Every finding on record at Cheshire County Home

Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate less than 5 percent (%) for 2 of 33 medication administration opportunities observed. (Resident Identifier is #21).Findings include:Observation on 9/10/25 at 9:06 a.m. of the morning medication administration for Resident #21 with Staff C (Licensed Practical Nurse) revealed Staff C to prepare one tablet of Vitamin D3 10 mcg (micrograms) and 17 g (grams) of Polyethylene Glycol (laxative) and prepared to administer the medications to Resident #21.Review on 9/10/25 of Resident #21's September Medication Administration Record (MAR) revealed a physician's order for Vitamin D3 25mcg. Further review revealed a physician's order to administer Polyethylene Glycol 8.5 g with the morning medication administration.Interview on 9/10/25 at approximately 9:08 a.m. with Staff C confirmed that he/she was going to administer the wrong doses Vitamin D3 and Polyethylene Glycol to Resident #21.Review on 9/11/25 of facility policy titled Medication Administration- General guidelines, revised December 2019, revealed .FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away. a. Check #1: Select the Medication- label, container and contents are checked for integrity and compared against the medication administration record (MAR) by reviewing the 5 Rights. b. Check #2: Prepare the dose- the dose is removed from the container and verified against the label and the MAR by reviewing the 5 Rights. c. Check#3: Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights.There were 2 medication errors out of a total of 33 medication administration opportunities resulting in a 6.06% error rate.

Based on record review and interview, it was determined that the facility failed to collaborate in the development of a coordinated plan of care for each resident receiving hospice services for 1 of 2 residents reviewed for hospice services in a final sample of 23 residents (Resident Identifier is #12).Findings include:Review on 9/9/25 of Resident #12's medical record revealed an order, dated 8/27/25, to admit to hospice. Further review of Resident #12's medical record revealed no information regarding frequency of visits by hospice staff or services to be provided.Review on 9/10/25 of Resident #12's hospice binder revealed no information regarding the frequency of visits by hospice staff or services to be provided.Interview on 9/10/25 at approximately 12:07 p.m. with Staff A (Unit Manager) confirmed that there was no plan of care from the hospice provider with frequency of visits or services provided for Resident #12. Staff A stated they were not aware of when hospice staff were coming to provide services for Resident #12.

Based on interview and record review, it was determined that the facility failed to remove equipment from use that was not in safe working order for 1 of 2 residents reviewed for falls in a final sample of 23. (Resident Identifier is #11.)Findings include:Interview on 9/9/25 at approximately 9:30 a.m. with Resident #11 revealed that he/she had a fall last week due to his/her wheelchair brake not locking properly. Further interview revealed that Resident #11 lost his/her balance and fell when transferring from their recliner to their wheelchair.Review on 9/11/25 of Resident #11's medical record revealed a progress note, dated 9/6/25, Resident stating [pronoun omitted] was getting up to use the bathroom and [pronoun omitted] wheelchair wasn't locked fully-when [pronoun omitted] went to sit in the wheelchair it moved and [pronoun omitted] fell. Interview on 9/11/25 at approximately 8:40 a.m. with Staff D (Rehabilitation Technician) revealed that Staff D was aware of Resident #11's wheelchair brake not working properly at times. Staff D stated that he/she did check Resident #11's wheelchair brakes after the fall and the brakes did require tightening at that time, the same tightening that had been required periodically (approximately 1-2 weeks) prior to the fall. Interview on 9/11/25 at approximately 9:15 a.m. with Staff F (Licensed Nursing Assistant) revealed that Resident #11's wheelchair brakes were loose about 3 weeks ago. Staff F reported this to the Rehabilitation Technician. Interview on 9/11/25 at approximately 9:30 a.m. with Staff E (Rehabilitation Director) revealed that Staff E was aware of the brakes being loose prior to Resident #11's fall. Staff E further revealed they had been checking Resident #11's wheelchair brakes routinely to see if they need to be tightened but did not document it. Review on 9/12/25 of facility policy titled Durable Medical Equipment Maintenance and Replacement, dated October-2022, revealed .will provide adequate, safe and clean w/c's [wheel chairs], walkers, wheelchair . will be clean and in working order, . f. Examples of needed repairs: . Loose or poorly locking brakes, .

Based on record review and interview, it was determined that the facility failed to follow an established antibiotic stewardship program and system of monitoring antibiotic use for 2 of 3 residents that were reviewed (Resident Identifiers are #36 and #7). Findings include: Review on 9/25/24 of facility policy titled, Antibiotic Stewardship Program (ASP), undated, revealed that the program support statement is to reduce the overuse of antibiotics. Further review revealed .Providers .Document conversation with residents and their representative regarding the current medical treatment plan and the appropriate use of antibiotics .Infection Preventionist .Help ensure antibiotics are prescribed only when appropriate. Review on 9/25/24 of facility policy titled, Policy for Infection Control Surveillance, dated 9/2023, revealed: .1.e ICC will identify using the McGeer's definitions to see if an antibiotic is ordered that met criteria . Interview on 9/26/24 at approximately 9:00 a.m. with Staff C (Administrator in Training) revealed that a discussion with medical providers takes place in the facilities Quality Assurance and Performance Improvement (QAPI) meetings regarding prophylactic antibiotic treatments. Resident #36 Review on 9/25/24 of the July 2024 antibiotic line list revealed Resident #36 was treated for a Urinary Tract Infection (UTI) following a urinalysis and culture, performed on 7/9/24, for a symptom of confusion with indwelling catheter use. Review on 9/25/24 of the July 2024 urinalysis and culture results dated 7/11/24 for Resident #36 revealed 1,000-9,000 colony forming units / milliliter (cfu/ml) of Escherichia coli bacteria growth. Review on 9/26/24 of Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, OCTOBER 2012 , VOL. 33 , NO. 10, revealed: .B. For residents with an indwelling catheter .2. Urinary catheter specimen culture with at least 100,000 cfu/ml of any organism(s) . Interview on 9/26/24 at approximately 9:00 a.m. with Staff F (Infection Preventionist) revealed he/she utilizes McGeer's Criteria for antibiotic use and appropriateness, and confirmed Resident #36's UTI treatment did not meet McGeer's criteria, due to minimal growth of Escherichia coli (under 100,000 cfu/ml). Resident #7 Review on 9/25/24 of the August 2024 antibiotic line list revealed Resident #7 was treated for Cellulitis for symptoms of 1. redness 2. raised. Review on 9/26/24 of Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria, OCTOBER 2012 , VOL. 33 , NO. 10, revealed: .A. Cellulitis, soft tissue, or wound infection .2. New or increasing presence of at least 4 of the following sign or symptom subcriteria: a. Heat at the affected site b. Redness at the affected site c. Swelling at the affected site d. Tenderness or pain at the affected site e. Serous drainage at the affected site . Interview on 9/26/24 at approximately 9:00 a.m. with Staff F (Infection Preventionist) confirmed that only 2 of the 4 symptoms were present and did not meet McGeer's criteria.

Based on observation, interview, record review, it was determined that the facility failed to provide foot care for 1 of 1 resident reviewed for foot care in a final sample of 21 residents (Resident Identifier #87). Findings include: Observation on 9/24/24 at approximately 10:50 a.m. of Resident #87's toenails revealed long and overgrown toenails by approximately 1 inch over the toe. His/her toenails were thick and curling in and around his/her toes. Record review on 9/25/24 of Resident #87's Podiatry note, dated 5/20/24, revealed toenail care for thick, dystrophic, elongated nails B/L [bilaterally] and to follow up in 60 days. Interview on 9/24/24 at approximately 8:30 a.m. with Staff A (Unit Manager) confirmed that Resident #87's last podiatry visit was on 5/20/24. Staff A revealed the podiatrist was in the facility seeing residents yesterday (9/24/24) and the podiatrist did not see Resident #87. Record review on 9/26/24 of Resident #87's nurses note dated 9/8/24 revealed that Resident #87's toenails had been assessed as long and thick. Further review revealed that there was no evidence that nail care was provided on 9/8/24.

Based on record review and interview, it was determined that the facility failed to ensure that as needed (PRN) psychotropic drugs were limited to 14 days for 1 of 5 residents reviewed for unnecessary medications in a final sample of 21 residents (Resident Identifier #31). Findings include: Review on 9/24/24 of Resident #31's September 2024's Medication Administration Record revealed the following physician's order: Lorazepam 0.5 mg [milligram] Tablet by mouth every 2 hours as needed for restlessness/agitation, Start Date 6/2/24. Further review revealed that Resident #31 received a dose of the PRN medication on 9/11/24. Interview on 9/25/24 at approximately 1:45 p.m. with Staff D (Unit Manager) confirmed the above findings and that Resident #31's above order was not limited to 14 days. Review on 9/25/24 of the facility policy titled, Antipsychotic and Psychotropic Medications, Dated August 2023 revealed: .PRN orders for Psychotropic drugs (anti-psychotic, Anti-depressant, anti-anxiety, Hypnotic and or any medication ordered for psychotropic use) are limited to 14 days .

Based on observation and interview, it was determined that the facility failed to ensure that medications were disposed of properly, to prevent potential unauthorized access, during observation of medication administration in a survey sample of 16 medications prepared for administration. Findings include: Observation on 9/24/24 at approximately 8:30 a.m. of Staff G (Registered Nurse (RN)) revealed he/she disposed of a medication capsule in the open trash on the medication cart. Further observation revealed Staff G disposed of a second medication capsule in the open trash on the medication cart. Interview on 9/24/24 at approximately 8:30 a.m. with Staff G revealed his/her usual practice is to dispose medications in the trash. Interview on 9/25/24 at approximately 3:15 p.m. with Staff C (Administrator in Training) revealed medication disposal should be in the drug buster stored in the locked medication room.

Based on record review, interview, and policy review, it was determined that the facility failed to establish a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation; and determine that drug records are in order; and that an account of all controlled drugs is maintained in 3 of 4 narcotic books reviewed. Findings include: Review on 7/18/22 of the facility's policy titled Narcotic Count and Book Policy Version C dated August 2017 revealed, .Policy: Narcotics are to be counted and the narcotic book signed by both oncoming and outgoing shift at the beginning and end of every shift and anytime the keys to the med carts are passed to another licensed nursing staff .Procedure: When doing count: off duty nurse does the narcotic book reading the resident, drug, and dosage. Nurses must be side by side so they both can see the page and medication cart .The back pages of the narcotic book are designated for signatures. Entry must be dated, timed, yes or no indicated if count is correct, and both nurses must sign with their title. If you leave early, arrive late, or are called away, you must make note of this record .Count must be done when leaving and then again upon return . Review on 7/17/23 at 9:45 a.m. of the Odd Side 200 Medication Cart Narcotic Shift Count Book revealed that on 7/17/23 Staff D (Registered Nurse) had pre-signed her/his name in the column as the Nurse Going Off Duty prior to her/his shift ending around 3:00 p.m. Interview on 7/17/23 at 9:47 a.m. with Staff D confirmed that he/she had pre-signed the Narcotic Shift Count Book that morning for coming on duty and for going off duty (which would be at around 3:00 p.m.). Staff D stated that the practice of signing before the shift was over was not facility policy. Review on 7/17/23 at 2:50 p.m. of the Odd Side Medication Cart Narcotic Shift Count Book for June 2023 and July 2023 revealed the following: - Time AM/PM was not documented on 6/1, 6/4, 6/12, 6/16, 6/17, 6/19, 6/20, 6/25, 6/28, and 7/13; - Status Of Count Exact Yes/No was not documented on 6/1, 6/4, 6/16, 6/17, 6/18, 6/19, 6/21, 6/22, 6/25, 6/27, 6/30, 7/10, 7/13, 7/15, 7/16, and 7/17; - Nurse Coming On Duty was not documented on 6/18; - Nurse Going Off Duty was not documented on 6/21, 7/11, 7/13, and 7/16. Interview on 7/17/23 at 2:55 p.m. with Staff D confirmed the above findings. Review on 7/17/23 at 3:00 p.m. of the Even Side Medication Cart Narcotic Shift Count Book for June 2023 and July 23 revealed the following: -Date was not documented six times during June and July; - Time AM/PM was not documented on 6/1, 6/13, 6/14, 6/25, 6/27, 6/28, and 7/4; - Status Of Count Exact Yes/No was not documented on 6/1, 6/7, 6/8, 6/11, 6/13, 6/14, 6/15, 6/17, 6/18, 6/22, 6/24, 6/25, 6/26, 6/27, 6/28, 6/30, 7/4, 7/5, 7/8, and 7/14; - Nurse Coming On Duty was not documented on 6/2, 6/30, and 7/7; - Nurse Going Off Duty was not documented on 6/1, 6/20, 6/30, and 7/7. Interview on 7/17/23 at 3:05 p.m. with Staff C (Licensed Practical Nurse (LPN)) confirmed that the above. 43002 Review on 7/17/23 at 2:10 p.m. of the Fourth floor Medication Cart Narcotic Shift Count Book revealed that on 7/17/23 Staff B (LPN) had already signed as the nurse going off duty despite still being on duty. Continued review of this form revealed that columns for time, status of the exact count, and nurse coming on duty were completed. Further review of this narcotic book revealed the following: - Nurse Coming On Duty was not documented on 7/2 and 7/4 - Nurse Coming Off Duty was not documented on 7/2 and 7/7 Interview on 7/17/23 at 2:10 p.m. with Staff B confirmed that he/she had pre-signed the Narcotic Shift Count Book that morning as the Nurse Going Off Duty. Staff B stated that he/she should have signed the book when count was completed and not at the beginning of his/her shift. Interview on 7/17/23 at 3:30 p.m. with Staff A (Director of Nurses) revealed that Narcotic Shift Count Books should be signed and dated by the nursing staff when the actual counts are done.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that narcotics were properly stored in 1 of 4 medication storage rooms observed. Findings include: Observation on 7/17/23 at 9:25 a.m. of the Second Floor Medication Room (room [ROOM NUMBER]) revealed an unlocked refrigerator. There was a padlock resting on top of the refrigerator. Inside the refrigerator were 4 vials (2 milligrams/1 milliliter) of Lorazepam injection (a Schedule IV controlled substance). Interview on 7/17/23 at 9:30 a.m. with Staff C (Licensed Practical Nurse) confirmed that the refrigerator was unlocked. Staff C stated that medications must have been removed from the refrigerator that morning and the refrigerator should have been locked after the medications were removed. Review on 7/18/22 of the facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles revised on 10/31/16 revealed, . 3. General Storage Procedures: 3.1 Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device .12. Controlled Substances Storage: 12.1 Facility should ensure that Scheduled II-V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Scheduled II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). 12.3 Facility should ensure that all controlled substances are stored in a manner that maintains their integrity and security .

Based on observation, record review, and interview, it was determined that the facility failed to assess a resident's ability to self-administer medications for 2 out of 2 residents reviewed for self-administration of medication in a final sample of 23 residents. (Resident Identifiers are #15 and #96.) Findings include: Resident #96 Observation on 8/30/22 at approximately 11:32 a.m. of Resident #96's room revealed one bottle of [MEDICATION(S)] eye drops and one bottle of saline nasal spray on the over-bed table. Interview on 8/30/22 at approximately 11:33 a.m. with Resident #96 revealed that he/she uses the eye drops and nasal spray up to 4 times per day as needed. Interview on 8/30/22 at approximately 11:35 a.m. with Staff J (RN) confirmed that Resident #96 had one open bottle of eye drops with no open date or expiration date and one open bottle of saline nasal spray with no open date. Review on 8/31/22 of Resident #96's medical record revealed no assessment for self-administration of medication and no order for self-administration of medications. Interview on 8/31/22 at approximately 2:25 p.m. with Staff G (Unit Manager) revealed that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G confirmed that there was no assessment or order for self-administration of medications. Review on 9/1/22 of the facility's policy 2.1 Self Administration of Medications with revision date of 11/28/16 revealed . 2.Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. 5. Facility should ensure that orders for Self-Administration list the specific medication(s) the resident may Self-Administer . Resident #15 Observation on 8/31/22 at approximately 8:08 a.m. of Resident #15's room revealed one bottle of nasal mist extra strength and one bottle of saline nasal spray on the over-bed table. Interview on 8/31/22 at approximately 8:08 a.m. with Resident #15 revealed that he/she uses both nasal sprays approximately 3-4 times per day as needed. Review on 8/31/22 of Resident #15's August 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of the nasal spray being administered during the month. Review on 8/31/22 of Resident #15's medical record revealed no assessment for self-administration of medication and no order for self-administration of medication. Interview on 8/31/22 at approximately 2:15 p.m. with Staff G confirmed that Resident #15 had both nasal sprays in their room. Staff G confirmed that Resident #15 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff G confirmed that there were no entries in the August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER]

1. Based on observation, interview, and record review, it was determined that the facility failed to ensure that medical supplies used for blood draws (blood container tubes) were stored and not expired according to professional standards for 1 out of 2 medication rooms observed. Findings include: Observation on [DATE] at 9:25 a.m. of the Second Floor Even Side Medication Room with Staff J (Licensed Practical Nurse) revealed a plastic box labeled lab box that contained a red capped blood container tube with a manufacturer's expiration date of [DATE]. Further review of the medication room revealed in a cabinet drawer a red capped blood container tube with a manufacture's expiration date of [DATE] and a blue capped blood container tube with a manufacturer's expiration date of [DATE]. Interview on [DATE] at 9:25 a.m. with Staff J confirmed that the blood container tubes were expired. Staff J stated that the tackle box was used for blood draws by the nurses, and that the vials in the drawer would also be used (once the vials in the tackle box were used). Staff J stated that the blue capped blood container tubes were used for Prothrombin time and international normalized ratio (PT/INR). Staff J stated that the expired vacutainers should not be used. Interview on [DATE] at 10:49 a.m. with Staff I (Director of Nurses) confirmed that the facility would not want to use the expired vacutainers. Interview on [DATE] at 2:58 p.m. with Staff I confirmed that all blood work was drawn by the facility's nursing personnel. Review on [DATE] of BD Vacutainer Evacuated Blood Collection System retrieved from https://www.fda.gov/media/ 7/download revealed . Storage Do not use tubes after their expiration date. Tubes expire on the last day of the month and year indicated . 2. Based on observation, interview and record review, it was determined that the facility failed to follow physician orders for 1 out of 2 residents reviewed for mood and behavior and for 1 of 4 residents reviewed for weight loss in a final sample of 23 Residents (Resident Identifier is #35 and #39). Findings Include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed., St. Louis, Missouri, Mosby Elsevier, 2009, pp. 336 - Physician's Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #35 Review on [DATE] of Resident #35's medical record revealed a consult with (pronoun omitted) Geriatrics on [DATE]. Resident #35's consultation note revealed: .Reason for Consultation: Management of psychiatric issues.Medical Decision-Making: At this time, I would not change the medications. Given the fact that the patient has had sleep problems for some time and is on [MEDICATION(S)], which has worked well for (pronoun omitted), I would recommend maintaining that for right now and then, tracking the behavioral issues, we will be able to address the treatment plan. I will follow up with the patient in 3 months or p.r.n. (as needed) Review on [DATE] of Resident #35's medical record revealed no other consultation notes or follow up notes with (pronoun omitted) Geriatrics. Review on [DATE] of Resident #35's medical record revealed a behavior nursing note stating Upon approaching resident for (pronoun omitted) HS (bed time) meds, (pronoun omitted) stated that (pronoun omitted) does not want anything (from me). (pronoun omitted) stated (pronoun omitted) was upset about last night, because (pronoun omitted) wanted a pain pill and I was questioning (pronoun omitted) about why (pronoun omitted) needed it. I explained to (pronoun omitted) that because (pronoun omitted) [MEDICATION(S)] is not scheduled, I have to ask (pronoun omitted) about (pronoun omitted) pain (ie. Location, scale/rating, ect). (pronoun omitted) told me that (pronoun omitted) should not need to ask for it or tell people every night about how (pronoun omitted) is feeling. (pronoun omitted) then moved away from me and cursed at me before returning to (pronoun omitted) room. Interview on [DATE] at approximately 9:05 a.m. with Staff G (Unit Manager) revealed he/she was unable to produce documentation of a follow up visit with psychiatric services. Resident #39 Record review revealed that the Dietitian's August's dietary progress note dated [DATE] stated resident previously lost significant weight and is followed for nutrition risk. (Pronoun omitted) is on level 2 ground mechanical Soft diet that is low fat and avoids ice cream r/t gallbladder dx. (Pronoun omitted) is also on a CC (consistent carbohydrate) diet with SF (sugar free) jelly and syrups, no sugar. Intakes recently have been 50% breakfast, 64% lunch and 89% supper w/55% intakes of snacks. Weight is now 141.2 on ,d+[DATE] vs 140.9 on ,d+[DATE] and 141.5 on ,d+[DATE]. Further record review revealed a physician order on [DATE] to begin weekly weights until [DATE]. Further review revealed that the physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the monthly weights on [DATE] revealed the following: [DATE] 148.1 lbs [DATE] 147.2 lbs [DATE] 145.8 lbs [DATE] 139.0 lbs [DATE] 144.8 lbs [DATE] 139.2 lbs [DATE] 142.2 lbs [DATE] 142.2 lbs [DATE] 140.9 lbs [DATE] 141.2 lbs There were no additional weights documented. Interview on [DATE] at 2:03 p.m. with Staff D, Minimum Date Set Coordinator (MDS) and Staff B, License Practical Nurse (LPN) confirmed that there was no physician order to discontinue the weight in the resident's chart. They also confirmed that the resident's weight for [DATE] was missing. Interview was performed at [DATE] at 10:57 AM with Staff A, (Dietitian). Staff A stated that he/she was aware of the resident's plan of care relating to his/her nutrition. He/she said that they did not know why his/her weekly weights would have been dc'd. When asked if he/she initiated the dc, he/she said that they hadn't and wasn't sure who would have done it. Interview on [DATE] at 1:44 p.m. with Staff L, Infection Preventionist, revealed that he/she discontinued the physician order by mistake and that the order should have remained active. Review on [DATE] of the facility's policy titled Monitoring Resident Body Weight dated July-2020, read, in part .Based on a resident's comprehensive assessment, the facility must ensure that a resident: (1) Maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible; .Goal: To prevent weight loss/gain .7. The RD will assess all residents for weight changes quarterly following the MDS schedule and will update documentation in the medical record and care plan . 8. Daily or weekly weights may be ordered at the discretion of the MD/PA/APRN, NM or RD, to include instruction for parameters of loss gain.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that narcotics were properly stored in 1 of 2 medication storage rooms observed (4th floor 'Open' side). Findings include: Observation on 8/30/22 at 9:40 a.m. of the Fourth Floor Open Side medication room revealed an unlocked refrigerator. There was a padlock on the refrigerator that was not secured (locked). Inside the refrigerator were 5 vials (2 milligrams/1 milliliter) of [MEDICATION(S)] injection (a schedule IV controlled substance) for Resident #400. Interview on 8/30/22 at 9:40 a.m. with Staff B (Licensed Practical Nurse) and Staff H (Medication Nursing Assistant) confirmed that the refrigerator was unlocked and should have been (locked). Both staff stated that they had access to the medication room. Interview on 8/30/22 at 10:49 a.m. with Staff I (Director of Nursing) confirmed that the above refrigerator should be locked. Review on 8/30/22 of the facility's policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles revised on 10/31/16 revealed, . 3. General Storage Procedures: 3.1 Facility should store Schedule II Controlled Substances and other medications deemed by Facility to be at risk for abuse or diversion in a separate compartment within the locked medication carts and should have a different key or access device .12. Controlled Substances Storage: 12.1 Facility should ensure that Scheduled II-V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. 12.2 After receiving controlled substances and adding to inventory, Facility should ensure that Scheduled II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). 12.3 Facility should ensure that all controlled substances area stored in a manner that maintains their integrity and security .

Based on record review and interview, it was determined that the facility failed to ensure laboratory services were provided when ordered by a physician for 1 out of 4 residents reviewed for nutrition in a final sample of 23 residents. (Resident identifier is #51.) Findings include: Review on 9/15/22 of Resident #51's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Increase [MEDICATION(S)] to 2.5 mg (milligrams) po (by mouth) QD (daily) . 3. Review in 1 week 4. BMP (Basic Metabolic Panel) 7/5/22 Review on 9/14/22 of Resident #51's lab (laboratory) results revealed that there was no bloodwork drawn on Resident #51 until on 7/12/22. Interview on 9/15/22 at approximately 12:15 p.m. with Staff D (Registered Nurse) revealed that the staff member that draws laboratory samples was not at the facility on 7/5/22 and the labs were delayed until 7/12/22. Staff D could not provide any documentation that the physician was notified of the delay in the lab draw. Review on 9/15/22 of the facility policy titled, Laboratory Testing, dated October 2017 revealed: Procedure: 1. Routine laboratory blood work to be done as stated below or as ordered by a physician 4. Routine laboratory test slips are completed by the Unit Assistants, and the blood work drawn by the [pronoun omitted] laboratory technician on specialized days 5. All other blood work is to be drawn by Nursing personnel 8. Other labs drawn as required

Based on interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the status of 2 residents in a final sample of 23 residents. (Resident identifiers are #5 and #67.) Findings Include: Resident #5 Antipsychotic Medications Review on 8/31/22 of Resident #5's Quarterly MDS with an Assessment Reference Date (ARD) of 8/16/22 revealed in Section N0410 Medications Received: Days: Antipsychotic was coded as 6. Review of Section N0450 Antipsychotic Medication Review: Days was coded as 0 meaning antipsychotics were not received. Interview on 9/01/22 at approximately 9:10 a.m. with Staff E (MDS Coordinator) confirmed that Section N0450 Antipsychotic Medication Review: Days of Resident's most recent Quarterly MDS was marked in error and should have been coded as 1 meaning antipsychotics were received on a routine basis only. Resident #5 Catheter Review on 8/31/22 of Resident #5's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 8/31/22 of Resident #5's MDS with an ARD of 4/1/22 and look back date of 3/25/22 revealed in Section H0100 Appliances: A. Indwelling Catheter was coded as having a catheter. Review on 8/31/22 of Resident #5's Quarterly MDS with an ARD of 5/31/22 and look back date of 5/25/22 revealed in Section H0100 Appliances: A. Indwelling Catheter was coded as having a catheter. Review on 8/31/22 of Resident #5's MDS with an ARD of 6/23/22 and a look back date of 6/16/22revealed in Section H0100 Appliances: A. Indwelling Catheter was coded as having a catheter. Interview on 8/31/22 at approximately 1:45 p.m. with Staff E confirmed that Section H0100 Appliances: A. Indwelling Catheter on the above MDS' were marked in error and should not have been checked off. Resident #67 Review on 8/31/22 of Resident #67's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 8/31/22 of Resident #67's Quarterly MDS with an ARD of 2/22/22 revealed in Section O0100 Special Treatments, Procedures and Programs: Other: K. Hospice was coded for being on hospice. Review on 8/31/22 of Resident #67's Quarterly MDS with an ARD of 5/10/22 revealed in Section O0100 Special Treatments, Procedures and Programs: Other: K. Hospice was coded for being on hospice. Review on 8/31/22 of Resident #67's Quarterly MDS with an ARD of 7/12/22 revealed in Section O0100 Special Treatments, Procedures and Programs: Other: K. Hospice was coded for being on hospice. Interview on 8/31/22 at approximately 1:50 p.m. with Staff E confirmed that Section O0100 Special Treatments, Procedures and Programs: Other: K. Hospice on the above MDS' were marked in error and should not have been checked off as Resident #67's hospice services were discontinued on 12/8/21.

Based on interview, observation and manufacturer's instruction review, it was determined that the facility failed to ensure that drugs were labeled and stored in accordance with accepted professional standards for 2 out of 2 medication storage rooms and 2 out of 3 medication carts observed. (Resident identifiers #24, #31, #33, #41, #59 and #97.) Findings include: Observation on [DATE] at approximately 9:30 a.m. of the 4th floor TLC (Therapeutic Living Community) medication room with Staff A (Unit Manager) revealed Resident #59's open bottle Nuplazide 10 mg (milligrams) with a pharmacy label reading use by [DATE]. Interview on [DATE] at approximately 9:30 a.m. with Staff A confirmed the above findings. Staff A stated Resident #59 had not received this medication. Observation on [DATE] at approximately 9:45 a.m. of the 4th floor TLC medication/treatment storage cart with Staff A revealed Resident #97's unopened Basglar Kwikipen with pharmacy labels reading, refrigerate until open, discard 28 days after opening and a pharmacy delivery date of [DATE]. Interview on [DATE] at approximately 9:45 a.m. with Staff A confirmed the above findings. Staff A stated the [MEDICATION(S)] Kwikpen was removed from refrigerator that day. Observation on [DATE] at approximately 10:15 a.m. with Staff B (Licensed Practical Nurse) of the 2nd floor medication cart revealed Resident #24's [MEDICATION(S)] with a manufacturer's expiration date of ,d+[DATE], and Resident #33's [MEDICATION(S)] with a manufacturer's expiration date of ,d+[DATE]. Interview on [DATE] at approximately 10:15 a.m. with Staff B confirmed the above findings. Observation on [DATE] at approximately 10:30 a.m. of 2nd floor medication room with Staff C (unit manager) revealed Resident #41's unopened box of [MEDICATION(S)] 2.5mg/3ml (milliliters) with a manufacturer's expiration date of ,d+[DATE], and Resident #31's [MEDICATION(S)] 90 mcg inhaler with a manufacturer's expiration date of ,d+[DATE]. Interview on [DATE] at approximately 10:30 a.m. with Staff C confirmed the above findings. Staff C stated Resident #41's [MEDICATION(S)] 2.5mg/3ml and Resident #31's [MEDICATION(S)] 90 mcg inhaler had not been used as the orders were discontinued. Review on [DATE] of [MEDICATION(S)] Kwikpen manufacturer's instructions revealed .Storage of [MEDICATION(S)] Kwikpen. Store unused pens in the refrigerator .Unused pens maybe used until expiration date printed on the label if the pen has been kept in the refrigerator .Store the pen you are currently using at room temperature. Throw away pen you are using after 28 days . Interview on [DATE] at approximately 12:07 a.m. with Staff D (Director of Nursing) revealed the expectation for any discontinued or expired medication is that it is to be removed from the medication storage area, all pharmacy medications are to be returned to pharmacy and all over the counter medications are to be returned to central supply for destruction.

Based on observation, documentation review and interview, the facility failed to provide quality laboratory services for residents that are required to receive physician ordered blood glucose monitoring on 1 of 4 care units. Findings include: On 4/7/16 at 8:40 a.m. during observation on The Locked Unit, the glucometer control solutions were labeled with a use by date of 3/10/16. Review of Facility Glucometer Testing Log documentation indicated that the night shift nurses conducted daily calibrations on dates 3/1/16 through 4/7/16. Twenty-eight of these dates were beyond the use by date. An interview on 4/7/16 at 8:40 a.m. with Staff A (MNA) and Staff B (LPN) confirmed that the glucometer solution had been used after the use by date.

Based on observation and interview, the facility failed to discard over the counter expired medications from 3 of 4 patient care unit medication carts. Findings include: On 4/7/16 at 8:35am during inspection of the medication cart on The Locked Unit, a bottle of magnesium oxide 400 mg (milligrams) had an expiration date of 3/16. A bottle of Ocular Vitamin had an expiration date of 3/16. An interview with Staff A (MNA) and Staff B (LPN) on 4/7/16 at 8:35 a.m. confirmed the above. On 4/7/16 at 8:50 a.m. during inspection of the medication cart on the 4th floor, a bottle of Vitamin C 250 mg (milligrams) had an expiration date of 2/16. A bottle of Ocean Nasal Spray had an expiration date of 10/11. An interview with Staff C (LPN) on 4/7/16 at 8:50 a.m. confirmed the above. On 4/7/16 at 9:10 a.m. during inspection of the medication cart on the second floor, a bottle of Oscal 500 mg (milligrams) had an expiration date of 12/15. A bottle of Vitamin B Complex had an expiration date of 3/15. A bottle of Allergy Relief nasal spray had an expiration date of 1/16. A bottle of Zinc Sulfate 200 mg (milligrams) had an expiration date of 2/16. An interview with Staff D (LPN) and Staff E (RN) unit manager on 4/7/16 at 9:10 a.m. confirmed the above. When interviewed on 4/7/16, all nurses listed above indicated that it is all nurses and MNA's responsibilities to check the expiration of all medications. An interview on 4/7/16 at 9:10 a.m. with Staff E (RN) indicated that there was not a specific system in place to check medications for expiration dates.

Based on record review and interview the facility failed to ensure that the comprehensive care plans were reviewed and updated for 2 residents in a survey sample of 24. (Resident identifiers are #2 and #12). Findings include: Resident # 2 Medical record review on 2/4/15 Resident #2 revealed that the facility had long standing issues with their bowel program, review of the Medication Administration Record [REDACTED]. Review of the care plan revealed no documented care plan to maintain normal bowel function for this resident. Interview at same time as record review with Staff A (Unit Manager) confirmed the above findings. Resident #12 Medical record review on 2/4/15 for Resident #12 revealed that the following care plans had not been updated and were missing appropriate goal dates: Vision (goal date was 10/1/2014) Communication (goal date was 10/1/2014) ADL's (goal date was 10/1/2014) Falls (goal date was 10/1/2014) Nutrition (goal date was 10/1/2014) Dehydration (goal date was 10/1/2014) Skin Integrity (goal date was 10/1/2014) Pain/Comfort (goal date was 10/1/2014) Interview at the same time as the record review with Staff A (Unit Manager) confirmed the above findings.

Based on record review and interview the facility failed to ensure that all physician orders [REDACTED]. (Resident identifier is #2). Findings include: Review of the Medication Administration Record [REDACTED]"FLEET"..."ENEMA RECTALLY AS NEEDED IF NO BOWEL MOVEMENT IN 9 SHIFTS". Review of the elimination record for this resident for the periods 11/6/14 (PM) through 11/12/14, 12/7/14 through 12/11/14 and 12/27/14 through 12/31/14 identified 14, 12 and 12 shifts respectively with no documentation indicating bowel movements for this resident. Review of the medication administration records for these times showed no documented evidence of receiving the aforementioned ordered enemas. Interview with Staff A (Unit Manager) during review confirmed the above findings.

Based on medical record review and interview it was determined that the facility failed to notify a resident's physician of missing a dose of medication for 1 resident in a survey sample of 24. (Resident identifier is #4.) Findings include: Review on 12/11/13 of Resident #4's "Medication Administration Record" dated 10/1/13-10/31/13 revealed on 10/3/13 that "[MEDICATION NAME] 160 mg (milligrams) tablet 1 tab (tablet) by mouth every day" was not given. Review of the back side of the "Medication Administration Record" under "Nurse's Medication Notes" revealed the following: "10/3, 0800, [MEDICATION NAME] 160 mg po (by mouth) not given not available Notified Pharmacy." Interview on 12/11/13 with Staff B (Registered Nurse) verified that [MEDICATION NAME] was not available to be given to Resident #4 on 10/3/13 and the pharmacy was notified. Staff B confirmed that Resident #4 received the next scheduled dose of [MEDICATION NAME] on 10/4/13. Staff B explained that Resident #4's physician should have been notified of this missed dose of [MEDICATION NAME] thru the physician communication log. Staff B reviewed the physician communication log and did not find evidence that Resident #4's physician was notified of the missed dose of [MEDICATION NAME].

Based on record review and interviews it was determined that immediate jeopardy existed when the facility failed to ensure that it develop and implement written policies and procedures that prohibit the neglect of residents while being transported via wheelchair in the facility van resulting in harm to 1 resident that sustained bilateral ankle fractures. (Resident identifier is: #1.) Findings include: During interview on 10/25/10 with Staff B, DON, Staff B indicated that there is no facility policy and procedure on resident transportation in the facility van for residents using a wheelchair. Staff B was unable to provide written instruction or documented evidence of training for staff who provide transportation to residents in wheelchairs using the facility van to ensure the proper securing of residents. During interviews with Staff A, Administrator, Staff B, Staff C LNA-Transportation Aide, Staff D, Occupational Therapist, Staff E LNA, Staff F, Facilities Manager all indicated that by manufacturer no lap belt existed for securing residents in a wheelchair in the facility van. Review on 10/25/10 of the incident report for Resident #1 reveals on 10/20/10 Staff C, was driving the facility van with Resident #1 in a wheelchair back from an appointment in Vermont when Resident #1 stated "I'm sliding." Staff C began to pull over and Resident #1 then stated "It's too late I'm down." Resident #1 had slid under the seat belt landing on knees with lower legs and feet twisted underneath body with Resident #1's head resting on the wheelchair seat with the shoulder strap across neck area. Staff C loosened the anchors and shoulder strap and called 911. Review of Resident #1's medical record on 10/25/10 reveals [DIAGNOSES REDACTED]. Review of nurses notes dated 10/20/10 at 4:06 p.m. indicates that Resident #1 had an incident in the facility wheelchair van while being transported from an appointment and was transferred to hospital for evaluation. At 7:30 p.m. the facility was notified by the hospital that Resident #1 sustained bilateral ankle fracture, fibular fracture and tibial fracture. Resident was returned to facility on 10/20/10 at 8:10 p.m. with casts applied to both lower extremities. Further investigation and interview on 10/26/10 with the vendor of the facility van revealed that the restraint system installed for securing residents in wheelchairs was a Sur-Lock system. On 10/27/10 interview with the Sur-Lock vendor revealed that the system installed in the facility van was a Sur-Lock FF612S retractable system for 3 wheelchairs and did include lap belts when the van was delivered to facility in June 2006. On 10/28/10 at 10:00 a.m. during interview with Staff A, Staff A indicated contacting the Sur-Lock vendor to inquire on the system in the facility van and Staff A was informed that lap belts were included. Staff A indicated that the lap belts were located in the van in the afternoon of 10/27/10 and confirmed that the application of the safety restraint system was not in accordance with the manufacturers instructions as well as the lap belt was being used inappropriately as an extension to the shoulder belt. Review of the facility's ad hoc report "Transportation Appointment Schedule 05/03/2010 - 10/28/2010" on 10/28/10 at 11:15 a.m. reveals that Staff C LNA-Transportation Aide, transported 187 wheelchair residents with the facility van to appointments. Facility Actions Taken to Remove Immediate Jeopardy revealed that: The facility has developed a policy and procedure and has in serviced all transportation staff to the facility policy and procedure for resident transportation in the wheelchair van and at 1:00 p.m. on 10/28/10 a Sur-Lock representative arrived at the facility to provide the staff education in accordance with the operation instructions of the restraint system by the vendor.

Based on observation, review of facility policy and procedure, facility documentation and staff interviews it was determined that immediate jeopardy existed when the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for residents traveling in the facility van resulting in 1 resident sustaining fractures. (Resident identifier is: #1.) Findings include: Review of Resident #1's medical record on 10/25/10 reveals [DIAGNOSES REDACTED]. Review of nurses notes dated 10/20/10 at 4:06 p.m. indicates that Resident #1 had an incident in the facility wheelchair van while being transported from an appointment and was transferred to hospital for evaluation. At 7:30 p.m. the facility was notified by the hospital that Resident #1 sustained bilateral ankle fracture, fibular fracture and tibial fracture. Resident was returned to facility on 10/20/10 at 8:10 p.m. with casts applied to both lower extremities. Review on 10/25/10 of the incident report for Resident #1 reveals on 10/20/10 Staff C, LNA-Transportation Aide was driving the facility van with Resident #1 in a wheelchair back from an appointment in Vermont when Resident #1 stated "I'm sliding." Staff C began to pull over and Resident #1 then stated "It's too late I'm down." Resident #1 had slid under the seat belt landing on knees with lower legs and feet twisted underneath body with Resident #1's head resting on the wheelchair seat with the shoulder strap across neck area. Staff C loosened the anchors and shoulder strap and called 911. During telephone interview on 10/26/10 at 1:30 p.m. with Staff C, Staff C indicated that a lap belt has not been used on residents using a wheelchair in the facility van. Staff C indicated that Staff C has been the LNA Transportation Aide since May 2010 and received training by another LNA in which no lap belts were used and no written instruction available. On 10/28/10 Staff C is observed in demonstrating how Staff C applied the wheelchair van restraints to Resident #1's wheelchair on 10/20/10. Observation revealed inappropriate application of the system as follows: A lap belt is present but is used as an extension to the shoulder belt to the floor with the excess wrapped around the right rear wheel and handrim with the snap hook latched to the back of the wheelchair frame. The back floor anchors are crisscrossed with both of the S-hooks attached to the lower left crossbar. During interview on 10/25/10 with Staff B, DON, Staff B indicated that there is no facility policy and procedure on resident transportation in the facility van for residents using a wheelchair. Staff B was unable to provide written instruction or documented evidence of training for staff that provide transportation to residents in wheelchairs using the facility van to ensure the proper securing of residents. During interviews with Staff A-Administrator, Staff B, Staff C, Staff D-Occupational Therapist, Staff E- LNA and Staff F- Facilities Manager all indicated that by manufacturer no lap belt existed for securing residents in a wheelchair in the facility van. Investigation and interview on 10/26/10 with the vendor of the facility van revealed that the restraint system installed for securing residents in wheelchairs was a Sur-Lock system. On 10/27/10 interview with the Sur-Lock vendor revealed that the system installed in the facility van was a Sur-Lock FF612S retractable system for 3 wheelchairs and did include lap belts when the van was delivered to facility in June 2006. On 10/28/10 at 10:00 a.m. during interview with Staff A, Staff A indicated contacting the Sur-Lock vendor to inquire on the system in the facility van and Staff A was informed that lap belts were included. Staff A indicated that the lap belts were located in the van and confirmed that the application of the safety restraint system was not in accordance with the manufacturers instructions as well as the lap belt was being used inappropriately as an extension to the shoulder belt. Review of the facility's ad hoc report "Transportation Appointment Schedule 05/03/2010 - 10/28/2010" on 10/28/10 at 11:15 a.m. reveals that Staff C LNA-Transportation Aide, transported 187 wheelchair residents with the facility van to appointments. Facility Actions Taken to Remove Immediate Jeopardy revealed that: The facility has developed a policy and procedure and has in serviced all transportation staff to the facility policy and procedure for resident transportation in the wheelchair van and at 1:00 p.m. on 10/28/10 a Sur-Lock representative arrived at the facility to provide the staff education in accordance with the operation instructions of the restraint system by the vendor.