body does not use insulin well, causing high blood sugar overtime that damages the kidneys and makes them work less effectively), dehydration (when the body does not have enough fluids, making it hard for organs to work properly) and Alzheimer's disease (a brain disease that slowly affects memory and the ability to do daily activities). During an observation on December 15, 2025, at 11:56 AM, inside Resident 63's room, Resident 63 was lying in bed with his eyes closed. On his right side, there was an IV (intravenous, a small tube that gives fluids into a vein) infusion actively running. The IV fluid was 0.9% Normal Saline (salt water that helps keep the body hydrated) was hanging on an IV pole, (a tall stand that holds the IV bag above the patient) and infusing at a rate of 100 ml (milliliter, unit to measure liquids) per hour. The IV bag displayed an orange-colored label indicating an amount of 100 cc (cubic centimeter, a small unit used to measure liquid); however, the label did not include the medication name, infusion rate, date, time, expiration date, or staff initials. A 300 mL reminder marking (a line on the bag used to track how much fluid has been given) was visible on the IV bag. During a concurrent observation and interview on December 15, 2025, at 12:06 PM, inside Resident 63's room, with Registered Nurse (RN 1), RN 1 stated that a temporary pharmacy label is sometimes used for a new order of IV fluids. RN 1 confirmed that the IV bag did not include the medication name, infusion rate, date, time, expiration date, or staff initials at the time it was hung. RN 1 further stated the nurse who hung the IV should have included all required labeling information, as this information is important for safe medication administration. During a review of Resident 63's Physician Orders, dated December 15, 2025, the Physician Orders indicated, Sodium Chlorine intravenous Solution 0.9 % (Sodium Chloride) Use 100 ml/hr (100 milliliters each hour, intravenously every shift for hydration (having enough water in the body) until December 16, 2025, at 23:59 (11:59 PM) x 48 hrs. (for a total duration of forty-eight hours). During a concurrent interview and record review on December 18, 2025, at 4:25 PM, with the Director of Nursing, (DON), the facility's policy and procedure (P&P) titled, INFUSION THERAPY PRODUCT LABELS, dated January 2025, was reviewed. The P&P indicated, Infusion therapy products shall be labeled in accordance with facility requirements and applicable state and federal laws. The Label shall include sufficient additional information as required to assure safe and efficient administration to residents., b. An auxiliary label shall be affixed to each infusion therapy product container, which provided for information about its administration to be completed., IV solution / additives administration, Resident, Rm (room), Infusion Rate, Time started a.m., p.m.; started by, date, medication(s) added, by (nurse), date, time a.m., p.m. The DON stated that the IV bag labeling did not meet policy requirements and confirmed that the policy was not followed by staff. 2. During an observation on December 17, 2025, at 5:20 AM, one of two facility treatment carts (the cart in the 400 hall) was observed to have five drawers which contained multiple supplies and medications used for wound treatment. The cart was left unlocked and unattended by staff and each of the five drawers could easily be opened. During a concurrent observation and interview on December 17, 2025, at 5:30 AM, with Registered Nurse 2 (RN 2), RN 2 stated all treatment carts were supposed to be locked when not in use. RN 2 observed the treatment cart in hallway 400 and acknowledged it was unlocked, and stated the last assigned individual should have the keys and ensure the cart is locked when not in use. RN 2 further stated sometimes staff would leave the treatment cart unlocked because nurse's unintentionally take home the keys , preventing access to medications and supplies RN 2 stated the last nurse assigned to the treatment cart worked yesterday during the morning shift. During an interview on December 18, 2025, at 10:28 AM, with the Director of Nursing (DON), the DON stated all medication and treatment carts were supposed to be locked when not in use and the carts should not be left unlocked. The DON further stated it was important to ensure the carts were locked for safety of the residents because there were medications in the carts. During a review of the facility policy and procedure (P&P) titled, Storage of Medications, dated January 2025, the policy indicated, Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.b. Only licensed nurses.and those lawfully authorized to administer medications shall be allowed access to medications. Medication rooms, carts, and medication supplies shall be locked or attended by persons with authorized access. 3. During a concurrent observation and interview on December 17, 2025, at 2:36 PM, with a Licensed Vocational Nurse 1 (LVN 1), one medication cart was found unlocked and unattended in station 1 hallway. LVN 1 verified the medication cart was unlocked and stated, the expectations are to keep medication carts locked to keep the residents from opening it. During a concurrent interview and record review on December 18, 2025, at 4:46 PM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Pharmaceutical Services Policy and Procedure Manual-Storage of medications, dated January 2025, was reviewed. The P&P indicated, Medications and biologicals shall be stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The DON stated, the policy was not followed and should have been, for medication safety.

Based on observation, interview, and record review, the facility failed to ensure medication error rate was less than five percent. There were two medication errors observed out of 26 opportunities for errors, affecting two of 13 observed residents (Residents 19 and 103), resulting in an overall medication error rate of 7.69 percent when:1. Resident 19 had an order to received Levothyroxine (medication to treat hypothyroidism - low levels of thyroid hormone) and was not available for administration. This failure had the potential to increase Resident 19's symptoms of hypothyroidism and can cause long - term health complications. 2. Resident 103 did not receive Sevelamer Carbonate (a medication used to control high phosphorus levels in patients with kidney disease) 800 mg (milligram - unit of measure) oral tablet with meals as ordered by the physician. This failure had the potential for Resident 103 to have increased levels of phosphorus in the blood, which could negatively affect Resident 103's health and safety. These failures had the potential for Resident 19 and 103 not to be administered the prescribed medication and increased the resident's risk for adverse reactions and side effects.1. During a record review of Resident 19's admission Record (Contains demographic and medical information), it indicated Resident 19 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (a condition where the brain does not work normally, type 2 diabetes mellitus with complications (a long term conditions where the body has trouble controlling blood sugar levels) and hypertensive heart disease with heart failure (heart disease caused by long term high blood pressure that makes the heart weak and not pump well). During a medication administration pass observation for Resident 19 on December 17, 2025, at 6:50 AM a.m., with Licensed Vocational Nurse (LVN 3), the LVN 3 reviewed the medication card for Resident 19 and was unable to locate the prescribed dose of Levothyroxine Sodium Oral Table, 175 mcg (micrograms, a unit used to measure very small amount of medication), oral tablet. which was scheduled to be administered during the morning. The medication was not available at the time of the scheduled administration and was not administered as ordered. During a record review for Resident 19's Physician Orders, it indicated, Levothyroxine Sodium Oral Tablet: (Levothyroxine Sodium) give 175 mcg by mouth in the morning at 6:30 AM, for hypothyroidism (A medical condition where the thyroid gland does not make enough thyroid [small gland in the neck] hormone and can affects the energy level and heart rate). During an interview on December 17, 2025, at 7:32 AM with LVN 3, the LVN 3 stated when a medication is not available, she notified the Registered Nurse (RN) supervisor, the RN supervisor checks for available emergency or cycle mediations and notified the physician regarding the medication unavailability. The LVN further stated that Levothyroxine is scheduled to be administered early in the morning and must be given on an empty stomach to properly regulate the resident's thyroid levels. The LVN 3, confirmed that Levothyroxine 175 mcg was not available at the time of the scheduled dose and therefore was not administered as ordered for Resident 19. During a concurrent interview and record review on December 18, 2025, at 4:36 PM, with the Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Ordering and receiving medications from (name of the pharmacy) Inc, dated January 2025, was reviewed. The P&P indicated, . Medications and related products shall be ordered and received from (name of the pharmacy), Inc on a timely basis., Procedures, . d. Refills of medications should be called to the pharmacy 3 to 4 days in advance of need to assure an adequate supply is on hand. The DON stated that nursing staff are responsible for ensuring prescribed medication is available for administration and confirmed that for Resident 19, the facility's policy and procedure was not followed by the staff. 2. During a review of Resident 103's clinical records, the admission Record indicated Resident 103 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease, abnormal posture, and dependence on renal dialysis. During a concurrent medication administration observation and interview on December 17, 2025, at 6:31 AM, with a Licensed Vocation Nurse 4 (LVN 4) in Resident 103's room, LVN 4 was preparing to administer morning medications to Resident 103. LVN 4 pulled out a bottle with the label Sevelamer Carbonate 800mg- *give with meals* and administered to Resident 103, without meals. LVN 4 stated breakfast is served between 7:00 AM- 7:30 AM. LVN further stated patient wants to take the medication with meals, however because of time conflict, she is unable to take it with meals. During a follow-up interview on December 17, 2025, at 7:07 AM, with LVN 4, LVN 4 acknowledged the medication should have been given with meals. During a review of Resident 103's physicians orders, it indicated Sevelamer Carbonate Oral Tablet 800 M, give 4 tablets by mouth three times a day for hyperphosphatemia, take it with meals- start date: December 4, 2025. During a concurrent interview and record review on December 18, 2025, at 4:47 PM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled Medication Administration-General Guidelines, dated January 2025, was reviewed. The P&P indicated, Medication shall be administered in accordance with good nursing principles and practices and only by persons legally authorized to do so.Administration. J. Medications shall be administered in accordance with written orders of the attending physician. The DON stated the medical should have been given as ordered.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR - a screening assessment to ensure individuals who are identified to have a significant mental illness (SMI), intellectual or developmental disability (I/DD)) are not inappropriately placed in nursing homes for long term care) were completed accurately for two of two sampled residents (Resident 7 and 36) when: 1. PASRR screening assessment for Resident 7 did not include his diagnosis of cerebral palsy (disorders affecting movement, posture, and muscle coordination, caused by damage to the developing brain). 2. PASRR screening assessment for Resident 36 did not include her diagnoses of generalized anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), bipolar disorder (a mental health condition causing extreme mood swings, from manic highs [high energy, irritability] to depressive lows [sadness, hopelessness, low energy], affecting energy, sleep, focus, and daily functioning) and major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a diminished ability to function in daily life). These failures had the potential to result in Resident 7 and 36's condition not being identified prior to admission and their needs for treatment and services not being accurately assessed, placing them at risk of inadequate care. Findings: 1.During a review of Resident 7's admission Record (contains medical and demographic information), the admission Record indicated Resident 7 was admitted to the facility on [DATE], with diagnoses which include major depressive disorder, anxiety disorder, Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by experiencing or witnessing a terrifying, shocking, or dangerous event) and Cerebral Palsy. During a review of Resident 7's Preadmission Screening and Resident Review (PASRR) Level I screening (a level 1 screening includes assessment of the resident's medical diagnoses to determine if the resident has or is suspected of having a PASRR condition [i.e. SMI, or I/DD]), dated July 14, 2023, indicated in section II for Intellectual or Developmental Disability(ID) / (DD) or Related Conditions (RC) . 4. The individual has or is suspected of having a primary diagnosis of ID/DD/RC include . cerebral palsy., marked NO. Further review of the PASRR indicated, Result of Level I Screening: Level I- Positive, resolution status [NAME]- Submitted (submitted for level 2 assessment [level 2 assessment is done when the resident is positive for possible SMI and/or I/DD]). During an interview on December 17, 2025, at 9:44 AM, with Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 7's PASRR dated July 14, 2023, did not reflect Resident 7's existing diagnosis of cerebral palsy. The MDSC further stated the facility should have accurately screened the resident and corrected the PASRR to include the diagnosis on admission to the facility. The MDSC acknowledged that the facility did not accurately screen or correct the PASRR for Resident 7. During a concurrent interview and record review on December 17, 2025, at 2:56 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, was reviewed. The P&P indicated, . Documentation in the medical record will be objective. complete, and accurate. The DON acknowledge that based on Resident 7's admission records, the PASRR was not accurate, and that the P&P was not being followed. The DON further states, it was important to have accurate documentation, ensuring the residents were provided with the services they needed, and to prevent harm. 2. During a review of Resident 36's admission Record, it indicated Resident 36 was admitted on [DATE], with diagnoses that included major depressive disorder, bipolar disorder, and generalized anxiety. During a review of Resident 36's Preadmission Screening and Resident Review (PASRR) Level I screening, dated October 6, 2025, the PASRR Level 1 screening indicated in section III for Serious Mental Illness. 9. Diagnosed Serious Mental Illness. Does the individual have a serious diagnoses mental disorder such as. Depressive Disorder, Anxiety Disorder. symptoms of Psychosis, Delusions, and/or Mood Disturbance? This question was marked NO. Further review of the PASRR indicated a resolution status LII- Not Required (Level 2 assessment is not required). During an interview on December 17, 2025, at 9:02 AM, with Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 36's PASRR dated October 6, 2025, did not accurately reflect Resident 36's existing diagnoses of anxiety, depression, and bipolar disorder. The MDSC further stated the facility should have accurately screened the resident and corrected the PASRR to include her diagnoses on admission to the facility. The MDSC acknowledged that the facility did not accurately screen or correct the PASRR for Resident 36. During a concurrent interview and record review on December 17, 2025, at 2:58 PM, with the Director of Nursing (DON), facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017 was reviewed. The P&P indicated, . Documentation in the medical record will be objective. complete, and accurate. The DON acknowledge that based on Resident 36's admission record, the PASRR was not accurate, and that the P&P was not being followed. The DON further states, the importance of accurate documentation in PASRR was to ensure the residents are getting the individualized care and services they require.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 10) investigated for urinary catheter (a medical device that drains urine from the bladder) received services for the care and maintenance of her catheter when Resident 10's urinary bag (a bag attached to the catheter that collects urine) was found in Resident 10's wheelchair and was not placed lower than her bladder to allow proper flow of urine from the bladder.This failure had the potential for Resident 10 to experience a backflow of urine from the urine drainage bag into the bladder, or for the urine flow to be obstructed which can lead to pooling of urine and urinary infections.A review of Resident 10's admission Record (contains medical and demographic information), the admission Record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included retention of urine (a condition in which you are unable to empty all the urine from your bladder), multiple fractures of the ribs, abnormalities of gait (walking) and mobility, and Dementia (a decline in mental ability which interferes with daily life, affecting memory, thinking, language, judgement, and behavior).During a concurrent observation and interview on December 15, 2025, at 10:45 AM, in Resident 10's room, Resident 10 was sitting in her wheelchair next to her bed and had her foley catheter drainage bag next to her, in the wheelchair. There were approximately 300 milliliters (mls- unit of measure) of urine in the drainage bag. Resident 10 stated she returned from the rehab gym 40 minutes ago and was brought to her room by a staff member, in her wheelchair. Resident 10 further stated the rehab staff member left the urine drainage bag in her wheelchair.During a concurrent interview and record review on December 15, 2025, at 10:54 AM, with Licensed Vocational Nurse 5 (LVN 5), LVN 5 observed Resident 10 in her wheelchair and acknowledged Resident 10's foley catheter drainage bag was next to her in the wheelchair. LVN 5 stated there was approximately 300 mls of urine in the drainage bag and stated the bag was supposed to be below the level of the bladder but it was not. LVN 5 further stated it was important to have the drainage bag lower than the bladder to ensure urine could not backflow into the bladder.During an interview on December 15, 2025, at 10:59 AM, with Certified Occupational Therapy Assistant 1 (COTA 1), COTA 1 stated she was the staff member who brought Resident 10 back to her room in her wheelchair after Resident 10's rehab session in the facility gym approximately 45 minutes prior. COTA 1 stated Resident 10's foley drainage bag should be lower than the resident's bladder and she (COTA 1) thought she had placed Resident 10's foley drainage bag lower.During an interview on December 18, 2025, at 10:20 AM, with the Director of Nursing (DON), the DON stated it was the staff's responsibility to make sure the foley drainage bag was placed at a level below the bladder to prevent the backflow of urine and to prevent urinary tract infections.During a review of Resident 10's History and Physical progress note (H&P), titled, admission Summary, dated November 24, 2025, the H&P indicated Resident 10 was admitted to the facility after experiencing a fall downstairs, and sustaining multiple bone fractures. The H&P also indicated, She also developed urinary retention and was not able to void on her own, so foley was re-inserted. She was sent to SNF [Skilled Nursing Facility] for PT/OT [physical therapy/occupational therapy].During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated September 2025, the P&P indicated, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on observation, interview, and record review, the facility failed to ensure utensils used for eating were kept in a clean and sanitary condition during lunch on December 15, 2025, when Resident 62 received a built up spoon (a type of adaptive utensil with an enlarged handle, designed to help individuals with a weak or limited grip) which had water pooled in its handle. When Resident 62 picked up the spoon and attempted to eat her food, the water spilled out of the handle and onto her food.This failure had the potential to cause food-borne illness as a result of contamination of food served to Resident 62 by water from an unknown source which had pooled in the handle of the spoon.During a concurrent observation and interview on December 15, 2025, at 12:38 PM, in the facility's dining room, Resident 62 was eating a sandwich for lunch. Resident 62 stated she was eating a sandwich for lunch because she received a tray of food but when she went to use her built up spoon to eat, the spoon was missing a cap on the end of the handle and water spilled out of the handle directly onto her food. Resident 62 further stated there had been at least 5 previous occasions when she received a built-up spoon with her meals and the spoon was missing the cap at the end of the handle and water spilled onto her food when she attempted to use it. Resident 62 stated today she was provided with a sandwich after the water spilled onto her food.During an interview on December 15, 2025, at 12:44 PM, in the facility's dining room, Resident 52 (who was sitting next to Resident 62) stated he too required a built up spoon and on numerous occasions, had received a built up spoon without an end cap on the handle and subsequently water which had pooled in the handle spilled onto his food when he went to use the spoon. Resident 52 further stated, it seemed like for every meal, either him or Resident 62 received the spoon without an end cap and water is almost always pooled in its handle.During a concurrent observation and interview on December 15, 2025, at 12:50 PM, in the facility's dining room, a Certified Nursing Assistant 5 (CNA 5) stated Resident 62 was eating a sandwich instead of the regular meal because the resident received a spoon that had no cap on its handle and water from the spoon spilled onto her food. CNA 5 showed Resident 62's tray and built-up spoon which had been provided to Resident 62. The spoon on Resident 62's tray had a large hollow handle and was missing an endcap on the rear of the handle which left an opening into the handle approximately the size of a quarter. CNA 5 further stated she provided Resident 62 with the sandwich after the water fell on the resident's food.During an interview on December 18, 2025, at 10:22 AM, with the Director of Nursing (DON), the DON stated adaptive devices which were not in good repair should be disposed of and not provided to residents. The DON further stated he was made aware that water pooled inside of the handle of a spoon which had no cap and spilled onto a resident's food. The DON further stated it was unknown where the water originated from and that it could have been from the dishwasher and would potentially contaminate any food it came into contact with. The DON stated the spoon should have been either repaired or discarded and not provided to Resident 62.During an interview on December 18, 2025, at 1:50 PM, with the facility's Registered Dietician (RD), the RD stated facility staff should ensure adaptive devices are safe for the resident to use and that water should not be able to pool in the handle of a spoon and if it did, the spoon should be cleaned prior to being given to a resident. The RD further stated if an adaptive device was broken or needed to be repaired, it should not be given to a resident for use.During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals, (undated), the P&P indicated, .1. Adaptive devices (special eating equipment utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/padded handles, plate guards, and/or specialized cups.During a review of the facility's P&P titled, Food and Nutrition Services, (undated), the P&P indicated, .6. Nursing staff will ensure that assistive devices are available to residents as needed, and in good working order.During a review of the facility's P&P titled, Sanitation, dated 2023, the P&P indicated, The Food and Nutrition Services Department shall have equipment of the type and in the amount necessary for the proper preparation, serving, and storing of food.All equipment shall be maintained as necessary and kept in working order.11. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas.

Based on observation, interview, and record review, the facility failed to ensure medications for two of 26 residents (Resident 19 and 103) observed for medication pass were administered according to the facility's policy & procedure, and maintain accurate records of controlled medications (medications that are controlled by the government because it may be abused or cause addiction) when:1. Resident 19 had an order to received Levothyroxine (medication to treat hypothyroidism - low levels of thyroid hormone) and was not available for administration. This failure had the potential to increase Resident 19's symptoms of hypothyroidism and can cause long - term health complications. 2. Resident 103 did not receive Sevelamer Carbonate (a medication used to control high phosphorus levels in patients with kidney disease) 800 mg (milligram - unit of measure) oral tablet with meals as ordered by the physician. This failure had the potential for Resident 103 to have increased levels of phosphorus in the blood, which could negatively affect Resident 103's health and safety. 3. For one of four medication carts (Medication Cart Station 1), the Controlled/Narcotic Emergency Kit Shift to Shift Check for Licensed Nurses (a narcotic log used by the facility to verify counting of controlled medications at the change of shift by incoming and outgoing licensed nurses), had a missing signature for December 17, 2025. These failures and had the potential for drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by staff in a highly vulnerable population of 93 residents and for Resident 19 and 103 to not be administered prescribed medication and increased the resident's risk for adverse reactions and side effects1.During a record review of Resident 19's admission Record (Contains demographic and medical information), it indicated Resident 19 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (a condition where the brain does not work normally, type 2 diabetes mellitus with complications (a long term conditions where the body has trouble controlling blood sugar levels) and hypertensive heart disease with heart failure (heart disease caused by long term high blood pressure that makes the heart weak and not pump well). During a medication administration pass observation for Resident 19 on December 17, 2025, at 6:50 AM a.m., with Licensed Vocational Nurse (LVN 3), the LVN 3 reviewed the medication card for Resident 19 and was unable to locate the prescribed dose of Levothyroxine Sodium Oral Table, 175 mcg (micrograms, a unit used to measure very small amount of medication), oral tablet, which was scheduled to be administered during the morning. The medication was not available and was not administered as ordered. During a record review for Resident 19's Physician Orders, it indicated, Levothyroxine Sodium Oral Tablet: (Levothyroxine Sodium) give 175 mcg by mouth in the morning at 6:30 AM, for hypothyroidism (A medical condition where the thyroid gland does not make enough thyroid [small gland in the neck] hormone and can affects the energy level and heart rate). During an interview on December 17, 2025, at 7:32 AM with LVN 3, the LVN 3 stated when a medication is not available, she notified the Registered Nurse (RN) supervisor, the RN supervisor checks for available emergency or cycle mediations and notified the physician regarding the medication unavailability. The LVN further stated that Levothyroxine is scheduled to be administered early in the morning and must be given on an empty stomach to properly regulate the resident's thyroid levels. LVN 3 confirmed that Levothyroxine 175 mcg was not available at the time of the scheduled dose and therefore was not administered as ordered for Resident 19. During a concurrent interview and record review on December 18, 2025, at 4:36 PM, with the Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Ordering and receiving medications from (name of the pharmacy) Inc, dated January 2025, was reviewed. The P&P indicated, . Medications and related products shall be ordered and received from (name of the pharmacy), Inc on a timely basis., Procedures, . d. Refills of medications should be called to the pharmacy 3 to 4 days in advance of need to assure an adequate supply is on hand. The DON stated that nursing staff are responsible for ensuring prescribed medication is available for administration and confirmed that for Resident 19, the facility's policy and procedure was not followed by the staff. 2. During a review of Resident 103's clinical records, the admission Record indicated Resident 103 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease, abnormal posture, and dependence on renal dialysis. During a concurrent medication administration observation and interview on December 17, 2025, at 6:31 AM, with a Licensed Vocation Nurse 4 (LVN 4) in Resident 103's room, LVN 4 was preparing to administer morning medications to Resident 103. LVN 4 pulled out a bottle with the label Sevelamer Carbonate 800mg- *give with meals* and administered to Resident 103, without meals. LVN 4 stated breakfast is served between 7:00 AM- 7:30 AM. LVN further stated Resident 103 would like to take the medication with meals, however because of time conflict, she is unable to take it with meals. During a follow-up interview on December 17, 2025, at 7:07 AM, with LVN 4, LVN 4 acknowledged the medication should have been given with meals. During a review of Resident 103's physicians orders, it indicated Sevelamer Carbonate Oral Tablet 800 M, give 4 tablets by mouth three times a day for hyperphosphatemia, take it with meals- start date: December 4, 2025. During a concurrent interview and record review on December 18, 2025, at 4:47 PM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled Medication Administration-General Guidelines, dated January 2025, was reviewed. The P&P indicated, Medication shall be administered in accordance with good nursing principles and practices and only by persons legally authorized to do so.Administration. J. Medications shall be administered in accordance with written orders of the attending physician. The DON stated the medical should have been given as ordered. 3. During a concurrent interview and record review on December 17, 2025, at 2:39 PM, with Licensed Vocational Nurse 1 (LVN 1), in Station 1 hallway, the Medication Cart's Controlled/Narcotic Emergency Kit Shift to Shift Check for Licensed Nurses (a narcotic log used by the facility to verify counting of controlled medications at the change of shift by incoming and outgoing licensed nurses), dated December 1, 2025, through December 17, 2025, was reviewed. The narcotic log indicated there was a missing signature on December 17, 2025, for the outgoing nurse (7:00 PM to 7:00 AM). LVN 1 confirmed the missing signature and stated the expectation is for the narcotic log to be counted by two nursing staff and signed every shift change. During a concurrent interview and record review on December 18, 2025, at 4:44 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Pharmaceutical Services Policy and Procedure Manual- Controlled Medication Storage dated January 2025. The P&P indicated, .d. At each shift change, a physical inventory of all controlled medications shall be conducted by two licensed nurse and is documented on the controlled substances accountability record. The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure one of twenty-seven (27) sampled residents (Resident 10) received medications as ordered by the physician, and the facility did not inform the physician of the missed medication doses when:a. Resident 10's anticoagulant Heparin (a blood thinner medication used to prevent the formation and growth of blood clots) was not administered on November 28, 2025, for 9:00 AM and 9:00 PM dose. Additionally, on November 29, 2025, she was not given her 9:00 AM dose (total of three missed doses). There was no documented evidence indicating the physician was notified of the missed doses.b. Resident 10's antibiotic Keflex (a medication used to treat a bacterial infection) was not administered on November 29, 2025, for 6:00 AM dose and 12:00 PM dose (total of two missed doses). There was no documented evidence indicating the physician was notified of the missed doses.These failures had the potential for Resident 10 to experience subtherapeutic (less than optimal) benefits from her medications and for increased risk for worsening infection and/or the development of blood clots. Additionally, by not informing the physician of missed doses, the physician was not provided with an opportunity to consider the potential medical impact on the patient and consider if additional orders were necessary.A review of Resident 10's admission Record (contains medical and demographic information), indicated Resident 10 was admitted to the facility on [DATE], with diagnoses which included thrombocytosis (a disorder in which your body produces too many platelets which can cause blood clots or bleeding problems), Guillain-Barre Syndrome (a condition in which the body's immune system attacks the nerves), and hereditary motor and sensory neuropathy (an inherited disorder that progressively damages the nerves, causing muscle weakness and sensory loss). During and interview on December 16, 2025, at 8:58 AM, Resident 10 stated she was receiving Heparin and Keflex a few weeks ago but was not provided a few doses of each medication because the facility did not have the medications available. Resident 10 further stated the Keflex medication was to treat an infection on her scalp. a. During a review of Resident 10's physician's orders, an order dated June 28, 2025, indicated, Heparin Sodium.injection 5000 unit/ml [units per milliliter] inject 0.5 milliliter subcutaneously [beneath the skin] every 12 hours for DVT [deep vein thrombosis - a condition where a blood clot forms in a deep vein] prophylactic [prevention]. During a review of Resident 10's Medication Administration Record (MAR - document used to record the administration of medications to the resident), dated November 1, 2025, through November 30, 2025, the MAR indicated Resident 10 did not receive her 9:00 AM and 9:00 PM doses of Heparin on November 28, 2025. Additionally, the MAR indicated Resident 10 did not receive her 9:00 AM heparin dose on November 29, 2025. During a review of Resident 10's progress notes, a progress note dated November 28, 2025, at 9:35 AM, indicated, Heparin Sodium.injection solution 5000 unit/ml inject 0.5 milliliter subcutaneously every 12 hours for DVT prophylactic.medication not here. Will cont [continue] to f/u [follow up] with pharm [pharmacy]. During a review of Resident 10's care plan (an individualized plan for the medical care of a resident) titled, [name of Resident 10] is on anticoagulant therapy Heparin Sodium injection. dated April 25, 2025, the care plan interventions indicated, Administer anticoagulant medications as ordered by physician. b. During a review of Resident 10's physician's orders, an order dated November 27, 2025, indicated, Keflex oral capsule give 500 mg [milligrams - unit of measure] by mouth every 6 hours for scalp cellulitis [inflammatory disease of the scalp] for 7 days. During a review of Resident 10's MAR, Dated November 1, 2025, through November 30, 2025, the MAR indicated Resident 10 did not receive her 6:00 AM and 12:00 PM doses of Keflex on November 29, 2025. During a review of Resident 10's progress notes, a progress note dated November 29, 2025, at 5:44 AM, indicated, Keflex oral capsule give 500 mg by mouth every 6 hours for scalp cellulitis for 7 days. Waiting for pharmacy to deliver. Org [original] order on the 27th [of November], sent reorder the 29th, e-kit [an emergency kit with a supply of medications] has none available. During a review of Resident 10's care plan titled, Red raised bump on scalp, dated November 27, 2025, the care plan interventions indicated, give medication as ordered. During a concurrent interview and record review on December 18, 2025, at 10:46 AM, with the Director of Nursing (DON), the DON stated when medications are not administered to a resident as ordered by the physician, the physician needs to be notified. The DON further stated physician notification of missed medication doses should be documented in the resident's progress notes. Resident 10's MAR dated November 1, 2025, through November 30, 2025, was reviewed. The DON acknowledged Resident 10 had three missed doses of heparin and two missed doses of Keflex in November 2025 and there was no documented evidence in Resident 10's Electronic Health Record (EHR) regarding physician notification of the missed doses. The DON stated it was important for the resident to receive the entire course of antibiotics (Keflex) to ensure the infection did not get worse and there should be no laps in antibiotic administration. During a continued interview on December 18, 2025, at 4:46 PM, with the DON, the DON stated medications can be brought in by the pharmacy immediately when requested for cases of emergencies or for antibiotics like Keflex. The DON stated the facility should have had the medications Keflex and heparin available for Resident 10 as ordered by the physician. The DON further stated the pharmacy should have been contacted by staff to provide a STAT (immediate) order of the medications for Resident 10. During a concurrent interview and record review on December 18, 2025, at 4:57 PM, with the facility's Consultant Pharmacist (CP), the CP reviewed Resident 10's electronic health record and stated regarding Resident 10's Keflex, the facility staff did not send the Keflex order to the pharmacy for filling until November 29, 2025 (two days after it was ordered by the physician). The CP further stated staff must have been taking the first few doses of the Keflex from the facility's E-kit (emergency kit) and did not send the order to the pharmacy until two days later which is why the medication was not available for a few doses. The CP stated, in regard to the Heparin, the facility received a 30-day supply of the medication on November 3, 2025, and they should have had enough medication to last through December 3, 2025. The CP further stated the facility should have had both Keflex and Heparin available for Resident 10 as ordered by the physician. During a review of the facility's policy and procedure P&P titled, Ordering and Receiving Medications from [name of pharmacy], dated January 2025, the P&P indicated, Medications and related products shall be ordered and received from [name of pharmacy] on a timely basis.b. New medications, except for emergency or stat medications, are ordered as follows: 1) if needed before the next regular delivery, the facility shall phone the medication order to the pharmacy immediately upon receipt. Inform pharmacy of the need for prompt delivery and request within 4 hours. 2) Anti-infectives and drugs used to treat severe pain, nausea, agitation, diarrhea, or other severe discomfort that are not ordered stat shall be available and administered within 4 hours of the time ordered. 3) The emergency kit shall be used when the resident needs a medication prior to pharmacy delivery.C. Stat and emergency medications are ordered as follows: 1) During regular pharmacy hours, the emergency or stat order shall be phoned or faxed to the pharmacy. Such medications shall be delivered and administered within 4 hour. If available, the initial dose shall be obtained from the emergency kit, when necessary.

Based on observations, interviews, and record reviews, the facility failed to ensure careplan (a structured and individualized approach that helps clinicians provide effective care for patients) was initiated to address weight loss for one of six Residents (Resident 63) reviewed for nutrition / hydration. This failure had the potential to placed Resident 63 at risk for malnutrition and dehydration.During a review of Resident 63's admission Record (Contains demographic and medical information), it indicated Resident 63 was admitted to the facility on [DATE], with the diagnoses which included type 2 diabetes mellitus with diabetic chronic kidney disease (a condition where the body does not use insulin well, causing high blood sugar overtime that damages the kidneys and makes them work less effectively), dehydration (when body does not have enough fluids, making it hard to organs to work properly), and Alzheimer's disease (a brain disease that slowly affects memory, think and the ability do daily activities).During an observation on December 17, 2025, at 12:02 PM, inside Resident 63's room. Resident 63 was laying in bed, facing the door, covered with a blanket. The resident was awake and able to respond by nodding his head Yes or No. When asked if he was eating his meals, the resident nodded his head no. When asked if he liked the food provided, Resident 63 again nodded his head no, when asked if he would like to eat something else the resident nodded his head no and closed his eyes.During a concurrent observation and interview on December 17, 2025, at 12:30 PM with Certified Nursing Assistant, CNA 2, CNA 2 was assisting Resident 63 with his lunch meal. CNA 2 stated Resident 63 requires assistance with meals and was able to consume about 50% of his breakfast but refused to eat lunch. CNA 2 further stated that when residents do not eat their meals, staff offer alternative food items, and notify the licensed nurses' residents of meal poor meal intake or meal refusal. The LVN came to the resident's room and offered fruit and milk, however the resident continued to refused. During a concurrent interview and record review of Resident 63's monthly weights, on December 18, 2025, at 4:38 PM with the director of Nursing (DON), the following was reviewed:i. October 6, 2025, Resident 63 weight 130 pounds (-11 pounds loss over approximately 6 weeks; approximately 7.8% weight loss.) ii. November 2, 2025, Resident 63's weight 130 pounds. iii. December 1, 2025, Resident 63's weight 120 pounds (-10 pounds loss over approximately 8 weeks; approximately 7.7% weight loss.) DON stated Resident 63 should have weekly weights, but the staff did not do it. DON further confirmed no care plan addressing Resident 63's his total weight loss. During a review of Resident 63's Physician Order, it indicated, CCHO Diet (a carbohydrate-controlled diet used to help manage blood sugar levels) soft and bite-sized - Level 6 texture (soft foods that require some chewing but can be easily broken apart with a fork), Thin/Regular - Level 0 consistency (the liquids flows exactly like water)., Daily Snacks, Nepro or Equivalent (a nutritional supplement drink designed to provide extra calories and protein) Daily. Order dated December 10, 2025.During a review of Resident 63's Change in Condition Evaluation, dated November 13, 2025, it indicated, 1. The change in condition, symptoms or sings I am calling about is/are. 30. Weight loss, 2. This started on: November 13, 2025., 4. Summarize your observations, evaluations and recommendations: pt. (patient) lost weight of 12 LBS (pounds) in 3 months. No RD recommendation noted at this time.During a concurrent interview and record review on December 18, 2025, at 1:14 PM, with the Registered Dietitian (RD), the RD reviewed the nutritional record for Resident 63. RD stated Resident 63's weight decreased from 130 pounds on October 6, 2025, to 120 pounds on December 1, 2025, representing a 10-pound weight loss in approximately one month. RD further stated nursing staff reported the resident exhibited behavioral issues, including spitting out food and medications, contributing to poor oral intake. RD stated appetite stimulants were not recommended because Resident 63 refuses and spits out medications and the dietary interventions in place included liberalizing food choices, offering preferred food and snacks and continuing with supplements.During a concurrent interview and record review on December 18, 2025, at 4:42 PM with Director of Nursing (DON) the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated March 2022, was reviewed. The P&P indicated, Resident weights are monitored for undesirable or unintended weight loss or gain. Care Planning. 1. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address the extent possible: a. The identified causes of weight loss; b. goals and benchmarks for improvement and c. time frame and parameters for monitoring and reassessment. DON confirmed should have had weekly weights for Resident 63 weight loss and that a care plan addressing his weight loss should be in place. The DON further confirmed that a care plan addressing the resident's weight loss was not located in Resident 63's clinical records, for review.

Based on interview and record review, the facility failed to ensure adequate supervision for one (1) of four (4) sampled residents (Resident 1), when Resident 1 left the facility without staff knowledge. Resident 1 was found five hours later in an adjacent building. This failure had the potential to result in serious injuries/accidents or death of Resident 1 due to lack of supervision.A review of Resident 1's Face Sheet (contains resident demographic), the Face Sheet indicated, Resident 1 was admitted on [DATE], with diagnoses that included spinal stenosis cervical region (the bony tunnel (spinal canal) in the neck gets too narrow squeezing the spinal cord), abnormalities of gait and mobility (your usual way of walking is off).During an interview on December 12, 2025, at 2:52 PM, with the License Vocational Nurse (LVN 1), LVN 1 stated that during the shift change, she received a communication from LVN 2 that on December 12, 2025, around 5:00 AM they could not locate Resident 1, prompting a search. LVN 1 further stated the resident was found at the adjacent facility around 11:00 AM (5 hours after) and was subsequently taken to hospital.During a telephone interview on December 12, 2025, at 3:32 PM, with LVN 2, LVN 2 reported she last saw, and briefly spoke with Resident 1 in the hallway on December 12, 2025 (day of incident) at approximately 5:00 AM. After that, LVN 2 proceeded to perform her duties. When she conducted her rounds, shortly after 5:00 AM, she noticed that Resident 1 was not in his room, prompting her to inform the supervisor. They began searching for him and attempted to call his phone, which went directly to voicemail.During an interview on December 12, 2025, at 4:00 PM, with the Administrator (Admin 1), Admin 1 stated that approximately 10 minutes after the facility reported to CDPH that Resident 1 was missing, the police contacted the facility by phone to inform them that the resident had been found at the assisted living facility adjacent to theirs. Admin 1 further stated upon their investigation, Resident 1 mentioned he went out the building to get some fresh air.During concurrent record review and telephone interview on December 17, 2025, at 10:48 AM, with Admin 1, Admin1 indicated that Resident 1 does not have a pass or authorization to exit the facility and does not possess an order from the physician. To mitigate the risk of elopement for residents who are alert and oriented, elopement assessments are conducted, and constant supervision is ensured. The facility's Policy and Procedure titled Wandering and Elopements was examined, which states, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If a resident is missing: a. Determine if the resident is out on an authorized leave or pass; . Admin 1 affirmed that it is their policy that constant supervision is required for residents who are not authorized to leave, acknowledging that insufficient supervision have contributed to the incident.

Based on interview and record review, the facility failed to ensure blood pressure medication was not administered in duplicated dose for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to receive an excessive dosage of the medication which could jeopardize her health and safety. Findings: During a review of Resident 1's admission record (information about the patient's personal details, reason for admission, and medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included cardiac arrest (the heart suddenly and unexpectedly stops pumping blood to the brain and other vital organs). During a review of the facility provided document titled Progress Notes, for Resident 1, dated May 24, 2025, at 2:18 AM, the Progress Notes indicated an entry from Licensed Vocational Nurse (LVN 1) stating: Double dose given, MD [Doctor of Medicine] notified, and receive the order for continually monitor for Hypotensive [low blood pressure]. During a review of the physician's order for Resident 1, dated April 28, 2025, the physician's order indicated Metoprolol Tartrate Oral Tablet 100 mg (Metoprolol Tartrate) Give 100 mg via G-Tube [ Gastrostomy tube - is a tube inserted into the stomach, providing a pathway for nutrition, fluids, and medications.) every 12 hours for HTN [hypertension-high blood pressure] Hold for SBP [systolic blood pressure- is the top number in a blood pressure reading, representing the pressure in arteries when the heart beats]. During a telephone interview on June 23, 2025, at 12:39 PM, LVN 1 stated Resident 1 was given Metoprolol (medication to lower blood pressure) twice - first by him and then by another Licensed Vocational Nurse (LVN 2). LVN 1 stated he initially administered the medication at approximately 8:00 PM but was interrupted by another resident before he could document it. Upon returning to document the medication, he found that LVN 2 had already recorded the administration, as he saw LVN 2 had just left the room. When LVN 1 questioned LVN 2 about this, LVN 2 admitted to giving the medication as well, mistakenly thinking that Resident 1 was assigned to him. During an interview with LVN 2 on July 1, 2025, at 7:25 AM, LVN 2 stated he had been assigned to care for Resident 1 for the two nights leading up to the incident. LVN 2 stated he did not check their assignment before administering medications. He further stated LVN 1 approached him that night claiming he also gave the same medication to Resident 1. The doctor was called, and Resident 1 was monitored and remained stable. Additionally, LVN 2 confirmed the Metoprolol was in a bubble pack (type of packaging) in his cart, and noted there was also the same medication, intended for Resident 1, in LVN 1's cart. However, they did not know how this situation occurred. During a review of the Medication Administration Record (MAR), dated May 2025, for Resident 1, the MAR indicated that Resident 1 received Metoprolol Tartrate 100 mg on May 23, 2025, at 9:00 PM signed by LVN 2. MAR did not 3indicate that the administration of the same medication, which is Metoprolol Tartrate 100 mg, which LVN 1 reported administering approximately thirty (30) minutes earlier on May 23, 2025, after LVN 2 accidentally administer the same medication was documented. During a concurrent interview and record review on June 23, 2025, at 1:56 PM, with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Documentation of Administration of Medication, dated November 2022 was reviewed. The P&P indicated, .Administration of medication is documented immediately after it is given . The Admin stated that policy was not followed. During a concurrent interview and record review on June 23, 2025, at 2:02 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Documentation of Administration of Medication, dated November 2022 was reviewed. The P&P indicated, .Administration of medication is documented immediately after it is given . The DON stated the staff must verify the orders and adhere to the five rights of medication administration. Additionally, proper documentation is required. When asked whether this P&P was followed, the DON stated, It was not followed.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to ensure residents received care and services with activities of daily living (ADL) when two out of three residents (Resident 1 and Resident 2) waited a long time to be cleaned and changed. This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) ' s health and safety at risk, when the residents ' activities of daily living were not met in timely manner. Findings: 1. During review of Resident 1 ' s Admission Record (general demographics), the document indicated Resident 1 was last admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a condition when the lungs cannot get enough oxygen into the blood or get rid of the waste product from the blood), morbid obesity (a condition with too much body fat), dependence on respirator (a condition when one cannot breath on their own and needs a machine) , and quadriplegia (a condition in which all four limbs are paralyzed). During an observation and interview on April 3, 2025, at 6:10 AM with Resident 1, Resident 1 stated, I had to wait a long time to be changed a couple of times, and I understand that I am not the only that needs help, but you don ' t get the help quickly. During a review of the clinical record for Resident 1, the Care Plan Report dated October 20, 2024, indicated, Focus: Resident has problems with ADL decline . related to muscle wasting and atrophy. Goal: Resident will improve ADL performance on grooming, upper body dressing lower body dressing toileting . 2. During review of Residents 2 ' s Admission Record (general demographics), the document indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included Chronic respiratory failure, chronic obstructive pulmonary disease (a condition that makes it harder to breath), paraplegia (a condition that the legs and not able to that part of the body) and dependence on respirator. During an observation and interview on April 3, 2025, at 6:15 AM, with Resident 2, Resident 2 stated, It is bad on the night. Sometimes I wait a while before I get help with a change. During a review of the clinical record for Resident 2, the Care Plan Report dated January 29, 2025, indicated, Focus: [name of Resident 2], has an ADL self-care performance deficit related to disease process paraplegia unspecified. Goal: [name of Resident 1] will maintain current level of function . Intervention: . The resident total dependent on 1 staff with personal hygiene and oral care. During an interview with Certified Nursing Assistant (CNA 2), on April 3, 2025, at 6:30 AM, CNA 2 stated, I am able to provide care to the residents but sometimes it takes a while to attend to a resident need when there is not enough help. During an interview with Director of Nursing (DON), on April 3, 2025, at 7:35 AM, DON stated, I expect nursing staff to attend to residents and provide assistance in a timely manner. During a concurrent interview and review on April 15, 2025, at 3:09 PM with DON, facility ' s policy and procedure (P&P), titled, Activities of Daily Living (ADLs), Supporting, dated March 2018 was reviewed. The P&P indicated, . 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical conditions(s) demonstrate that diminishing ADLs are unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care . DON stated, Residents needs should have been met in a timely manner.

Based on observation, interviews, and record reviews, the facility failed to follow its policy and procedure regarding medication error and adverse drug reaction reporting, for one of four sampled residents (Resident 1) when Resident 1 did not receive Pirfenidone (a medication to treat pulmonary fibrosis - a disease that damages the lung tissue, making it difficult to breathe) on December 21, 2024. This failure resulted in Resident 1 not receiving one dose of Pirfenidone and had the potential to adversely affect the health and safety of Resident 1 by causing a decline in lung function (when lung tissues cannot expand enough). Findings: During a review of Resident 1's Admission Record (It contains demographic information), the Admission Record indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis that included acute respiratory failure (is a serious condition that occurs when the body's respiratory system is unable to meet the body's need for oxygen or remove carbon dioxide). During a review of Resident 1's clinical records, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated November 22, 2024, indicated, Resident 1's score was a 15, which indicated Resident 1 had no mental impairment. During a review of Resident 1's Medication Administration Record (MAR- is the report that serves as a legal record of the drugs administered to a patient at the facility) for the month of December 2024, the MAR indicated Resident 1 was prescribed Pirfenidone 267 mg (milligram-unit of measurement) for interstitial lung disease (ILD - which causes scarring in the lungs, making it difficult to breathe). to be taken three times a day for seven days, starting December 16, 2024, until December 26, 2024. The MAR indicated the 5:00 p.m. dose on December 21, 2024, was not administered. During an interview on December 26, 2024, at 1:32 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she had disposed of a bottle of the Resident 1's medication Pirfenidone, in the designated medication disposal container after the morning medication administration, believing that the medication had been discontinued. She realized this at approximately 3:00 PM, that same day, December 21, 2024. LVN 1 further stated, as a result, the medication was not administered. During a concurrent interview and record review on December 26, 2024, at 2:48 PM, with the Director of Nursing (DON ), the MAR for the month of December 2024, was reviewed. The DON stated Pirfenidone 267 mg scheduled to be given on December 21, 2024, at 5 PM, was not given to Resident 1 because it was not available. The DON further stated LVN 1 mistakenly disposed of all the specific medications believing it was discontinued, as the facility's regular pharmacy did not supply them, [name of the pharmacy] provided the required medication. During a telephone interview on January 6, 2025, at 5:18 PM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated, she was unable to administer the 5:00 PM dose of Pirfenidone medication on December 21, 2024, because the medication was not available. LVN 2 further stated, according to what she heard, the medication was accidentally discarded by another staff member. During a concurrent telephone interview and record review on January 8, 2025, at 11:47 AM with the DON, the facility's policy and procedure (P&P) titled, Medication Error and Adverse Drug Reaction Reporting, dated March 2024. The P&P indicated, Definitions . Medication Error/Discrepancy: An incorrect medication prescribed, dispensed, or administered to a resident; an omission of a vital medication due to a prescribing, dispensing, or administering error; medication administered to an individual with a documented allergy to that medication. The DON stated, the facility staff did not follow the policy.

Based on observations, interviews, and record review, the facility failed to maintain a sanitary kitchen when: 1. There was a cabinet that stored a juice dispenser, the door to the cabinet had a sticky residue. Inside the cabinet there was a red juice spill. The cabinet under the steam table had food crumbs and trash. There was food residue around the floor sink under the steam table. This had the potential to attract pests and for microorganisms' growth. 2. The industrial mixer was stored with white food residue on the mixer. This had the potential to contaminate food being mixed in the mixer. 3. The ice machine had some brown build-up in the area where ice is formed. This had the potential to contaminate the ice. The facility failures had the potential to attract pests and cause foodborne illness to a population of 59 residents eating facility prepared meals. Findings: 1. During an observation on October 14, 2024, at 08:02 AM, on the stainless-steel counter there was a juice dispenser and below there was a cabinet. The handle to open the cabinet had a sticky residue. When the cabinet door was removed, there was a red juice spill. During an observation on October 14, 2024, at 08:13 AM, below the steam table there was a compartment which was opened and noted to have a large piece of foil with crumbs and other pieces of debris/nonfood items. During an observation on October 14, 2024, at 08:14 AM, there were crumbs and some food residue around one of the floor sinks (drains) under the steam table. During an interview on October 14, 2024, at 08:09 AM, with [NAME] 1, she stated that the area with the juice spill and the sticky residue on the handle of the cabinet should be kept clean. During an interview on, October 16, 2024, at 3:00 PM, with the Registered Dietitian Nutritionist (RDN 1) and Registered Dietitian Nutritionist (RDN 2), RDN 2 stated it was her expectation that the cabinet with the sticky residue be cleaned and cleaned frequently to avoid any issues. In addition, RDN 2, stated the area below the steam tables should be cleaned and maintained clean. During an interview on October 16, 2024, at 03:10 PM, with RDN 2, RDN 2 stated it was her expectation that the area below the steam tables be cleaned and that the domes be placed in their proper location. Finally, regarding the crumbs and food residue found around the floor sink under the steam table, RDN 2 stated it should be kept clean. During a review of the facility's policy and procedure titled, Sanitization, dated January 2024, indicated, The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, NonFOOD - CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 2. During an observation on October 14, 2024, at 08:30 AM, the industrial mixer was stored with a black plastic bag covering it. When the bag was removed the exterior of the mixer had some white food material splashes. During an interview on October 16, 2024, at 3: 08 PM, with RDN 1 and RDN 2, RDN 2 stated that the mixer should be cleaned thoroughly before putting the bag over it. During a review of the facility's policy and procedure titled, Sanitization, dated January 2024, the P&P statement indicated, The food service areas is maintained in a clean and sanitary manner. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, NonFOOD -CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 3. During an observation on October 14, 2024, at 10:24 AM in the kitchen, in the ice maker part of the ice machine there was a spot of brown buildup. During a concurrent observation and interview on October 14, 2024, at 10:26 AM, with the facility Maintenance Director (MD 1), in the kitchen, the tray below the ice maker part of the ice machine had a spot of brown buildup. The maintenance director stated that this area should be kept clean. During an interview on, October 16, 2024, at 3:00 PM, with Registered Dietitian Nutritionist (RDN 2), RDN 2 stated that it was her expectation that the ice machine be kept clean. During record review of the facility's policy and procedure titled, Ice Machines and Ice Storage Chests, dated January 2024, the policy and procedure indicated, Ice machines and storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. During a review of the FDA Federal Food Code, dated 4-602.11 indicated, (4) In Equipment such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. In addition, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on observation, interview, and record review, the facility failed to implement their infection control program to help prevent the spread of COVID-19 (Corona Virus Disease, a highly infectious disease caused by the SARS-CoV-2 virus) when the facility did not have any tracking and documentation of staff COVID-19 vaccination status. This failure had the potential to cause harm to the 95 residents residing within the facility by causing cross contamination of the environment and increasing the risk of exposure and spread of the COVID-19 virus. Findings: During a concurrent interview and record review on October 17, 2024, at 9:40 AM, with the Infection Control Preventionist (ICP) nurse, the ICP nurse was asked to review the staff COVID-19 vaccination status. The ICP nurse was not able to provide a document that indicated a tracking system of staff members and their COVID-19 vaccination status. The ICP nurse stated she was unaware of her responsibility to maintain a system for documenting staff COVID-19 vaccination. The ICP nurse further stated she realized this duty only after reading the facility's Policy and Procedure on COVID-19 Vaccination for Staff, which she provided to the surveyor. During an interview on October 17, 2024, at 9:55 AM, with the Director of Nursing (DON), the DON stated the ICP nurse did not have any tracking and documentation of staff COVID-19 vaccination status. Furthermore, the DON emphasized that this documentation should have been consistently maintained and regularly updated to helps the facility implement targeted infection control measures to protect residents and staff. During a follow up interview and record review, on October 17, 2024, at 10:10 AM, with the DON and ICP nurse the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Staff, revised January 2024, was reviewed. The P&P indicated . Policy Statement . It is the policy of this facility to offer current COVID-19 vaccination to all healthcare providers and all residents . Policy Interpretation and Implementation . Tracking, Documentation and Reporting 1. The infection preventionist maintains a tracking worksheet of staff members and their vaccination status. 2. The tracking worksheet provides the most current vaccination status of all staff who provide any care, treatment, or other services for the facility and/or its residents. The worksheet includes: a. staff name (and/or employee ID); b. initial start of employment or service; c. termination of employment or service (if applicable); d. job title or role; e. assigned work area; f. a brief description of how they interact with residents; g. vaccination status: (1) the specific vaccine received; (2) dates of each dose; (3) date of the next scheduled dose (for a multi-dose vaccine); and (4) any booster doses (date and specific type of vaccine); 3. The facility maintains documentation related to staff COVID-19 vaccination that includes, at a minimum, the following (as applicable): a. That staff were offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine, b. That staff were provided education regarding the benefits and potential risks associated with COVID- 19 vaccine; c. A copy of the informed consent; and d. Verification of vaccination or documentation of exemption/delay. The DON stated the facility did not follow the policy.

Based on observations, interviews, and record review, the facility failed to ensure their equipment was maintained in safe operating condition when: The countertop water dispenser was found leaking and collecting standing water in the drain. This facility's failure to ensure a safe, operating equipment has the potential to increase risk of resident harm and attract pests due to the standing water which can affect the population of 59 residents who receive food from the kitchen. Findings: During an observation on October 14, 2024, at 08:04 AM, there was a leaking water dispenser on the countertop, with sitting water in the drain underneath the cover. During an interview on October 14, 2024, at 08:09 AM, with [NAME] 1, she stated they do not use it and it that it looks like it is leaking and needs to be fixed. During an interview on, October 16, 2024, at 3:10 PM, with Registered Dietitian Nutritionist (RDN 1), and Registered Dietitian Nutritionist (RDN 2), RDN 2 stated that it was her expectation that the water dispenser should be fixed as soon as possible. During a review of the facility's policy and procedure titled, Maintenance Service, dated January 2024, the policy and procedure statement indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. During further review of the FDA Federal Food Code, dated 2022, under Section: Equipment, 4-501.11 titled, Good Repair and Proper Adjustment, indicated, EQUIPMENT shall be maintained in a state of repair and condition Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk.

Based on the observation, interview and record review, the facility failed to ensure a Significant Change of Status Assessments (SCSA) of the Minimum Data Set (MDS-a computerized assessment instrument) was completed within 14 days for one resident (Resident 36) when Resident 36 had a significant change in the nutrition route from enteral (nutrition delivered directly to the stomach or intestines) to oral (nutrition taken by mouth) after gastric tube (g-tube is a small tube that is placed through the skin into the stomach, used to give food, water, or medicine to people who can't eat by mouth) removal and a changed in the level of eating assistance. This failure resulted in Resident 36's care plan not being updated and revised to reflect his current status, which had the potential to delay the implementation of care and support needs. Findings: During a review of Resident 36's Admission Record (a document that contains demographic and clinical data), indicated, Resident 36 was admitted to the facility on [DATE], with diagnoses which included acute kidney failure (a condition where the kidneys suddenly stop working properly) and metabolic encephalopathy (a brain problem caused by issues with how the body uses food and energy). During an observation on October 14, 2024, at 12:25 PM, Activity Director (AD) serve and set up Resident 36's lunch tray in the dining room, Resident 36 began to eat his lunch independently. He continued to eat independently throughout his meal. During a record review on October 14, 2024, at 2:00 PM, with Director of Nursing (DON), the DON reviewed Resident 36's physician order dated July 10, 2024, which indicated . Order Summary: Regular diet. Pureed texture (smooth soft consistency, like pudding) , Regular/Thin consistency, large portion . During a concurrent interview and record review, October 17, 2024, at 2:20 PM, with the DON and MDS nurse, the DON and the MDS nurse reviewed Resident 36's clinical record dated July 26, 2024, which indicated, .Summarize your observations, evaluation, and recommendations: resident noted to have g-tube removed able to tolerate PO [by mouth] diet . Recommendation of Primary Clinician(s): [name of the Nurse Practitioner] in facility to remove G-Tube . The MDS nurse stated she did not know Resident 36's g- tube was removed on July 26, 2024. During a concurrent interview and record review, October 17, 2024, at 2:40 PM, with the DON and MDS nurse, the DON and the MDS nurse reviewed Resident 36's clinical record of MDS assessments. The assessments indicated the following levels of eating assistance for Resident 36: a. July 18, 2024, MDS Quarterly assessment , indicated, Partial/moderate assistance [helper does less than half the effort] b. April 19, 2024, MDS Quarterly assessment , indicated, Not attempted . c. January 23, 2024, MDS Quarterly assessment , indicated, Not attempted . d. October 25, 2023, MDS Admission assessment, indicated, Not applicable. The DON and MDS nurse stated Resident 36's level of assistance changed from dependent gastric tube feeding to oral partial/moderate assistance for eating. A review of the MDS assessments for Resident 36 revealed the last assessment completed was a quarterly assessment completed July 18, 2024. No other MDS assessments had been completed since July 18, 2024, the DON and MDS nurse confirmed that no additional MDS assessments had been completed since July 18, 2024. The MDS nurse stated that she missed completing the SCSA for Resident 36, which should have been completed by August 10, 2024. (It has been 68 days since the SCSA was due, and it has not been completed to reflect Resident 36's current status). A review of the facility policy and procedure titled Change in Resident's Condition or Status revised January 2024, indicated . 2. A significant change of condition is major decline or improvement in resident status that: a. will not normally resolve itself without intervention . b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan; . 9. If a significant change in resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA [is a federal law that establishes regulations for nursing facilities] regulations governing resident assessments and as outlined in the MDS RAI [Resident Assessment Instrument. It's a tool used in nursing homes to assess residents' health and needs] Instruction Manual . A review of the RAI manual revised October 2023, indicated . The SCSA is a comprehensive assessment for a resident . It can be performed at any time after the completion of an Admission assessment .The MDS completion date (item Z0500B) must be no later than 14 days from the ARD [(Assessment Reference Date) is the last day of this observation period] (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met

Based on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed accurately to reflect the resident's status, care, and services for one of two sampled residents (Resident 68) reviewed for restraints (tools used to keep a patient safe by limiting their movement. They can be things like special belts, mittens, or straps that prevent a person from hurting themselves or others, or from pulling out important medical equipment). This failure had the potential to cause inaccuracy in identifying Resident 68's care and support needs. Findings: During a review of Resident 68's Admission Record (a document that contains demographic and clinical data), the Admission Record indicated, Resident 68 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain problem caused by issues with how the body uses food and energy) and attention of tracheostomy (tube helps people breathe when they can't breathe normally through their mouth or nose). During an observation on October 14, 2024, at 2:30PM, in room [ROOM NUMBER], Resident 68 was wearing mittens (in a medical care setting, a type of cloth glove that covers the hands to limit movement and prevent self-harm or pulling out medical devices) on both hands and an abdominal binder (a stretchy piece of fabric that wraps around the stomach) on his abdomen. During a concurrent observation and interview on October 17, 2024, at 12:30 PM, with a License Vocational Nurse 1 (LVN 1), in room [ROOM NUMBER], Resident 68 was wearing mittens on both hands and an abdominal binder on his abdomen. LVN 1 stated the mittens were used to prevent Resident 68 from pulling out his tracheostomy, and the abdominal binder was used to block him [Resident 68] from pulling on his gastric tube (g-tube is a small tube that is placed through the skin into the stomach, used to give food, water, or medicine to people who can't eat by mouth). During a concurrent interview and record review, on October 17, 2024, at 3:00 PM, with the Director of Nursing (DON) and Minimum Data Set Nurse (MDS Nurse), the DON and MDS Nurse reviewed Resident 68's physician orders. The order dated August 8, 2024, indicated, May have abdominal binder due to pulling at G-tube, and the order dated August 23, 2024, indicated, May have bilateral mittens as needed due to pulling at medical equipment. The DON and MDS Nurse confirmed the orders. The MDS Nurse stated she was aware of Resident 68 uses both mittens and an abdominal binder. During a further record review and interview on October 17, 2024, at 3:10 PM with the DON and MDS Nurse, the DON and MDS Nurse reviewed Resident 68's Quarterly MDS assessment dated [DATE], the assessments under Section P titled Restraints and Alarms, indicated Resident 68 did not use physical restraints. The DON and MDS Nurse confirmed Trunk restraint [a device or strap that secures a person's torso (their trunk, which includes the chest and abdomen) to a bed or chair] and Limb restraint [using straps or devices to secure a person's arms or legs] were not coded for Resident 68's Quarterly MDS Assessments. The MDS nurse stated it should have been coded. During a concurrent interview and record review on October 17, 2024, at 3:40 PM, with the DON and MDS Nurse, the DON and MDS Nurse reviewed the facility policy and procedures (P&P) titled Certifying Accuracy of the Resident Assessment, revised January 2024. The P&P indicated . 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. The DON and MDS Nurse stated that the facility did not follow the policy. During a review of CMS (The Centers for Medicare & Medicaid Services) RAI manual (Resident Assessment Instrument, this manual provides guidelines and definitions for completing MDS assessment) dated October 2023, it indicated .The RAI process .require that (1) the assessment accurately reflects the resident's status . When the use of physical restraints is considered, thorough assessment of problems to be addressed by restraint use is necessary to determine reversible causes and contributing factors and to identify alternative methods of treating non-reversible issues . Steps for Assessment 1. Review the resident's medical record (e.g., physician orders, nurses' notes, nursing assistant documentation) to determine if physical restraints were used during the 7-day look-back period. 2. Consult the nursing staff to determine the resident's cognitive and physical status/limitations. 3. Considering the physical restraint definition as well as the clarifications listed below, observe the resident to determine the effect the restraint has on the resident's normal function .

Based on the observation, interview and record review, the facility failed to store all drugs and biological in accordance with currently accepted professional principles and the facility's policies and procedures when one of four medication carts (200's hall medication cart ) reviewed for medication storage found to be unsanitary on October 16, 2024. This failure had the potential increase the risk of infection to a resident's receiving medications with unwanted chemical reactions and decreased efficacy. Findings: During an observation on October 16, 2024, at 10:50 AM with License Vocational Nurse 2 (LVN 2), LVN 2 inspected the contents of the 200's hall medication cart. The left bottom drawer, was noted with yellow moist build up. LVN 2 stated the drawer contains the as needed over the counter medications and acknowledged there was a yellow build up on the paper towel used to wipe inside of the 200's hall medication cart left bottom drawer. During a concurrent observation and interview on October 16, 2024, at 11:10 AM with Infection Control Preventionist (ICP) nurse. The ICP nurse inspected the 200's hall medication cart and acknowledged there was a yellow build up on the paper towel used to wipe inside of the 200's hall medication cart left bottom drawer. The ICP nurse stated all medication carts should have been clean to maintain the efficacy of the medications and prevent contamination, (when something harmful, like dirt, germs, or chemicals, mixes with something clean or safe, making it unsafe to use). During an interview and concurrent record review on October 16, 2024, at 4:10 PM with the Director of Nurses (DON), the DON reviewed the facility's policy and procedure (P&P) titled, Storage of Medications, effective date January 2024, which indicated, Policy heading . The facility stores all drugs and biologicals in a safe, secure, and orderly manner . Policy Interpretation and Implementation . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The DON stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure all mobility equipment was safe to be used on residents during transfers from bed to chair, when an electric lift (a mobility tool used to allow a person to be lifted and transferred with minimum physical effort. A weighing scale can be attached to the lift to weigh residents when lifted) used by two Certified Nursing Assistants (CNA 1 and 2) to transfer a resident (Resident 8) had a base that did not securely lock into place, causing the lift to tilt and the digital scale to hit Resident 8 on the forehead. This failure resulted in harm for one of eight sampled residents (Resident 8), when Resident 8 sustained two abrasions (the surface layers of the skin has been broken) on the right side of the forehead. Findings: During an interview on August 11, 2023 at 10:46 AM with Resident 8, Resident 8 stated there was a time when she was being transferred from bed to chair using an electric lift that did not lock, causing the lift to tilt and hit her on the forehead. Resident 8 further stated CNA 1 and CNA 2 were present when the incident occurred. During an interview on August 11, 2023 at 10:55 AM with CNA 1, CNA 1 stated Resident 8 required two-person assist for transfers. CNA 1 further stated she was transferring Resident 8 from bed to chair using an electric lift with the help of CNA 2, when the two legs of the lift did not lock and collapsed closer together, causing the electric lift to tilt over and the weight scale attached to the lift hit Resident 8 on the right side of the forehead. CNA 1 was unable to state the date and time of the incident. During an interview on August 11, 2023 at 11:52 AM with CNA 2, CNA 2 stated they were transferring Resident 8 from bed to chair when the legs of the electric lift closed and caused the lift to tilt and part of the weighing scale hit Resident 8 on the right forehead. CNA 2 further stated she noticed redness on the right forehead of Resident 8 and reported the incident to the Charge Nurse. CNA 2 was unable to state the date and time of incident. During an observation on August 11, 2023 at 12:00 PM within facility hallway 200, CNA 1 and CNA 2 identified the electric lift located along hallway 200 that was used for Resident 8. The electric lift had a sticker label that indicated, Brand name and model, with #1 (number one) handwritten on the boom (a beam used to move and carry the load) and mast (the vertical bar that fits into the base). During a concurrent observation and interview on August 11, 2023 at 12:05 PM with the Maintenance Supervisor (MS), the MS demonstrated the use and operation of electric lift number one. The MS stated the legs of the base will spread wide and open by using the shifter handle located behind the mast of the lift. The MS further stated the lift should only be used to lift residents with the legs in maximum open position and locked in place. The MS was unable to demonstrate the legs of the base were able to lock securely in place during use. During a concurrent interview and record review on August 11, 2023 at 2:00 PM with the MS, the electric lift number one's Operations Manual (OM) for Brand name and model, titled, Manual/Electric Portable Patient Lift Owner's Installation and Operating Instructions, undated, was reviewed. The OM indicated, . Operation . Warning . Only operate this lift with the legs in maximum open position and locked in place. The base legs must be locked in the open position at all times for stability and patient safety when lifting and transferring a patient . The MS stated the electric lift number one did not lock securely into place when in an open position during use for resident transfer. The MS further stated the OM's instruction for safe transfer of residents using the lift was not followed. During a review of Resident 8's Face Sheet (a document containing basic information), dated August 9, 2023, the face sheet indicated Resident 8 was admitted to the facility on [DATE], with diagnoses that included morbid obesity (having too much body fat), other symptoms and signs involving the nervous (includes the brain, spinal cord, and a complex network of nerves) and musculoskeletal (includes the bones and muscles) system. During a review of Resident 8's MDS (Minimum Data Set - a standardized assessment tool that measures health status in nursing home residents) Section C (Cognitive [involving conscious intellectual activity] Patterns), dated June 1, 2023, the MDS Section C indicated, Resident 8 had a BIMS (Brief Interview for Mental Status- a tool used to screen how a resident is functioning cognitively) score of 12 (a BIMS score of 8 to 12 suggests moderately impaired cognition). During a review of Resident 8's MDS Section G (Functional Status), dated June 1, 2023, the MDS Section G indicated, Resident 8 was totally dependent for transfers to and from bed, requiring two-person physical assist. During a concurrent interview and record review on August 11, 2023 at 2:10 PM with the Director of Rehabilitation (DOR), Resident 8's medical record document titled, PT (Physical Therapy) Evaluation and Plan of Treatment (PT evaluation), dated with Certification Period 4/29/2023 - 5/25/2023 was reviewed. The PT evaluation indicated, .Functional Mobility Assessment . Transfers= Total Dependence w/o (without) attempts to initiate (Pt [patient] is [brand of lift] dep [dependent] .). The DOR stated Resident 8 required two-person assist during transfers with the use of a lift. During a concurrent interview and record review on August 11, 2023 at 2:15 PM with the Registered Nurse Supervisor 1 (RN 1), Resident 8's Progress Notes, dated July 18, 2023 was reviewed. The Progress Notes indicated, a late entry for July 17, 2023. The Progress Notes further indicated, . while being transferred from bed to w/c (wheelchair) using (brand of lift) lift with two CNAs the (brand of lift) lift bumped her R (right) side of the face d/t (due to) falty (faulty) equipment . Resident was assessed with 2 small scrapes to the right side of the face . The RN 1 stated the lift used for Resident 8 had legs at the base that did not lock and tipped over, hitting Resident 8 on the right side of the forehead, causing two scrapes measuring two centimeters each that required first aid. During a concurrent interview and record review on August 11, 2023 at 2:26 PM with the Administrator, the facility's policy and procedure (P&P) titled, Lifting Machine, Using a Mechanical, revised July 2017 was reviewed. The P&P indicated, . The purpose of this procedure is to establish the general principles of safe lifting using mechanical lifting device. It is not a substitute for manufacturer's training or instructions . Steps in the Procedure . 7. Make sure the lift is stable and locked . 8. Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition . The Administrator stated the electric lift should have been in good repair and safe for resident use. The Administrator further stated both the P&P and operations manual for using the electric lift were not followed.

Based on observation, interview, and record review, the facility failed to ensure safe food storage was maintained in the walk-in refrigerator when inadequate temperature control (a temperature of greater than 41 degrees fahrenheit greater) occurred for 3 days (from (MONTH) 3 to 5, 2019). In addition, the facility served food items after being stored outside the safe temperature for three days. This had the potential to result in affecting a vulnerable population of 64 residents that received oral diets. In addition, this failure had the potential for residents to sustain serious gastro-intestinal illnesses resulting from consumption of food items unsafely stored. Due to this failure, the Administrator (ADM), Head Consultant (HC), and Nurse Consultant (NC), were verbally notified of an immediate jeopardy (IJ) situation, on (MONTH) 5, 2019, at 11:41 a.m. This was determined due to potentially hazardous foods being served after being stored outside the safe temperatures. The written removal plan for the IJ was accepted on (MONTH) 5, 2019, at 4:05 p.m. The IJ was removed in the presence of the ADM at the facility on (MONTH) 7, 2019, at 7:46 p.m., after the facility's removal plan of action to remove the IJ was verified to have been implemented. Findings: On (MONTH) 5, 2019, at 9:05 a.m., an initial kitchen tour was conducted with the Dietary Supervisor (DS). The walk-in refrigerator was inspected and observed. The refrigerator thermometer reading was at 46 degrees Fahrenheit (F). The walk-in freezer was inside the walk-in refrigerator. The following food items were found inside the walk-in refrigerator: - One unopened two-gallon milk; - One 64 ounces (oz) opened carton of liquid creamer; - One 64 oz opened lactose free milk labeled with the date (MONTH) 4, 2019; - Multiple unopened four oz carton of milk (about 300 cartons); - Four plates of tuna sandwiches labeled with the date (MONTH) 2, 2019 - Three fruit plates with cottage cheese labeled with the date (MONTH) 2, 2019; - Two plates of egg sandwich labeled with the date (MONTH) 2, 2019; - Two cartons of two pounds (lbs) liquid eggs (one labeled as opened on (MONTH) 4, 2019); - 12 unopened cartons of two lbs liquid eggs; - An opened box of shelled eggs with two trays of 30 eggs each tray; and - An unopened box of shelled eggs with six trays of 30 eggs each tray. In a concurrent interview, the DS stated the walk-in refrigerator temperature was checked by the cook on (MONTH) 5, 2019, at around 5 a.m., and was at 48 degrees F. The DS stated the temperature of the refrigerator should be at 41 degrees F or below. The DS stated the walk-in refrigerator temperature had been above 41 degrees F since (MONTH) 3, 2019. The DS stated she was notified by dietary staff on the morning of (MONTH) 3, 2019, about the refrigerator temperature issue. The DS stated she notified the Maintenance Supervisor (MS) and ADM of the refrigerator not maintaining appropriate temperatures on (MONTH) 3, 2019. On (MONTH) 5, 2019, at 9:29 a.m., Cook 1 was interviewed. Cook 1 stated she was the staff member that checked the refrigerator temperature of the walk-in refrigerator on (MONTH) 3, 2019, at around 5 a.m. She stated she checked the refrigerator temperature before dietary staff starts taking food items out from the refrigerator (first thing in the morning). Cook 1 stated the temperature was at 45 degrees F. She stated the DS was notified on (MONTH) 3, 2019, at around 6 a.m. about the refrigerator being out of acceptable temperature range. Cook 1 stated she was instructed by the DS on (MONTH) 3, 2019, to open the walk-in freezer in order to keep the walk-in refrigerator temperature at 41 degrees F or below. Cook 1 stated there was no way of knowing how long the refrigerator temperature had been above 41 degrees F since dietary staff does not come in until 5 a.m. Cook 1 stated she worked the first shift on (MONTH) 4 and 5, 2019. She checked the walk-in refrigerator temperature at around 5 a.m., and the temperature was 45 degrees F on (MONTH) 4, 2019; and on (MONTH) 5, 2019, the temperature was at 48 degrees F. Cook 1 stated the walk-in refrigerator temperature should have been under 40 degrees F. Cook 1 stated the food items found in the refrigerator on (MONTH) 5, 2019, (initial kitchen inspections) had been in the refrigerator since (MONTH) 3, 2019. On (MONTH) 5, 2019, at 9:33 a.m., a concurrent interview and record review with the DS was conducted. The DS stated the MS informed her that he defrosted the walk-in refrigerator unit by disconnecting the unit's compressor on (MONTH) 3, 2019. The DS stated she got instructions from the MS to leave the walk-in freezer door open for about two hours to keep the refrigerator cool, and then to close the walk-in freezer door to avoid the frozen foods to melt. The dietary staff was instructed to continuously do this process, until the refrigerator temperature was serviced. The DS was unable to provide documented evidence indicating monitoring of ensuring the food items did not have temperature above 41 degrees Fahrenheit from (MONTH) 3 to 5, 2019. The facility document titled, Refrigerator/Freezer Temperature Log, for (MONTH) 2019, was reviewed with the DS. The log indicated refrigerator temperature should be within 34 to 41 degrees F. The DS stated the walk-in refrigerator temperature was checked by the cook daily at 5 a.m. and 8 p.m. The document indicated the following temperatures of the walk-in refrigerator: - 45 degrees F on (MONTH) 3, 2019, at 5 a.m. and 8 p.m.; - 46 degrees F on (MONTH) 4,2019, at 5 a.m. and 50 degrees F at 8 p.m.; and - 48 degrees F on (MONTH) 5, 2019, at 5 a.m. In a concurrent interview with the DS, she stated the walk-in refrigerator temperature was not maintained at 41 degrees F or below since (MONTH) 3, 2019. The DS further stated the food items in the walk-in refrigerator were compromised and should have been transferred to a working refrigerator or discarded. The DS stated they did not have other refrigerators in the facility to store the food items. On (MONTH) 5, 2019, at 10:02 a.m., the MS was interviewed. The MS stated he was notified by the DS on (MONTH) 3, 2019, at around 6 a.m., that the walk-in refrigerator was not maintaining the temperature of 41 degrees F or below. The MS stated he came to the facility on (MONTH) 3, 2019, after 6 p.m., and defrosted the unit. The DS stated he contacted the refrigerator technician on (MONTH) 3, 2019, and the technician was not able to come to the facility on (MONTH) 3 or 4, 2019. The MS stated he did not come to the facility on (MONTH) 4, 2019 to check on the refrigerator. The MS stated he connected the unit of the walk-in refrigerator on (MONTH) 5, 2019, at around 10 a.m. The MS stated he was still waiting for the technician to check the walk-in refrigerator. On (MONTH) 5, 2019, at 10:28 a.m., random food items' temperature (currently stored in the refrigerator) were checked with the DS: - One 4-oz carton milk (temperature was 52.6 degrees F); - The lactose free milk (temperature was 46.2 degrees F); and - One tuna sandwich (temperature was 44.6 degrees F). In a concurrent interview with the DS, she stated the food items in the refrigerator were there since (MONTH) 3, 2019, and were not removed from the refrigerator. The DS stated the food items were exposed to unsafe storage temperature since (MONTH) 3, 2019. She stated the facility used the food items in the walk-in refrigerator from (MONTH) 3 to (MONTH) 5, 2019. The stated the food items should have been discarded and not served to residents. On (MONTH) 5, 2019, at 4:29 p.m., the Nutrition Consultant (NC) was interviewed. The NC stated he was notified by the DS that the walk-in refrigerator was not maintaining a safe temperature of 41 degrees F or below on (MONTH) 5, 2019, at around 10 a.m. He stated the walk-in refrigerator should have had a temperature of 41 degrees F or below. The NC stated the food items in the walk-in refrigerator should have been transferred to a working refrigerator or discarded four hours after the walk-in refrigerator stopped working properly. In review of the Food Code (YEAR), .Frozen TIME/TEMPERATURE CONTROL FOR SAFETY FOOD .shall be held .Under refrigeration that maintains the FOOD temperature at 5 C (degrees Celsius) (41 F) or less . .Holding Cold Food Without Temperature Control It is important to note that time/temperature control for safety foods held without cold holding temperature control for a period of 4 hours do not have any temperature control or monitoring. These foods can reach any temperature when held at ambient air temperatures as long as they are discarded or consumed within the four hours . The facility policy and procedure titled, Policy and Procedure .Freezer and Refrigerator Temperatures, revised (MONTH) 1, (YEAR), was reviewed. The policy indicated, .A potential cause of food borne illness is improper storage of TCS/PHF (Time/Temperature Control for Safety/Potentially Hazardous Food) food. The refrigerator must be in good repair and keep foods at or below 41 degrees F .All time/temperature control (TCS/PHF) refrigerated foods shall be held at or below 41 degrees F . The facility policy and procedure titled, Policy and Procedure .Freezer/Refrigeration Outage, revised (MONTH) 1, (YEAR), was reviewed. The policy indicated, .Policy: To serve safe foods .In the event of a freezer and/or refrigerator outage - foods will be transferred to a working unit .The facility has a 4-hour time frame when the unit is determined to be non-working, in which to transfer foods . Due to these failures, the Administrator (ADM), Head Consultant (HC), and Nurse Consultant (NC), were verbally notified of an IJ situation, on (MONTH) 5, 2019, at 11:41 a.m. This was determined due to potentially hazardous foods being served after being stored outside safe temperatures. The facility submitted a written removal plan to correct the IJ situation and was accepted on (MONTH) 5, 2019, at 4:05 p.m. The removal plan included the following: - All potentially hazardous food that were outside the safe temperature in the walk-in refrigerator were thrown out on (MONTH) 5, 2019 (after the facility had been notified of the IJ); - All residents on oral diet were monitored for signs and symptoms of gastrointestinal (GI) distress for 72 hours and to notify the physician when GI symptoms occur; - All dietary department staff were educated by the ADM on the policy and procedure for freezer and refrigerator temperatures and freezer/refrigerator outages on (MONTH) 5, 2019; - All staff were in-serviced by the Director of Nursing on the signs and symptoms of GI distress by (MONTH) 7, 2019; and - The DS, MS, and ADM received disciplinary action for failure to follow protocol. The IJ was removed in the presence of the ADM at the facility on (MONTH) 7, 2019, at 7:46 p.m., after the facility's removal plan of action for the IJ was reviewed and was verified to have been implemented.

Based on observation, interview, and record review, the facility failed to ensure the needed care and treatment were provided for two of 24 residents (Residents 48 and 45), when: 1. For Resident 48, the itchiness and rashes on the arms, back, and legs were not provided treatment that relieved and/or improved the resident's skin condition. In addition, the dermatology (branch of medicine concerned with the [DIAGNOSES REDACTED]. These failures resulted for Resident 48 to experience continuous itchiness and rash in the arms, back, and legs, causing for the resident to sustain multiple open [MEDICAL CONDITION] and scabs on the body from scratching; and 2. For Resident 45, the physician's orders [REDACTED]. This failure increased the risk for heart complications which could negatively impact the resident's health condition. Findings: 1. On (MONTH) 6, 2019, at 11:05 a.m., Resident 48 was observed sitting in the wheelchair. Resident 48 have long nails on both hands, with the fourth and fifth fingernails appearing to be hypertrophied (thick). Resident 48's palms on both hands were dry and scaly. In addition, Resident 48 have multiple small open skin areas with scabs on both of her arms and face, and multiple pink raised rashes on both arms. In a concurrent interview, Resident 48 stated her hands and arms were itchy. Resident 48 stated she had been applying cream on her arms and hands and the itchiness was not improving. Resident 48 was observed to be scratching her arms with her fingernails and rubbing her legs together throughout the conversation. On (MONTH) 7, 2019, at 9:13 a.m., Resident 48 was observed rubbing her legs together and scratching her arms. Resident 48's fingernails on both hands were observed to be long (about more than half centimeter (cm)), jagged, and had dark matter under the nails. In a concurrent interview, Resident 48 stated her arms and legs had been itching for months. Resident 48 stated she felt there were bugs biting her. She stated they were putting cream before. Resident 48 stated she thought the rashes had gotten worst. On (MONTH) 7, 2019, at 12:03 p.m., Resident 48 was observed in the dining room, scratching her right arm with her left hand. On (MONTH) 7, 2019, at 3:49 p.m., Resident 48 was observed in the dining room, sitting in the wheelchair and rubbing her legs together. In a concurrent interview, Resident 48 stated, It's itchy. On (MONTH) 7, 2019, Resident 48's record was reviewed. Resident 48 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The facility document titled, .Admission Nursing Evaluation, dated (MONTH) 10, (YEAR), indicated Resident 48 did not have skin problems on admission. A review of Resident 48's Minimum Data Set (MDS- an assessment tool) dated (MONTH) 10, 2019, indicated the resident's Brief Interview for Mental Status (BIMS-assessment tool for cognition status) score was five (0-7 means severe impairment). The facility document titled, BEHAVIOR/SIDE EFFECTS MONITORING, for the months of (MONTH) 2019 to (MONTH) 2019, was reviewed. The document indicated Resident 48 was monitored for behavior of scratching herself every shift with the following episodes: - (MONTH) 21, 2019 to (MONTH) 31, 2019 (4 episodes); - (MONTH) 2019 (33 episodes); - (MONTH) 2019 (26 episodes); - (MONTH) 2019 (26 episodes); - (MONTH) 2019 (28 episodes); - (MONTH) 2019 (43 episodes); and - (MONTH) 2019 (38 episodes). The physician's Progress Notes, dated (MONTH) 2, 2019 and (MONTH) 1, 2019, for Resident 48, indicated, .Scattered [DIAGNOSES REDACTED]tous (redness) [MEDICAL CONDITION] to the left cheek, abdomen, and BLE (both lower extremities), and bilateral wrists . The Treatment Administration Record, for the month of (MONTH) 2019, indicated Resident 48's itchiness on the back and arms were treated with [MEDICATION NAME] (a topical drug used the relief of itching and inflammation associated with a wide variety of skin conditions) cream three times a day from (MONTH) 3 to (MONTH) 15, 2019. There was no documented evidence Resident 48 had any other skin treatment after (MONTH) 15, 2019. The care plan titled, PURITUS (sic; should read pruritus - severe itching of the skin), CHRONIC RASH, dated (MONTH) 2, 2019, indicated, .@ (At) Risk for altered skin integrity R/T (related to) puritus (sic) .Keep nails trim/clean .encourage not to scratch .monitor for altered skin integrity & notify MD (physician)/RP (responsible party) . The physician's Progress Notes, dated (MONTH) 2, 2019, indicated, .Diffused rash .Patient's digits and toes are extremely dry and cracked with multiple dry fissures (crack or split) . The document indicated the physician recommended to obtain dermatology (specialty that deals with the skin, nails, hair and its diseases) consult. The Physician's Telephone Order, dated (MONTH) 3, 2019, indicated, .Dermatology consult for fingers & toes. The care plan titled, RISK FOR SKIN BREAKDOWN, dated (MONTH) 3, 2019, indicated, .At risk for skin breakdown r/t . ASE (adverse side effects) to meds (medications) .Derma (dermatology) consult as ordered . The physician's Progress Notes, dated (MONTH) 10, 2019, indicated Resident 48 had [DIAGNOSES REDACTED].Diffuse papular (raised) rash . The Order Summary Report, dated (MONTH) 10, 2019, indicated, .Urgent Dermatology Consult for Fingers and Toes and diffuse rash . The facility document titled, SHOWER DAY SKIN INSPECTION, dated (MONTH) 8, 2019 to (MONTH) 3, 2019, was reviewed. The document indicated Resident 48 had generalized red raised rashes (skin reaction or eruption that occurs throughout the body). On (MONTH) 7, 2019, at 4:04 p.m., a concurrent interview and record review was conducted with Treatment Nurse (TN) 1. TN 1 stated Resident 48 complained of itching and had observed Resident 48 to be scratching her arms since last month. TN 1 stated there was currently no treatment being applied to Resident 48's rashes. TN 1 stated there was no documentation of a reassessment of Resident 48's generalized rash after the treatment order was completed on (MONTH) 15, 2019, to re-evaluate whether the treatment needed to be continued or changed. On (MONTH) 7, 2019, at 4:32 p.m., Resident 48 was observed with TN 1. Resident 48 was observed sitting in the wheelchair and scratching her arms. Resident 48 was transferred to bed and was talking fast about her itching and rashes. Resident 48 was observed rubbing her back against the bed repeatedly. In a concurrent interview with Resident 48, she stated she cannot sleep at night because of the itching and felt like something was inside her skin. Resident 48 was observed to be teary eyed as she was saying she had been itching for a long time and nothing was being done. Concurrently, TN 1 was observed to check Resident 48's skin. TN 1 stated Resident 48 had multiple scattered open [MEDICAL CONDITION] with scabs on both arms. TN 1 stated Resident 48 had raised rashes on both arms, back, and lower extremities. On (MONTH) 7, 2019, at 5:20 p.m., Case Manager (CM) 1 was interviewed. She stated she was not aware of the dermatology consult ordered on (MONTH) 3, 2019. CM 1 stated Resident 48 had an order for [REDACTED]. CM 1 stated she followed up with the doctor's office on (MONTH) 1, 2019 (21 days from the order for an urgent dermatology consult on (MONTH) 10, 2019 and 59 days after the initial order for a dermatology consult on (MONTH) 3, 2019) about the referral for dermatology consult for Resident 48. CM 1 stated she expected the urgent referral for dermatology consult to be processed within at least four days to two weeks. CM 1 further stated the dermatology consult referral should have been followed up in a timely manner. On (MONTH) 8, 2019, at 9:53 a.m., Resident 48's Responsible Party (RP) was interviewed. Resident 48's RP stated Resident 48 had the itchiness and rashes in her body since last year. The RP stated the family had tried different bath soaps and lotion, but were not effective. On (MONTH) 12, 2019, at 4:41 p.m., a policy was requested from the Infection Preventionist (IP) and stated the facility did not have a specific policy on non-pressure or rashes management. The IP provided a policy on pressure sore/skin breakdown. The facility policy and procedure titled, Referrals, Social Services, revised (MONTH) 2008, was reviewed. The policy indicated, .Social services personnel shall coordinate most resident referrals with outside agencies .Referrals for medical services must be based on physician evaluation of resident need and a related physician order [REDACTED]. 2. On (MONTH) 7, 2019, at 8:22 a.m., Licensed Vocational Nurse (LVN) 4 was observed during medication administration for Resident 45. LVN 4 took Resident 45's blood pressure prior to administering the routine medications, with Resident 4 blood pressure reading was 128/80 mmHg (millimeters of mercury). LVN 4 administered medications that included [MEDICATION NAME] 10 mg (milligrams) one tablet. On (MONTH) 7, 2019, at 10:13 a.m., Resident 45's record was reviewed. Resident 45 was admitted on (MONTH) 3, 2019, with [DIAGNOSES REDACTED]. Resident 45's physician's orders [REDACTED]. During an interview with LVN 4 on (MONTH) 7, 2019, at 10:50 a.m., LVN 4 stated she gave the [MEDICATION NAME] thinking the medication would lower the resident's blood pressure. The LVN stated I should have held it. The order says to hold it if SBP is greater than 100. Resident 45's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Hold for SBP greater than 100. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. According to the Centers for Diseases Control and Prevention (CDC), a blood pressure less than 120/80 mmHg is normal. People with levels from 120/80 mmHg to 139/89 mmHg have a condition called prehypertension, which means they are at high risk for high blood pressure. A blood pressure of 140/90 mmHg or more is too high. On (MONTH) 7, 2019, at 10:25 a.m., Resident 45's record was reviewed with the Assistant Director of Nursing (ADON). The ADON stated the [MEDICATION NAME] order indicated to hold the medication if SBP was greater than 100 mmHg. The ADON stated the [MEDICATION NAME] should have not been given to the resident when her SBPs were greater than 100 mmHg for the months of (MONTH) and (MONTH) 2019. The facility policy and procedure titled, Administering Medications, revised (MONTH) 2012, was reviewed. The policy indicated, .Medications must be administered in accordance with the orders .

Based on clinical record review and interview, the facility failed to ensure that: 1) Insulin was correctly administered to 10 residents (Sampled Residents 3, 11, 13 and Unsampled Residents C, D, E, G, J, K and Q) of 88 total residents as ordered by the resident's physician. These failures placed all 10 resident's at risk for extreme blood sugar flucuations potentially causing serious medical complications [REDACTED]. 2) Omeprazole (Prilosec - a medication used to reduce stomach acid) and clopidogrel (Plavix - a medication used to prevent blood clotting), which have a significant drug interaction that can increase the risk for stroke and heart attack, were not administered concurrently to the facility's residents (Unsampled Residents M and N). 3) The facility failed to implement its own policies and procedures for notifying the resident's physician for insulin being held for 1 resident (Sampled Resident 13) of 88 residents which could increase the risk for prolonged elevated blood sugar levels. 4) The facility failed to administer blood pressure medications as ordered by the resident's physician for five Residents (Unsampled Residents D, I, S, C, O). These failures placed all five resident's at risk for extreme blood pressure and pulse flucuations potentially causing serious medical complications [REDACTED]. 5) Fentanyl patch was not stored in the emergency medication supply available for immediate patient use in a universe of 88 Residents, which could cause decreased respiratory rate in residents that could lead to death. 6) A Sinemet (carbidopa/levodopa - a medication used for Parkinson's disease which causes rigidity of the muscles) was correctly carried over from October 2014 to July 2015 on the Medication Administration Record [REDACTED]. 7) A Novolog (insulin medication used to reduce blood sugar levels) was not replaced by Humalog (insulin medication used to reduce blood sugar levels) without an order by the physician for Unsampled Resident J which potentially caused the resident to have blood sugar levels fluctuate. As a result, the residents of the facility were placed at high risk for harm as a result of these medication errors. An Immediate Jeopardy situation was called on July 24, 2015, at 11:25 AM in the presence of the facility's Administrator who was verbally notified of the Immediate Jeopardy situation. Specific details of the Immediate Jeopardy situation were provided to the Administrator, including specific residents, and the Administrator had all questions answered at the time of presentation. On July 24, 2015, the facility provided an action plan that was approved by the survey team with the following elements: 1) Identification of potentially affected residents 2) Changing from electronic medication administration records to physical paper records 3) Education all licensed nursing staff 4) Replacing the current pharmacy consultant with a new one 5) Instituting daily audits of the medication administration records The Immediate Jeopardy was removed on July 24, 2015 at 5:17 PM, in the presence of the Administrator, after the following was observed, reviewed, and confirmed via interview: 1) Education observation and confirmed via interview: inservicing to all available licensed nursing personnel regarding administration and documentation of insulin and cardiovascular medications that require parameters to be checked and proper documentation of those medications on the medication administration record. All licensed nursing staff not present were scheduled to be presented the material at their return to the facility. 2) Observed nursing personnel implementing dual verification policy of medication administration for medications that required parameter monitoring. 3) Observed new pharmacist consultant communication and confirmed via interview with the Administrator. 4) Observed and reviewed new process for physical paper medication administration records. 5) Confirmed via interview that daily audits of medication administration records would be performed by administrative staff and medical records staff. Findings: 1. Physician orders [REDACTED]. a. During a review of the clinical record for Resident 3, the record indicated that Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review indicated a physician's orders [REDACTED]. The order indicated the following: Novolog 100 U/ML (units per milliliter) as per sliding scale at AC (before meals) and HS (bedtime) as follows: 150-200 (blood sugar level) = 2 units, 201-250 (blood sugar level) = 4 units, 251-300 (blood sugar level) = 6 units, 301-350 (blood sugar level) = 8 units, 351(blood sugar level) and above call MD (medical doctor). During further review of the clinical record for Resident 3, the Medication Administration Record [REDACTED] i. On May 2, 2015 at 11:30 AM, the resident's blood sugar was 348, and four units of Novolog insulin (a quick acting form of insulin) was administered. For a blood sugar of 348 the resident was to receive eight units of Novolog insulin. ii. On May 3, 2015 at 11:30 AM the blood sugar was 434. It was indicated that 8 units of Novolog insulin was administered. An order to administer insulin for a blood sugar level 351 or above was not in place. iii. During a further review of the clinical record for Resident 3, a nursing progress note written by LVN 4 documented the following, May 3, 2015 at 12:58 PM, Gave 8 units of Regular insulin, MD notified. No new orders received at this time . There was no documented evidence that a physician's orders [REDACTED]. iv. An interview was conducted with LVN 4 on July 24, 2015 at 12:25 PM. When asked about the insulin administered without a physician's orders [REDACTED]. v. On May 5, 2015 at 11:30 AM the blood sugar was 408 and eight units of Novolog insulin was administered. An order to administer insulin for a blood sugar level 351 or above was not in place. vi. During a further review of the clinical record for Resident 3, a nursing progress note written by LVN following, May 5, 2015 at 12:30 PM,.Administered Novolog 8 units per sliding.MD notified. There was no documented evidence that a physician's orders [REDACTED]. vii. On June 1, 2015 at 11:30 AM the blood sugar was 256 and four units of Novolog insulin was administered. For a blood sugar of 256 the resident should have received six units of Novolog insulin. viii. On June 15, 2015 at 9:00 PM, the blood sugar was 202 and two units of Novolog insulin was administered. For a blood sugar of 202 the resident should have received four units of Novolog insulin. ix. On June 18, 2015 at 11:30 AM, the blood sugar was 266 and four units of Novolog insulin was administered. For a blood sugar of 266 the resident should have received six units of Novolog insulin. x. On July 6, 2015 at 9:00 PM, the blood sugar was 328 and seven units of Novolog insulin was administered. For a blood sugar of 328 the resident should have received eight units of Novolog insulin. An interview was conducted with LVN 4 on July 24, 2015 at 12:25 PM. When asked about the discrepancies between the Novolog sliding scale physician order [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. b. During a review of the clinical record for Resident Q, the record indicated that Resident Q was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review indicated a physician's orders [REDACTED]. The order indicated the following: Levemir 100 U/mL (Units per milliliter).74 Units Subcutaneous (under the skin) BED TIME. Increase Levemir by 2 units QHS (bedtime) until FBS (fasting blood sugar) is 150. During further review of the clinical record for Resident Q, the Medication Administration Record [REDACTED]. The dose was subsequently increased by 2 units on May 20 (78 units documented as given) and May 21 (80 units documented as given). On May 22, 2015, only 4 units were documented as given. For May 23, 8 units were documented. On May 28, 10 units documented as given and May 29, 8 units documented as given. A review of the June MAR indicated [REDACTED]. A review of the July MAR indicated [REDACTED]. Additional review of the physician's orders [REDACTED].= 3 units, 220-269 = 5 units, 270-300 = 7 units, 301-360 = 9 units, 361-420 = 12 units, above 420 = 14 units and call MD was started on January 29, 2015. The following administration errors were noted for May 2015: i. 6:30 AM administrations: 10 units documented as given on May 1 for BS (blood sugar) 368 and 9 units on May 21 for BS 641. ii. 11:30 AM administrations: 10 units on May 1 for BS 399, 12 units on May 16 for BS 470, 12 units on May 20 for BS 428, 14 units on May 24 for BS 419, and 14 units on May 30 for BS 410. iii. 4:30 PM administrations: 8 units on May 1 for BS 344, 13 units on May 28 for BS 361. iv. Additionally, the following blood sugars were above 420 but there was no documentation on the MAR indicated [REDACTED]. In June 2015, the Novolog order was changed to Blood sugar fingerstick (a test using blood from the finger to determine blood sugar level in the blood) with Novolog 100 U/mL sol (solution) AC (before meals) TID (3 times daily) SQ (subcutaneous) per sliding scale as follows: 140-179 = 2 units, 180-219 = 3 units, 220-269 = 5 units, 270-300 = 7 units, 301-360 = 9 units, 361-420 = 12 units, above 420 = 14 units and call MD on June 5, 2015. The following administration errors were noted for June and July 2015: v. 8 units documented as given for BS 235 at 4:30 PM on June 15, 7 units for BS 162 at 6:30 AM on June 22, and 4 units for BS 274 at 6:30 AM on June 25. In addition, there was no documentation on the MAR indicated [REDACTED]. vi. 5 units for BS 208 at 6:30 AM on July 4, 14 units for BS 400 at 11:30 AM on July 5, and 7 units for BS 373 at 11:30 AM on July 6. In addition, there was no documentation on the MAR indicated [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. c. A review of the clinical record for sampled resident 13 on July 23, 2015, at 9:20 AM, revealed a sliding scale insulin order which had been written for this resident on March 1, 2015. The order read: Blood sugar finger sticks insulin QAC (before meals) and HS (bedtime) with Novolog insulin SQ (subcutaneously) per sliding scale: (with a blood sugar between) 140-179 (mg/dl, milligrams per deciliter) = 0 units (of insulin to be administered), 180-219 = 1 unit (of insulin to be given), 270-300 = 2 units, 301-360 = 2 units, 361-420= 3 units (of insulin), 420 = 3 units and call MD (Medical Doctor). i. Review of sampled resident 13's MAR for the month of March 2015 revealed that on March 11, 2015, at 9:00 PM, the resident had a blood sugar (BS) of 219 (mg/dl) and she received 0 units of insulin. The current physician's order [REDACTED]. ii. On March 14, 2015, at 11:30 AM, resident 13 had a blood sugar of 197 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. iii. On April 3, 2015, at 11:30 AM, resident 13 had a blood sugar of 198 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. iv. On April 29, 2015, at 11:30 AM, resident 13 had a blood sugar of 358 mg/dl, the nurse administered 3 units of insulin to the resident rather than the 2 units of insulin which had been ordered by this resident's physician. v. On May 10, 2015, at 11:30 AM, resident 13 had a blood sugar of 306 mg/dl, the nurse administered 1unit of insulin to the resident rather than the 2 units of insulin which had been ordered by this resident's physician. vi. On May 22, 2015, at 4:30 PM, resident 13 had a blood sugar of 197 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. vii. On July 12, 2015, at 9:00 PM, resident 13 had a blood sugar of 218 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. d. Review of the clinical record for unsampled resident E on July 24, 2015, at 9:40 AM, revealed a sliding scale insulin order had been written for this resident on July 22, 2015. The order read: Blood sugar finger sticks Novolog 100 units/milliliters (u/ml). DM per sliding scale before meals and at bedtime: (with a blood sugar between) 140-179 (mg/dl, milligrams per deciliter) = 0 units (of insulin to be administered), 180-219 mg/dl= 1 unit of insulin to be administered, 220-269 mg/dl = 1 unit of insulin, 270-300 mg/dl = 2 units of insulin, 301-360= 2 units of insulin, 361-420= 3 units of insulin, greater than 420 = 3 units and call MD. Review of unsampled resident E's MAR for the month of July 2015 revealed that on July 23, 2015, at 4:30 PM, the resident had a blood sugar (BS) of 337 (mg/dl) and she received 3 units of insulin. The current physician's order [REDACTED]. This resident had only been in the facility for 1 day and this was only her third dose of insulin which had been administered to her during her stay. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. e. Review of the clinical record for unsampled resident J on July 24, 2015, at 12:15 PM, revealed a sliding scale insulin order had been written for this resident on July 20, 2015. The order read: Blood sugar finger sticks Humalog 100 units/milliliters (u/ml). Subcutaneous before meals and at bedtime: (with a blood sugar between) 180-269 (mg/dl, milligrams per deciliter) = 1 units (of insulin to be administered), 270-360 mg/dl= 2 unit of insulin to be administered, 361-420 mg/dl = 3 unit of insulin, greater than 420 = 3 units and call MD. Review of unsampled resident J's MAR for the month of July 2015 revealed that on July 22, 2015, at 6:30 AM, the resident had a blood sugar (BS) of 232 (mg/dl) and she received 2 units of insulin. The current physician's orders [REDACTED]. This resident had only received three doses of insulin from this order before this medication administration error had been made. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. f. Review of the clinical record for unsampled resident K on July 24, 2015, at 12:00 PM, revealed a sliding scale insulin order had been written for this resident on July 8, 2015. The order read: Finger sticks with Humalog 100 units per milliliter Subcutaneously before meals and at bedtime sliding scale as follows: (with a blood sugar between) 121-150 (mg/dl, milligrams per deciliter) = 2 units (of insulin to be administered), 151-200 = 4 unit (of insulin to be given), 201-250 = 6 units, 251-300 = 8 units, 301-350= 10 units (of insulin), 351-400 = 12 units, and greater than 400 mg/dl = 14 units and call MD (Medical Doctor). i. Review of unsampled resident K's MAR for the month of July 2015 revealed that on July 11, 2015, at 6:30 AM, the resident had a blood sugar (BS) of 171 (mg/dl) and she received 2 units of insulin. The current physician's orders [REDACTED]. ii. On July 16, 2015, at 6:30 AM, resident K had a blood sugar of 160 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 4 unit of insulin which had been ordered by this resident's physician. iii. On July 21, 2015, at 9:00 PM, resident K had a blood sugar of 125 mg/dl, the nurse administered 1 units of insulin to the resident rather than the 2 unit of insulin which had been ordered by this resident's physician. iv. On July 22, 2015, at 11:30 AM, resident K had a blood sugar of 150 mg/dl, the nurse administered 4 units of insulin to the resident rather than the 2 units of insulin which had been ordered by this resident's physician. This resident had been admitted to the facility on [DATE]. This resident had four insulin administration errors during her 16 day stay in the facility. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. g. During a review of the clinical record for Unsampled Resident D, the record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record indicated physician orders [REDACTED].= 2 units (insulin to be administered), 251-300 = 4 units, 301-350 = 6 units, 351-400 = 8 units, greater than 400 give 8 units and notify MD (medical doctor), notify MD if less (blood sugar result) than 60. i. Further review of the clinical record indicated the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. h. During a review of the clinical record for Unsampled Resident G, the record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record indicated a physician order [REDACTED].= 2 units, 270-300 = 3 units, 301-360 = 4 units, 361-420= 5 units, greater than 420 give 7 units and call MD (medical doctor). Further review of the clinical record indicated the Medication Administration Record [REDACTED] i. On May 15, 2015 at 6:30AM, the resident's blood sugar was 200 and no Novolog Insulin (a quick acting form of insulin) was administered. The physician's orders [REDACTED]. ii. On June 21, 2015 at 9:00 PM, the resident's blood sugar was 269 and three units of Novolog insulin was administered. The physician's orders [REDACTED]. iii. On July 4, 2015, at 4:30 PM, the resident's blood sugar level was 250 and three units of Novolog insulin was administered. The physician's orders [REDACTED]. iv. On July 16, 2015 at 4:30 PM, the blood sugar was zero and three units of Novolog insulin was administered. The physician's orders [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. i. During a review of the clinical record for Resident 11, the record indicated that Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review indicated a physician's orders [REDACTED]. The order indicated the following: Lantus 10 Units Subcutaneous (under the skin) BED TIME.(Increase by 2 units nightly until fasting blood sugar below 150.) During further review of the clinical record for Resident 11, the Medication Administration Record [REDACTED] i. 22 Units of Lantus were documented as given from May 1, 2015 to May 19, 2015, May 22, 2015 to May 26, 2015, and May 29, 2015 to May 31, 2015. On May 20, 2015, May 21, 2015, and May 27, 2015, 10 Units of Lantus were documented as given. ii. 22 Units of Lantus were documented as given every day in June 2015 except for June 8, 2015, June 19, 2015, June 20, 2015, and June 26, 2015. On these dates, it was documented that 10 Units were given. iii. 22 Units of Lantus were documented as given every day in July 2015 except for July 11, 12, 14, 18, 19, 20, and 21, 2015. On these dates, it was documented that 10 Units were given. In an interview with LVN 4 on July 24, 2015 at 11:45 AM, she was asked why she documented 10 Units of Lantus as given on July 12, 2015 despite the dose increased to 22 Units according to physician order. She stated, That's what the order says here to give. She pointed to the order on the Medication Administration Record [REDACTED]. She confirmed that she should have given 22 Units instead. j. A review of the clinical record for unsampled Resident C, revealed unsampled Resident C was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. During a review of the clinical record for unsampled Resident C, the Physician order [REDACTED].=121-150=2U, 151-200=4U, 201-251=6U, 251-300=8U, 301-350=10U, 351-400=12U, BG>400=CALL MD Injection Every 6 Hours DX: DM. i. A review of the clinical record for unsampled Resident C, revealed the MAR (medication administration record) dated June 4, 2015 at 12:00 AM indicated blood glucose (blood sugar level) of 122 and 0 (zero) units of insulin (medication that lowers blood sugar levels) was given. During an interview with LVN 5 on July 24, 2015, at 10:00 AM, LVN 5 stated unsampled Resident C should have received 2 (two) units of Insulin for a blood sugar of 122 per the doctor's orders on June 4, 2015 at 12:00 AM. ii. A review of the clinical record for unsampled Resident C, revealed the MAR indicated [REDACTED]. During an interview with LVN 4 on July 24, 2015 at 10:30 AM, LVN 4 stated unsampled Resident C should have not received any insulin for a blood sugar of 120 according to the sliding scale (instructions for administering insulin based on blood sugar levels) on July 2, 2015 at 12:00 PM. LVN 4 stated I gave 2 (two) units according to the MAR, I think it was a type-o. LVN 4 further stated the documentation of 2 (two) units of insulin given was an error. LVN 4 stated, I know how to read a sliding scale. iii. A review of the clinical record for unsampled Resident C, revealed the MAR indicated [REDACTED]. During an interview with the DON on July 24, 2015 at 2:52 PM, the DON stated unsampled Resident C should have received 2 (two) units of insulin for blood glucose of 130 per the insulin sliding scale on July 21, 2015 at 6:00 PM. iv. A review of the clinical record for unsampled Resident C, revealed the MAR indicated [REDACTED]. During an interview with LVN 7 on July 24, 2015 at 2:57 PM, LVN 7 stated she did not administered insulin for a blood glucose of 124 to unsample Resident C on July 23, 2015 at 6:00 PM. LVN 7 stated per the insulin sliding scale she should have administered 2 (two) units of insulin. When asked why she did not follow the doctor's orders, LVN 7 stated, I remember I did give the resident 2 (two) units of insulin. LVN 7 further stated, there was no documented evidence that she administered 2 (two) units of insulin on July 23, 2015 at 6:00 PM. The facilities Policy and Procedure titled, Medication administration, revised April 16, 2012 indicated: Purpose: These policies and procedures are established to ensure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner .Policy: 3. IMPLIMENTATION (NOTING)-The nurse who receives the prescriber's order shall be responsible for its complete implementation. This includes proper transcribing, ordering of medications, and all other steps involved in carrying out the order. According to the American Diabetes Association (a respected organization that provides information to people diagnosed with [REDACTED]. In addition, the American Diabetes Association indicates that giving too much insulin can cause [DIAGNOSES REDACTED] (abnormally low blood sugar), which can lead to confusion, delirium, rapid/fast heartbeat, dizziness, nausea, blurred/impaired vision, weakness, fatigue, seizures, unconsciousness, coma, and even death. 2. Clinical record review on July 22, 2015, at 3:55 PM, for unsampled resident N, revealed that this resident had been receiving Plavix (Clopidogrel) 75mg once a day by mouth for Cerebrovascular Disease along with Omeprazole (Prilosec) 40mg for Esophageal Reflux (GERD) daily at breakfast. Both of these medications had been prescribed to the resident since 1/29/15. A review of the clinical record for unsample resident M revealed that they were also receiving Plavix 75mg once daily for cerebrovascular disease and omeprazole 20mg once daily for GERD. Both of resident M's medications had been prescribed since May 3, 2012. A review of the facility's drug reference on July 22, 2015, at 3:40 PM, revealed that Omeprazole and Plavix should not be administered concurrently. The facility's: Nursing 2012 Drug Handbook, stated under Omeprazole: Avoid use together. The combination of these two drugs being used concomitantly decreases the antiplatelet effect of the Plavix, which in turn reduces the resident's protection against stroke and heart attacks. This significant drug interaction placed Residents M & N, who had Cerebrovascular Disease (which includes stroke) at risk for a future reoccurrence. The drug interaction is so serious that the manufacturer of the drug Plavix and the Food & Drug Administration (FDA - a federal organization that regulates food and drugs for United States citizens) have issued a Black Box Warning (one of the most severe safety alerts issued by the FDA), in regards to certain metabolites (chemical compounds created when a drug goes through the human body) of Plavix being affected, (this includes

Based on clinical record review and interview, the facility failed to ensure that: 1) [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION] and to slow the heart rate in patients with [MEDICAL CONDITION] - a condition in which the heart beat rhythm is abnormal) was correctly administered according to the physician's orders [REDACTED]. Toxic levels of [MEDICATION NAME] can lead to increased falls and/or fatal arrhythmias (abnormal heart rhythms). 2) Insulin was correctly administered to 10 residents (Sampled Residents 3, 11, 13 and Unsampled Residents C, D, E, G, J, K and Q) of 88 total residents as ordered by the resident's physician. These failures placed all 10 resident's at risk for extreme blood sugar flucuations potentially causing serious medical complications [REDACTED]. 3) The facility failed to administer blood pressure medications as ordered by the resident's physician for five Residents (Unsampled Residents D, I, S, C, O). These failures placed all five resident's at risk for extreme blood pressure and pulse fluctuations potentially causing serious medical complications [REDACTED]. As a result, the residents of the facility were placed at high risk for harm as a result of these significant medication errors. An Immediate Jeopardy situation was called on July 24, 2015, at 11:25 AM in the presence of the facility's Administrator who was verbally notified of the Immediate Jeopardy situation. Specific details of the Immediate Jeopardy situation were provided to the Administrator, including specific residents, and the Administrator had all questions answered at the time of presentation. On July 24, 2015, the facility provided an action plan that was approved by the survey team with the following elements: 1) Identification of potentially affected residents 2) Changing from electronic medication administration records to physical paper records 3) Education all licensed nursing staff 4) Replacing the current pharmacy consultant with a new one 5) Instituting daily audits of the medication administration records In the presence of the Administrator, the Immediate Jeopardy was removed on July 24, 2015 at 5:17 PM, after the following was observed, reviewed, and confirmed via interview: 1) Education observation and confirmed via interview: in servicing to all available licensed nursing personnel regarding administration and documentation of insulin and cardiovascular medications that require parameters to be checked and proper documentation of those medications on the medication administration record. All licensed nursing staff not present was scheduled to be presented the material at their return to the facility. 2) Observed nursing personnel implementing dual verification policy of medication administration for medications that required parameter monitoring. 3) Observed new pharmacist consultant communication and confirmed via interview with the Administrator. 4) Observed and reviewed new process for physical paper medication administration records. 5) Confirmed via interview that daily audits of medication administration records would be performed by administrative staff and medical records staff. Findings: 1) During a review of the clinical record for Resident S, the record indicated that Resident S was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A clinical record review on July 20, 2015, revealed a physician's orders [REDACTED]. The order indicated the following: [MEDICATION NAME] 0.25mg (milligram) tab by mouth every day.hold for apical pulse (monitoring of the heart beat) of less than 60 BPM (beats per minute). During further review of the clinical record for Resident S, the Medication Administration Record [REDACTED] a. During May 2015, [MEDICATION NAME] was documented as given, instead of being held according to physician's orders [REDACTED]. b. During June 2015, [MEDICATION NAME] was documented as given, instead of being held according to physician's orders [REDACTED]. c. During July 2015, [MEDICATION NAME] was documented as given, instead of being held according to physician's orders [REDACTED]. A review of the facility's drug reference, Nursing 2012 Drug Handbook, indicated under Toxicity and Overdose: . Geri: (geriatric) Older adults are at increased risk for toxic efects of [MEDICATION NAME] due to age-related decreased renal (kidney) clearance, which can exist even when serum creatinine (SCr - a protein used to measure kidney function) levels are normal. [MEDICATION NAME] requirements in the older adult may change and a formerly therapeutic dose can become toxic. A review of the Resident's clinical record, under the laboratory results section, revealed that no [MEDICATION NAME] levels were done on or after the resident was admitted [DATE]. During a interview with the Director of Health Information Systems on July 23, 2015, at 11:00 AM, she confirmed that no [MEDICATION NAME] levels were listed as done in the resident's electronic health record. Further review of the laboratory section indicated that the resident had serum creatinine (SCr) levels done multiple times since December 2014 admission. The following results were noted: January 19, 2015 = 1.4mg/dL (milligrams/deciLiter) February 13, 2015 = 1.6 April 3, 2015 = 1.8 June 1, 2015 = 1.9 June 8, 2015 = 2.3 June 15, 2015 = 2.1 June 17, 2015 = 2.1 June 19, 2015 = 2.2 June 22, 2015 = 2.0 July 9, 2015 = 2.4 The normal level for reference, provided by the facility's laboratory that performed the testing, indicates the normal level is 0.6 - 1.1 mg/dL. Every serum creatinine result since admission was higher than the normal level indicating the resident had some degree of chronic renal dysfunction. [MEDICATION NAME] is cleared from the human body by the kidneys and chronic renal dysfunction can lead to [MEDICATION NAME] toxicity. 2. Physician orders [REDACTED]. a. During a review of the clinical record for Resident 3, the record indicated that Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review indicated a physician's orders [REDACTED]. The order indicated the following: [MEDICATION NAME] 100 U/ML (units per milliliter) as per sliding scale at AC (before meals) and HS (bedtime) as follows: 150-200 (blood sugar level) = 2 units, 201-250 (blood sugar level) = 4 units, 251-300 (blood sugar level) = 6 units, 301-350 (blood sugar level) = 8 units, 351(blood sugar level) and above call MD (medical doctor). During further review of the clinical record for Resident 3, the Medication Administration Record [REDACTED] i. On May 2, 2015 at 11:30 AM, the resident's blood sugar was 348, and four units of [MEDICATION NAME](a quick acting form of insulin) was administered. For a blood sugar of 348 the resident was to receive eight units of [MEDICATION NAME] insulin. ii. On May 3, 2015 at 11:30 AM the blood sugar was 434. It was indicated that 8 units of [MEDICATION NAME]was administered. An order to administer insulin for a blood sugar level 351 or above was not in place. iii. During a further review of the clinical record for Resident 3, a nursing progress note written by LVN 4 documented the following, May 3, 2015 at 12:58 PM, Gave 8 units of Regular insulin, MD notified. No new orders received at this time . There was no documented evidence that a physician's orders [REDACTED]. iv. An interview was conducted with LVN 4 on July 24, 2015 at 12:25 PM. When asked about the insulin administered without a physician's orders [REDACTED]. v. On May 5, 2015 at 11:30 AM the blood sugar was 408 and eight units of [MEDICATION NAME]was administered. An order to administer insulin for a blood sugar level 351 or above was not in place. vi. During a further review of the clinical record for Resident 3, a nursing progress note written by LVN following, May 5, 2015 at 12:30 PM,.Administered [MEDICATION NAME] 8 units per sliding.MD notified. There was no documented evidence that a physician's orders [REDACTED]. vii. On June 1, 2015 at 11:30 AM the blood sugar was 256 and four units of [MEDICATION NAME]was administered. For a blood sugar of 256 the resident should have received six units of [MEDICATION NAME] insulin. viii. On June 15, 2015 at 9:00 PM, the blood sugar was 202 and two units of [MEDICATION NAME]was administered. For a blood sugar of 202 the resident should have received four units of [MEDICATION NAME] insulin. ix. On June 18, 2015 at 11:30 AM, the blood sugar was 266 and four units of [MEDICATION NAME]was administered. For a blood sugar of 266 the resident should have received six units of [MEDICATION NAME] insulin. x. On July 6, 2015 at 9:00 PM, the blood sugar was 328 and seven units of [MEDICATION NAME]was administered. For a blood sugar of 328 the resident should have received eight units of [MEDICATION NAME] insulin. An interview was conducted with LVN 4 on July 24, 2015 at 12:25 PM. When asked about the discrepancies between the [MEDICATION NAME] sliding scale physician order [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. b. During a review of the clinical record for Resident Q, the record indicated that Resident Q was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review indicated a physician's orders [REDACTED]. The order indicated the following: [MEDICATION NAME] 100 U/mL (Units per milliliter).74 Units Subcutaneous (under the skin) BED TIME. Increase [MEDICATION NAME] by 2 units QHS (bedtime) until FBS (fasting blood sugar) is 150. During further review of the clinical record for Resident Q, the Medication Administration Record [REDACTED]. The dose was subsequently increased by 2 units on May 20 (78 units documented as given) and May 21 (80 units documented as given). On May 22, 2015, only 4 units were documented as given. For May 23, 8 units were documented. On May 28, 10 units documented as given and May 29, 8 units documented as given. A review of the June MAR indicated [REDACTED]. A review of the July MAR indicated [REDACTED]. Additional review of the physician's orders [REDACTED].= 3 units, 220-269 = 5 units, 270-300 = 7 units, 301-360 = 9 units, 361-420 = 12 units, above 420 = 14 units and call MD was started on January 29, 2015. The following administration errors were noted for May 2015: i. 6:30 AM administrations: 10 units documented as given on May 1 for BS (blood sugar) 368 and 9 units on May 21 for BS 641. ii. 11:30 AM administrations: 10 units on May 1 for BS 399, 12 units on May 16 for BS 470, 12 units on May 20 for BS 428, 14 units on May 24 for BS 419, and 14 units on May 30 for BS 410. iii. 4:30 PM administrations: 8 units on May 1 for BS 344, 13 units on May 28 for BS 361. iv. Additionally, the following blood sugars were above 420 but there was no documentation on the MAR indicated [REDACTED]. In June 2015, the [MEDICATION NAME] order was changed to Blood sugar fingerstick (a test using blood from the finger to determine blood sugar level in the blood) with [MEDICATION NAME] 100 U/mL sol (solution) AC (before meals) TID (3 times daily) SQ (subcutaneous) per sliding scale as follows: 140-179 = 2 units, 180-219 = 3 units, 220-269 = 5 units, 270-300 = 7 units, 301-360 = 9 units, 361-420 = 12 units, above 420 = 14 units and call MD on June 5, 2015. The following administration errors were noted for June and July 2015: v. 8 units documented as given for BS 235 at 4:30 PM on June 15, 7 units for BS 162 at 6:30 AM on June 22, and 4 units for BS 274 at 6:30 AM on June 25. In addition, there was no documentation on the MAR indicated [REDACTED]. vi. 5 units for BS 208 at 6:30 AM on July 4, 14 units for BS 400 at 11:30 AM on July 5, and 7 units for BS 373 at 11:30 AM on July 6. In addition, there was no documentation on the MAR indicated [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. c. A review of the clinical record for sampled resident 13 on July 23, 2015, at 9:20 AM, revealed a sliding scale insulin order which had been written for this resident on March 1, 2015. The order read: Blood sugar finger sticks insulin QAC (before meals) and HS (bedtime) with [MEDICATION NAME]SQ (subcutaneously) per sliding scale: (with a blood sugar between) 140-179 (mg/dl, milligrams per deciliter) = 0 units (of insulin to be administered), 180-219 = 1 unit (of insulin to be given), 270-300 = 2 units, 301-360 = 2 units, 361-420= 3 units (of insulin), 420 = 3 units and call MD (Medical Doctor). i. Review of sampled resident 13's MAR for the month of March 2015 revealed that on March 11, 2015, at 9:00 PM, the resident had a blood sugar (BS) of 219 (mg/dl) and she received 0 units of insulin. The current physician's order [REDACTED]. ii. On March 14, 2015, at 11:30 AM, resident 13 had a blood sugar of 197 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. iii. On April 3, 2015, at 11:30 AM, resident 13 had a blood sugar of 198 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. iv. On April 29, 2015, at 11:30 AM, resident 13 had a blood sugar of 358 mg/dl, the nurse administered 3 units of insulin to the resident rather than the 2 units of insulin which had been ordered by this resident's physician. x. On May 10, 2015, at 11:30 AM, resident 13 had a blood sugar of 306 mg/dl, the nurse administered 1unit of insulin to the resident rather than the 2 units of insulin which had been ordered by this resident's physician. vi. On May 22, 2015, at 4:30 PM, resident 13 had a blood sugar of 197 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. vii. On July 12, 2015, at 9:00 PM, resident 13 had a blood sugar of 218 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 1 unit of insulin which had been ordered by this resident's physician. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. d. Review of the clinical record for unsampled resident E on July 24, 2015, at 9:40 AM, revealed a sliding scale insulin order had been written for this resident on July 22, 2015. The order read: Blood sugar finger sticks [MEDICATION NAME] 100 units/milliliters (u/ml). DM per sliding scale before meals and at bedtime: (with a blood sugar between) 140-179 (mg/dl, milligrams per deciliter) = 0 units (of insulin to be administered), 180-219 mg/dl= 1 unit of insulin to be administered, 220-269 mg/dl = 1 unit of insulin, 270-300 mg/dl = 2 units of insulin, 301-360= 2 units of insulin, 361-420= 3 units of insulin, greater than 420 = 3 units and call MD. Review of unsampled resident E's MAR for the month of July 2015 revealed that on July 23, 2015, at 4:30 PM, the resident had a blood sugar (BS) of 337 (mg/dl) and she received 3 units of insulin. The current physician's order [REDACTED]. This resident had only been in the facility for 1 day and this was only her third dose of insulin which had been administered to her during her stay. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. e. Review of the clinical record for unsampled resident J on July 24, 2015, at 12:15 PM, revealed a sliding scale insulin order had been written for this resident on July 20, 2015. The order read: Blood sugar finger sticks Humalog 100 units/milliliters (u/ml). Subcutaneous before meals and at bedtime: (with a blood sugar between) 180-269 (mg/dl, milligrams per deciliter) = 1 units (of insulin to be administered), 270-360 mg/dl= 2 unit of insulin to be administered, 361-420 mg/dl = 3 unit of insulin, greater than 420 = 3 units and call MD. Review of unsampled resident J's MAR for the month of July 2015 revealed that on July 22, 2015, at 6:30 AM, the resident had a blood sugar (BS) of 232 (mg/dl) and she received 2 units of insulin. The current physician's orders [REDACTED]. This resident had only received three doses of insulin from this order before this medication administration error had been made. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. f. Review of the clinical record for unsampled resident K on July 24, 2015, at 12:00 PM, revealed a sliding scale insulin order had been written for this resident on July 8, 2015. The order read: Finger sticks with Humalog 100 units per milliliter Subcutaneously before meals and at bedtime sliding scale as follows: (with a blood sugar between) 121-150 (mg/dl, milligrams per deciliter) = 2 units (of insulin to be administered), 151-200 = 4 unit (of insulin to be given), 201-250 = 6 units, 251-300 = 8 units, 301-350= 10 units (of insulin), 351-400 = 12 units, and greater than 400 mg/dl = 14 units and call MD (Medical Doctor). i. Review of unsampled resident K's MAR for the month of July 2015 revealed that on July 11, 2015, at 6:30 AM, the resident had a blood sugar (BS) of 171 (mg/dl) and she received 2 units of insulin. The current physician's orders [REDACTED]. ii. On July 16, 2015, at 6:30 AM, resident K had a blood sugar of 160 mg/dl, the nurse administered 2 units of insulin to the resident rather than the 4 unit of insulin which had been ordered by this resident's physician. iii. On July 21, 2015, at 9:00 PM, resident K had a blood sugar of 125 mg/dl, the nurse administered 1 units of insulin to the resident rather than the 2 unit of insulin which had been ordered by this resident's physician. iv. On July 22, 2015, at 11:30 AM, resident K had a blood sugar of 150 mg/dl, the nurse administered 4 units of insulin to the resident rather than the 2 units of insulin which had been ordered by this resident's physician. This resident had been admitted to the facility on [DATE]. This resident had four insulin administration errors during her 16 day stay in the facility. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. g. During a review of the clinical record for Unsampled Resident D, the record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record indicated physician orders [REDACTED].= 2 units (insulin to be administered), 251-300 = 4 units, 301-350 = 6 units, 351-400 = 8 units, greater than 400 give 8 units and notify MD (medical doctor), notify MD if less (blood sugar result) than 60. i. Further review of the clinical record indicated the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. h. During a review of the clinical record for Unsampled Resident G, the record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review of the clinical record indicated a physician order [REDACTED].= 2 units, 270-300 = 3 units, 301-360 = 4 units, 361-420= 5 units, greater than 420 give 7 units and call MD (medical doctor). Further review of the clinical record indicated the Medication Administration Record [REDACTED] i. On May 15, 2015 at 6:30AM, the resident's blood sugar was 200 and no [MEDICATION NAME] Insulin (a quick acting form of insulin) was administered. The physician's orders [REDACTED]. ii. On June 21, 2015 at 9:00 PM, the resident's blood sugar was 269 and three units of [MEDICATION NAME]was administered. The physician's orders [REDACTED]. iii. On July 4, 2015, at 4:30 PM, the resident's blood sugar level was 250 and three units of [MEDICATION NAME]was administered. The physician's orders [REDACTED]. iv. On July 16, 2015 at 4:30 PM, the blood sugar was zero and three units of [MEDICATION NAME]was administered. The physician's orders [REDACTED]. An interview was conducted with the Director of Nurses (DON) on July 24, 2015 at 4:35 PM. When asked to review discrepancies of the above dated MARs, she stated, It is what it is. If that's what is documented, that's what's been given or not given. i. During a review of the clinical record for Resident 11, the record indicated that Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review indicated a physician's orders [REDACTED]. The order indicated the following: [MEDICATION NAME] 10 Units Subcutaneous (under the skin) BED TIME.(Increase by 2 units nightly until fasting blood sugar below 150.) During further review of the clinical record for Resident 11, the Medication Administration Record [REDACTED] i. 22 Units of [MEDICATION NAME] were documented as given from May 1, 2015 to May 19, 2015, May 22, 2015 to May 26, 2015, and May 29, 2015 to May 31, 2015. On May 20, 2015, May 21, 2015, and May 27, 2015, 10 Units of [MEDICATION NAME] were documented as given. ii. 22 Units of [MEDICATION NAME] were documented as given every day in June 2015 except for June 8, 2015, June 19, 2015, June 20, 2015, and June 26, 2015. On these dates, it was documented that 10 Units were given. iii. 22 Units of [MEDICATION NAME] were documented as given every day in July 2015 except for July 11, 12, 14, 18, 19, 20, and 21, 2015. On these dates, it was documented that 10 Units were given. In an interview with LVN 4 on July 24, 2015 at 11:45 AM, she was asked why she documented 10 Units of [MEDICATION NAME] as given on July 12, 2015 despite the dose increased to 22 Units according to physician order. She stated, That's what the order says here to give. She pointed to the order on the Medication Administration Record [REDACTED]. She confirmed that she should have given 22 Units instead. j. A review of the clinical record for unsampled Resident C, revealed unsampled Resident C was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. During a review of the clinical record for unsampled Resident C, the Physician order [REDACTED].=121-150=2U, 151-200=4U, 201-251=6U, 251-300=8U, 301-350=10U, 351-400=12U, BG>400=CALL MD Injection Every 6 Hours DX: DM. i. A review of the clinical record for unsampled Resident C, revealed the MAR (medication administration record) dated June 4, 2015 at 12:00 AM indicated blood glucose (blood sugar level) of 122 and 0 (zero) units of insulin (medication that lowers blood sugar levels) was given. During an interview with LVN 5 on July 24, 2015, at 10:00 AM, LVN 5 stated unsampled Resident C should have received 2 (two) units of Insulin for a blood sugar of 122 per the doctor's orders on June 4, 2015 at 12:00 AM. ii. A review of the clinical record for unsampled Resident C, revealed the MAR indicated [REDACTED]. During an interview with LVN 4 on July 24, 2015 at 10:30 AM, LVN 4 stated unsampled Resident C should have not received any insulin for a blood sugar of 120 according to the sliding scale (instructions for administering insulin based on blood sugar levels) on July 2, 2015 at 12:00 PM. LVN 4 stated I gave 2 (two) units according to the MAR, I think it was a type-o. LVN 4 further stated the documentation of 2 (two) units of insulin given was an error. LVN 4 stated, I know how to read a sliding scale. iii. A review of the clinical record for unsampled Resident C, revealed the MAR indicated [REDACTED]. During an interview with the DON on July 24, 2015 at 2:52 PM, the DON stated unsampled Resident C should have received 2 (two) units of insulin for blood glucose of 130 per the insulin sliding scale on July 21, 2015 at 6:00 PM. iv. A review of the clinical record for unsampled Resident C, revealed the MAR indicated [REDACTED]. During an interview with LVN 7 on July 24, 2015 at 2:57 PM, LVN 7 stated she did not administered insulin for a blood glucose of 124 to unsample Resident C on July 23, 2015 at 6:00 PM. LVN 7 stated per the insulin sliding scale she should have administered 2 (two) units of insulin. When asked why she did not follow the doctor's orders, LVN 7 stated, I remember I did give the resident 2 (two) units of insulin. LVN 7 further stated, there was no documented evidence that she administered 2 (two) units of insulin on July 23, 2015 at 6:00 PM. The facilities Policy and Procedure titled, Medication administration, revised April 16, 2012 indicated: Purpose: These policies and procedures are established to ensure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely and sanitary manner .Policy: 3. IMPLIMENTATION (NOTING)-The nurse who receives the prescriber's order shall be responsible for its complete implementation. This includes proper transcribing, ordering of medications, and all other steps involved in carrying out the order. According to the American Diabetes Association (a respected organization that provides information to people diagnosed with [REDACTED].