Every finding on record at Crestline Rehabilitation and Nursing Center

Based on the review of the staffing schedules, review of the timecard reports, and staff interview, the facility failed to ensure a Registered Nurse (RN) was designated as the Director of Nursing (DON) on a full-time basis and further failed to ensure an RN was working in the facility at least eight consecutive hours per day, seven days a week. This had the potential to affect all residents. The facility census was 21.Findings include:Review of the facility staff schedules and the staff timecards for the week of 05/03/26 through 05/09/26 revealed a Registered Nurse (RN) did not work on 05/07/26 and 05/08/26. Further review revealed a Director of Nursing (DON) was not present in the facility on 05/05/26 through 05/09/26.Interview on 05/26/26 at 11:41 A.M. with Licensed Practical Nurse (LPN) #55 revealed the facility did not currently have a DON. LPN #55 stated RN, DON #82 came every Wednesday to serve as both the DON, and a RN and DON #84 came two days a week to serve as the DON for the facility. LPN #55 was unable to recall any other persons serving as DON in the facility since RN, DON #85 quit.Interview on 05/26/26 at 11:59 A.M. with RN #79 revealed RN, DON #84 was the current DON. RN #79 stated she was unaware of how often RN, DON #84 was in the facility and stated LPN #55 would know as she was in the facility more often than her.Interview on 05/27/26 at 8:00 A.M. with RN, DON #84 revealed she is the Regional Nurse and does not punch a clock and did not have any documentation to support that she had worked in the facility since the previous Director of Nursing left on 04/29/26. Interview on 05/27/26 at 10:31 A.M. with RN, DON #82 revealed she worked in the facility twice on 05/13/26 and 05/20/26 and did not work in the facility at all from 05/03/26 to 05/09/26.Interview on 05/27/26 at 10:34 A.M. with RN, DON #83 revealed the only date she worked in the facility was 05/04/26 and did not work 05/05/26 through 05/09/26.Interview on 05/27/26 at 10:58 A.M. with the Director of Operations (DOO) #86 verified RN, DON #83 was only in the facility on 05/04/26. DOO #86 stated that RN, DON #82 was serving as the DON however RN, DON #82 was only in the building the last two Wednesdays, 05/13/26 and 05/20/26. DOO #86 verified there was no DON coverage in the facility for 05/05/26 through 05/09/26. Furthermore, DOO #86 verified there was no RN in the facility on 05/07/26 and 05/08/26 as required.Upon request of a policy regarding full time DON coverage and RN hours in the facility, RN, DON #84 verified the facility did not have a policy as they follow the regulation.This deficiency represents non-compliance investigated under Master Complaint Number 2989641 and Complaint Number 2805820.

Based on medical record review, staff interview, and policy review, the facility failed to ensure enteral tube feeding was administered per physician orders. This affected one (#22) of three residents reviewed for enteral tube feeding. The facility identified three residents not receiving any food by mouth and on enteral tube feeding. The facility census was 21.Findings include: Review of Resident #22's medical record revealed an admission date of 12/16/25 and a discharge date of 02/20/26. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, type two diabetes mellitus without complications, peripheral vascular disease, squamous cell carcinoma of the skin, heart failure, cerebral infarction, and persistent vegetative state.Review of Resident #22's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was comatose. Furthermore, Resident #22 received nothing by mouth, had a gastrostomy tube (G-tube) and required enteral feeding for nutrition.Review of Resident #22's care plan dated 12/17/25 and revised 02/13/26 revealed the resident required a tube feeding related to dysphagia, persistent vegetative state, cerebral vascular accident (CVA), and nothing by mouth (NPO) status. Interventions included to administer enteral feedings and fluids via the feeding tube as ordered, keep head of bed elevated 45 degrees while administering tube feed and 30 minutes after the administration of the tube feeding, check for tube placement and gastric contents/residual per facility protocol and record, Registered Dietitian (RD) to evaluate quarterly and as needed to monitor caloric intake, estimate needs, and make recommendations for changes to the tube feeding as needed. Furthermore, Resident #22 was dependent for tube feeding and water flushes and to reference the physician orders for current feeding orders.Review of Resident #22's physician orders revealed orders written on 12/16/25 for the resident to receive nothing by mouth (NPO), to receive Jevity 1.5 at 45 milliliters (ml) per hour with a water flush of 130 ml every four hours, check feeding tube placement every shift, and to check for tube feed residuals each shift. On 12/19/25 an order was written to clear the feeding pump and document intake of the amount of Jevity 1.5 daily on the night shift. The tube feed order for Jevity 1.5 was changed on 01/27/26 to 50 ml per hour from 9:00 A.M. until 7:00 A.M. Review of Resident #22's Medication and Treatment Administration Record (MAR/TAR) for December 2025 revealed no tube feeding was documented as being administered on 12/19/25 and 12/20/25. Further review of the MAR/TAR revealed an intake of 2723 ml of tube feeding was documented as being administered on 12/27/25. Review of the MAR/TAR for January 2026 revealed no tube feeding was documented as being administered on 01/06/26, 01/07/26, 01/20/26, and 01/31/26. Tube feed residuals were not completed on 01/05/26 and 01/24/26 for the evening shift, or on 01/19/26 and 01/31/26 for the day shift. Feeding tube placement was not checked on 01/01/26 and 01/24/26 on the evening shift and 01/19/26 and 01/31/26 on the day shift. Tube feed residuals were not completed on the day shift on 01/19/26 and 01/31/26 and on the evening shift on 01/05/26 and 01/24/26. Further review of the MAR/TAR revealed the amount of tube feeding documented as administered on 01/08/26, 01/09/26 and 01/23/26 was zero with a range of between 858 ml to 3626 ml of tube feeding being administered on the other days. Review of the MAR/TAR for February 2026 revealed no tube feeding was documented as being administered on 02/01/26, 02/05/26, 02/06/26, 02/10/26, 02/11/26, 02/15/26, 02/18/26 and 02/19/26 as ordered and a range of between 30 ml to 2420 ml of tube feed being administered on the other days of the month. Feeding tube placement was not checked on 02/06/26 and 02/19/26 on the night shift. Tube feed residuals were not completed on 02/06/26 for the night shift. Interview on 05/27/26 at 1:10 P.M. with the Registered Nurse Director of Nursing (RN DON) #84 verified for the months of December 2025 and January and February 2026 there were multiple dates where no documentation was recorded regarding the amount of tube feeding that was administered to Resident #22, where feeding tube placement was not verified, and tube feeding residuals were not checked. Furthermore, RN DON #84 verified on multiple dates in December, January, and February, the facility documented Resident #22 was administered a volume of tube feeding that was not consistent with the physician order.Review of the facility policy titled Enteral Nutrition, revised January 2014 revealed adequate nutritional support through enteral feeding will be provided to residents as ordered.This deficiency represents non-compliance investigated under Complaint Number 2789196.

Based on policy review, observation, completion of a test tray, and resident and staff interviews, the facility failed to ensure food was served to the residents at palatable temperatures. This had the potential to affect 19 out of 21 residents who received meals from the facility. The facility identified two residents (#16 and #17) that received no food by mouth. The facility census was 21. Findings include: Observation of tray line on 06/18/25 from 7:25 A.M. through 7:58 A.M. revealed there was no pellet warmer, no plate warmer and food was above 164 degrees Fahrenheit (F) on the tray line. The food cart left the kitchen at 7:58 A.M. and arrived at the unit within a minute. Observation on 06/18/25 at 8:02 A.M. revealed Dietary Manager (DM) #210 stopped the breakfast tray pass and took temperatures. It was explained to DM #210 that after the last resident tray was delivered, food temperatures will be taken and documented on the test tray. When the last tray on the food cart was delivered on 06/18/25 at 8:06 A.M., DM #210 went to take the temperature of the food and stated the temperature for the scrambled eggs was 101.5 degrees F and sausage gravy was 111.5 degrees F. The test tray observation revealed the food tasted lukewarm. DM #210 stated the food should be hotter. During resident interviews on 06/16/25, Residents #15 and #24 had concerns with food service. Resident #24 stated breakfast was always cold. The facility identified two residents (#16 and #17) who did not receive food from the kitchen. Review of the undated facility policy titled Food Temperatures revealed temperatures to the residents will be within 120 to 140 degrees F based on resident's preference.

Based on resident and staff interview, record review, and review of the facility policy, the facility failed to timely notify the physician of the resident's changes in condition and/or abnormal laboratory results. This affected five (#4, #7, #16, #18, and #19) of five residents reviewed for notification of change. The facility census was 21. Findings include: 1. Record review for Resident #16 revealed an admission date of 09/14/22. Diagnoses included gastrostomy tube and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had gastrostomy, had a feeding tube, had weight loss, and was not on a prescribed weight loss regimen. Review of the care plan dated 03/19/25 revealed Resident #16 was at risk for impaired nutritional status. Interventions included percutaneous endoscopic gastrostomy (PEG) tube feedings and supplements via PEG tube as ordered by the physician. Review of the physician orders for Resident #16 dated 09/14/22 revealed an order for nothing by mouth (NPO) diet related to gastrostomy status. Vital 1.5 (tube feed formula) at 55 milliliters (ml) per hour via PEG tube. On 09/27/24, an order to check residual every shift, if greater than 500 cubic centimeters (cc) hold for two hours then resume per dietary recommendation. Review of the Treatment Administration Record (TAR) for June 2025 revealed Resident #16's tube feed residual was 0 to 200 cc every shift. The TAR revealed no indication the tube feeding was held. Review of the progress note dated 06/06/25 revealed Resident #16 was moaning, checked residual prior to medication administration, noted 200 cc of residual, held tube feed at this time and gave medications. There was no indication the physician was notified the facility held Resident #16's tube feed. The progress note dated 06/13/25 completed by Primary Physician #301 revealed Resident #16's abdomen was soft, non-distended, and had a PEG tube present. Primary Physician #301 stated to continue with tube feeding via PEG tube. Resident #16 had no further episodes of nausea and vomiting and will continue to monitor. The progress note dated 06/13/25 revealed Resident #16 had small emesis, and the residual was 200 cc. The nurse turned off tube feeding at this time. There was no indication the physician was notified the facility held Resident #16's tube feed. The progress note dated 06/13/25 at 4:22 A.M. completed by Licensed Practical Nurse (LPN) #199 revealed Resident #16 had a residual at 175 cc and the tube feed continues to be held. There was no indication the physician was notified the facility held Resident #16's tube feed. The progress note dated 06/17/25 revealed the nurse held the tube feed from 8:30 P.M. to present (4:30 A.M.). The current residual was 50 cc, and restarted the tube feed. There was no indication the physician was notified they held Resident #16's tube feed. Interview with the Director of Nursing (DON) on 06/17/25 at 2:15 P.M. confirmed the physician and/or the certified nurse practitioner (CNP) were not notified of the nursing staff holding Resident #16's tube feeding on 06/06/25 when the residual was 200 cc; 06/13/25 when Resident #16 had an emesis and the tube feeding was off for an undocumented amount of time, or 06/17/25 when the tube feeding was held for unknown reason. The DON stated it was obvious the nurses were not following the physician orders, Resident #16 had a high residual so the nurses hold the tube feed. The DON verified the highest residual documented on the TAR was 200 cc. DON verified the physician order was to hold the tube feed if greater than 500 cc, hold for two hours. DON revealed staff had been holding it for months when it was less than 500 cc because he had a history of vomiting and confirmed, but they did not notify the physician of the times they held it when they did not follow physician orders or when the resident vomited. The DON confirmed the physician should have been notified of the nursing staff holding the tube feeding, why, and for how long on 06/06/25, 06/13/25, and 06/17/25. 2. Record review for Resident #7 revealed an admission date of 03/13/25. Diagnosis included urinary tract infection (UTI). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was moderately cognitively impaired. Review of the care plan revised 06/16/25 revealed Resident #7 had a UTI. Interventions included to give antibiotic therapy as ordered, obtain and monitor lab diagnostic work as ordered. Report results to physician and follow up as indicated. Review of the physician orders for Resident #7 revealed an order dated 06/11/25 for a urinalysis with a culture and sensitivity. An additional order dated 06/13/25 was received for Resident #7 for Cipro HCL (antibiotic) oral tablet 500 milligrams (mg) give one tablet by mouth two times a day five days for a UTI. Review of the Medication Administration Record revealed Resident #7 received the Cipro two times a day on 06/14/25 through 06/17/25 at 5:00 P.M. Review of a book located at the nurse's station titled 'Med One Healthcare Partners' revealed there were directions on the outside and the inside of the book. The directions included, Please write down non-emergent patient issues. These issues will be addressed by the Certified Nurse Practitioner (CNP) or Physician during their next visit; For emergent patient issues, please call (number provided) for the Med One Provider. Observation inside the book revealed Resident #7's sensitivity results from the urinalysis with a urine culture was dated 06/12/25 (Thursday). The results of the culture revealed greater than 100,000 of Escherichia coli (e-coli). The results of the sensitivity revealed there was no sensitivity to Cipro. The copy of the result was stamped at the top of the page as received by the facility on 06/16/25 at 7:33 A.M. There was no indication the physician and/or CNP was notified of the abnormal urinalysis with a urine culture from 06/12/25 through 06/16/25. Interview on 06/17/25 at 2:15 P.M. with Director of Nursing (DON) confirmed the book titled Med One Healthcare Partners was to be used by the nurses for your information (FYI) for the physician/CNP. The DON confirmed Resident #7's culture results were placed in the book for the physician/CNP to review on their next visit which was normally every Tuesday and Friday but this week, both were on vacation. The DON verified the abnormal lab result should have not been placed in the book and should have been addressed immediately by the physician. The DON confirmed the physician/CNP were not notified of Resident #7's abnormal results received by the facility on 06/16/25. Telephone interview on 06/17/25 at 2:20 P.M. with Physician #301 with the DON present confirmed if there was a change in condition with a resident, the nursing staff need to notify the physician at that time and confirmed the notification, including an abnormal lab should not put in a book for review on the next visit. Physician #301 spoke to the DON on the telephone and gave intravenous antibiotic orders to be initiated for Resident #7 due to the abnormal culture received 06/16/25 at 7:33 A.M. Interview on 06/17/25 at 3:14 P.M. with Registered Nurse (RN) #211 revealed the Med One book was used by nurses to write a note to the physician/CNP regarding the resident's conditions that the physician or CNP would need notified about that was not considered an emergency. RN #211 revealed lab results were also left in the book for the physician or CNP to review on their rounds. RN #211 revealed the nurses do not call or notify the physician/CNP of the notes or results placed in the book. The physician/CNP will review them when they come in to the facility. 3. Review of the medical record for Resident #4 revealed an admission date of 07/16/21 with diagnoses including gastro-esophageal reflux disease (GERD) without esophagitis. Review of the care plan last revised on 12/13/24 revealed Resident #4 has GERD related to inappropriate diet. Interventions included giving medications as ordered. Review of Resident #4's physician order revealed an order dated 11/08/24 for magnesium oxide oral tablet 400 milligrams (mg), give one tablet by mouth twice daily for GERD. Review of the Medication Administration Record (MAR) for June 2025 revealed Resident #4 did not receive her magnesium oxide as physician ordered on 06/10/25 at 5:00 P.M., 06/11/25 at 9:00 A.M. and 5:00 P.M., 06/12/25 at 9:00 A.M., and 06/13/25 at 9:00 A.M. Resident #4's medical record did not indicate the physician and/or certified nurse practitioner (CNP) were notified Resident #4 did not receive her magnesium oxide as physician ordered. Interview on 06/17/25 at 7:13 A.M. with the Director of Nursing (DON) revealed magnesium oxide was not available in the facility and she was unsure why. The DON stated if it was an over-the-counter medication then she would go to the store and get it, if it was unavailable at the facility. The DON further stated the facility should notify the doctor if the residents do not receive their medication as physician ordered, and confirmed the facility did not update the physician after Resident #4 did not receive her magnesium oxide for multiple doses. 4. Review of the medical record for Resident #18 revealed an admission of 11/28/22 with a re-admission on [DATE] with diagnoses including quadriplegia and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of the care plan dated 03/12/25 revealed Resident #18 has bowel incontinence related to being quadriplegic and constipation related to decreased mobility. Interventions included following the protocol for bowel management and keeping the physician informed of any problems. Review of the bowel function documentation for 06/05/25 through 06/18/25 (14 days) revealed Resident #18 had two bowel movements on 06/08/25 at 1:59 P.M. and 06/17/25 at 1:45 P.M. Review of the physician's orders for Resident #18 revealed a routine order for Senna (treats constipation) oral tablet 8.6 milligrams (mg) by mouth daily. The following orders were as needed for signs and symptoms of constipation: fleet enema 7-19 grams (gm) per 118 milliliters (ml) insert one applicator full rectally if suppository is ineffective; Milk of Magnesia 400 mg per 5.0 ml give 30 ml by mouth every day for constipation relief; Miralax 17 g one cupful every other day for constipation relief; and Biscolax suppository 10 mg insert one suppository rectally for constipation relief. Review of the Medication Administration Record (MAR) revealed Miralax 17 g was administered on 06/15/25 at 5:04 P.M. with unknown results, and a fleet enema 17-19 g per 118 ml was administered on 06/16/25 at 11:30 P.M. with unknown results. There was no documentation that Resident #18 was offered and/or refused any of her medications to relieve her signs and symptoms of constipation from 06/09/25 to 06/16/25. There was no documentation the physician was notified Resident #18 did not have a bowel movement for eight days from 06/09/25 through 06/16/25. Interview on 06/18/25 at 11:59 A.M. with Resident #18 stated she was not feeling well due to not having a bowel movement for eight days. Resident #18 stated she received an enema on 06/16/25 and when she receives enemas, it makes her nauseous. Resident #18 stated she did have a bowel movement on 06/17/25. Interview on 06/18/25 at 12:39 P.M. with Licensed Practical Nurse (LPN) #206 stated she would ask the resident after three days of no bowel movement, and if the resident refuses, then they would follow up with the resident at five days. LPN #206 stated a bowel assessment should be done when a resident has not had a bowel movement for three days, and confirmed Resident #18 had no recent bowel assessments documented. LPN #206 stated the Director of Nursing (DON) would get flagged within the electronic medical record when a resident has not had a bowel movement in three days. LPN #206 stated communication between nurses would be done verbally or through the progress notes for bowel interventions. LPN #206 stated the doctor should be updated for residents who have not had bowel movement after intervention was implemented. LPN #206 confirmed the physician was not updated about Resident #18 not having not having a bowel movement for eight days. Interview on 06/18/25 at 12:48 P.M. with the DON revealed she was responsible for getting alerts on dashboard from the electronic medical record. The DON has no response when asked why no bowel protocol was followed with Resident #18. The DON confirmed the doctor was not updated about Resident #18 not having a bowel movement, and further confirmed the staff should be implementing a bowel protocol after three days of no bowel movement. 5. Review of the medical record for Resident #19 revealed an admission date of 02/14/25. Diagnoses included chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19. Review of a book located at the nurse's station titled 'Med One Healthcare Partners' revealed there were directions on the outside and the inside of the book. The directions included, Please write down non-emergent patient issues. These issues will be addressed by the Certified Nurse Practitioner (CNP) or Physician during their next visit; For emergent patient issues, please call (number provided) for the Med One Provider. Inside the book dated 06/14/24, Resident #19 complained of a sore throat. Resident #19's medical record did not have any documentation Resident #19 had a sore throat and the physician/CNP was notified that Resident #19 had a sore throat from 06/14/25 through 06/17/25. The progress note dated 06/18/25 at 12:37 P.M. revealed Resident #19 requested Tylenol (treats mild pain) for pain on the right side of neck/face. There was no documentation the physician/CNP were notified. Interview on 06/18/25 at 8:38 A.M. with the Director of Nursing (DON) verified the Med One Healthcare Partners book stated Resident #19 had a sore throat. The DON verified there was no documentation in the medical record that Resident #19 had a sore throat and the physician was notified. Interview on 06/18/25 at 9:34 A.M. with Resident #19 stated she had a sore throat, and nursing has been giving her Tylenol but nothing else. She stated her throat was still sore but did not hurt as much. An interview on 06/18/24 at 11:45 A.M. with Unit Manager #206 stated she did not know that Resident #19 had a sore throat because she did not look at the Med One book. LPN #206 stated CNP #307 and Physician #301 review the book when they come into the facility. LPN #206 stated CNP #307 and Physician #301 were both on vacation this week. Review of the facility policy titled Change in Resident's Condition or Status revised December 2016 revealed the nurse will notify the resident's attending physician or physician on call when there has been a need to alter the resident's medical treatment significantly.

Based on record review, facility policy review, and staff interview, the facility failed to ensure the pharmacy recommendations had a rationale documented as to why the physician did not agree with the recommendation. This affected four (Residents #2, #15, #18, and #20) of five residents reviewed for unnecessary medications. The facility census was 21. Findings include: 1. Review of the medical record for Resident #2 revealed a readmission date of 03/20/21. Diagnoses included major depressive disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had intact cognition, and received medications including an antidepressant. Review of the monthly pharmacy recommendations to the attending physician dated 05/31/25 revealed the pharmacist made a recommendation to evaluate Imipramine (treats depression) 50 milligram (mg) for a gradual dose reduction (GDR) to 25 mg by mouth every evening. The physician addressed the pharmacist recommendations on 06/03/25 that he disagreed with the GDR trial with no rationale as to why he disagreed with the GDR. Interview on 06/18/25 at 8:55 A.M. with Regional Director of Clinical Services (RDCS) #300 verified the physician did not provide a rationale as to why he disagreed with the pharmacist's recommendation to trial a GDR for Resident #2. 2. Review of the medical record for Resident #20 revealed an admission date of 04/12/23. Diagnoses included anxiety disorder and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had moderately impaired cognition. Review of the monthly pharmacy recommendations to the attending physician dated 12/27/24 revealed the pharmacist made a recommendation to evaluate Buspirone (treats anxiety disorder) five milligram (mg) twice a day for a gradual dose reduction (GDR) to once a day. The physician addressed the pharmacist recommendations on 12/30/24 that he disagreed with the GDR trial with no rationale as to why he disagreed with the GDR. Interview on 06/18/25 at 8:57 A.M. with Regional Director of Clinical Services (RDCS) #300 verified the physician did not provide a rationale as to why he disagreed with the pharmacist's recommendation to trial a GDR for Resident #20. 3. Review of the medical record for Resident #18 revealed an admission of 11/28/22. Diagnoses included bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact. Review of the physicians orders for Resident #18 revealed on 10/15/24, there were orders for Seroquel 12.5 milligrams (mg) by mouth two times a day related to bipolar disorder, Seroquel 50 mg give one tablet at bedtime and trazodone (atypical antidepressant) 150 mg at bedtime. Review of the pharmacy recommendation for Resident #18 dated 11/29/24 revealed the pharmacist recommended to evaluate the use of low dose Seroquel as there was not an indication for a low dose unless being titrated upward to an effective dose. The use of low-dose Quetiapine (Seroquel) can increase the risk of adverse side effects. Seroquel was not a scored tablet and splitting was not recommended and can result in an uneven dose. The pharmacy recommended a trial gradual dose reduction (GDR) to Seroquel 50 mg at night time. Doctor #301 marked disagree and did not provide a rationale to why he disagreed with the pharmacy recommendation. Review of the pharmacy recommendation for Resident #18 dated 06/03/25 revealed the pharmacist recommended a GDR of trazodone 100 mg by mouth at night. If warranted and not clinically contraindicated suggest a trial GDR. Doctor #301 marked disagree and did not provide a rationale to why he disagreed with the pharmacy recommendation. Interview with Regional Director of Clinical Services (RDCS) #300 on 06/18/25 at 8:57 A.M. confirmed the physician did not provide a rationale as to why he disagreed with the pharmacist's recommendation to trial a GDR for Resident #18. 4. Review of the medical record for Resident #15 revealed an admission date of 12/21/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Review of the pharmacy recommendation dated 02/25/25 revealed Resident #15 was receiving Gabapentin oral capsule 300 milligrams (mg) by mouth three times a date related to lumbago with sciatic right and left side. The pharmacy recommended monitoring Basic Metabolic Panel (BMP) (laboratory work) and consider alternate dosing. Facility Doctor #300 marked disagree and did not provide his rationale. Interview with Regional Director of Clinical Services (RDCS) #300 on 06/18/25 at 8:57 A.M. confirmed the physician did not provide a rationale for disagreeing with the pharmacy recommendations for Resident #15. Review of the facility policy titled Medication Regimen Reviews dated April 2007 revealed the pharmacist will submit a quarterly report that includes key summary information including recommended solutions to problem areas and staff performance was complying with regulatory requirements related to medication utilization and monitoring.

Based on record review, facility policy review, and staff interview, the facility failed to ensure care plan meetings consisted of interdisciplinary team members determined by the residents' needs and failed to ensure the resident and/or resident representative were invited to attend the quarterly care conference meetings. This affected one (#3) of two residents reviewed for care plan meetings. The facility census was 21. Findings include: Record review for Resident #3 revealed an admission date of 03/01/24. Diagnoses included Parkinson's disease, chronic obstructive pulmonary disease, acute respiratory failure with hypercapnia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was severely cognitively impaired and required staff assistance with activities of daily living. Review of the previous 12 months of care conferences for Resident #3 revealed a care conference was held 08/24/24. Attendees included the Director of Nursing (DON), Activities, and Maintenance and no family attended. The next care conference dated 11/14/24 revealed the DON and Activities Director were the only facility staff who attended or participated. The care conference dated 02/21/25 revealed the attendees included DON and Social Worker, and no family were documented as invited. The care conference dated 05/23/25 revealed the DON, social worker and Resident #3's daughter attended. Interview on 06/16/25 at 12:09 P.M. with Social Worker Designee (SWD) #305 and the DON revealed she was new to the facility within the last month and confirmed she did complete the care conference for Resident #3 on 05/23/25. SWD #305 confirmed the DON, herself and Resident #3's daughter were the only attendees present during the care plan meeting. No other facility disciplines were involved. The DON confirmed on 02/21/25 no family members were invited to the care conference and the DON and Social Worker were the only disciplines involved in the meeting. Review of the facility policy titled Care Planning - Interdisciplinary Team revised September 2013 revealed the resident, the resident's family and or the residents legal representative/guardian or surrogate are encouraged to participate in the development of and revision to the resident's care plan. Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. The care plan is based on the resident's comprehensive assessment and is developed by the Care Planning/ Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: The resident's attending physician, Registered Nurse, Dietary Manager/Dietitian, Social Worker, Activity Director, Therapist, Consultants, DON, Charge nurse responsible for the resident's care, Nursing Assistant responsible for the resident's care, and others as appropriate or necessary to meet the needs of the resident.

2. Record review for Resident #16 revealed an admission date of 09/14/22. Diagnoses included anoxic brain damage, retention of urine, and paraplegia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was dependent on staff for all activities of daily living and Resident #16 had an indwelling catheter. Review of the care plan last revised 04/07/25 revealed Resident #16 had an indwelling catheter. The goals included Resident #16 would show no signs or symptoms of urinary tract infections (UTI) through review date. Review of the infection log for the previous 12 months revealed Resident #16 had a UTI and received antibiotics on 08/26/24, 12/27/24, 03/10/25, and 04/16/25. Review of the physician orders for Resident #16 dated 01/13/25 revealed an order for catheter care every shift and as needed. Observation on 06/17/25 at 9:10 A.M. of catheter care for Resident #16 provided by Certified Nursing Assistant (CNA) #215 revealed CNA #214 began catheter care by using a wet washcloth and began by washing between both Resident #16's thighs. CNA #215 then used the same area on the washcloth and with one continuous motion washed under Resident #16's scrotum/rectal area up to the meatus of the penis then the catheter tubing insertion site. CNA #215 then took a second wash cloth and rinsed the peri area and catheter tubing using the same pattern, from the bottom of the scrotal/rectal area to the catheter insertion site. CNA #215 confirmed the observation of catheter care. CNA #215 did not use circular strokes, did not start with meatus and work outward and instead worked inward, and did not change the washcloth with each stroke. Interview on 06/17/25 at 2:20 P.M. with Medical Director #301 revealed they were were Resident #16's primary care physician. Medical Director #301 stated Resident #16 could get a UTI when not providing catheter care appropriately. Medical Director #301 stated the facility staff needed to follow protocol. Review of the facility policy titled Catheter Care revised September 2014 revealed for a male resident, use a washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Based on medical record review, observation, resident and staff interview, and review of the facility policy, the facility failed to ensure Resident #16 received catheter care to prevent urinary tract infections and Resident #18 received care and treatment timely for constipation. This affected two of three residents reviewed (Resident #16 and #18) for bowel and bladder. The facility census was 21. Findings include: 1. Review of the medical record for Resident #18 revealed an admission of 11/28/22 with a re-admission on [DATE] with diagnoses including quadriplegia and neuromuscular dysfunction of bladder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 was cognitively intact and was dependent on staff for toileting. Review of the care plan dated 03/12/25 revealed Resident #18 has bowel incontinence related to being quadriplegic and constipation related to decreased mobility. Interventions included following the protocol for bowel management and keeping the physician informed of any problems. Review of the bowel function documentation for 06/05/25 through 06/18/25 (14 days) revealed Resident #18 had two bowel movements on 06/08/25 at 1:59 P.M. and 06/17/25 at 1:45 P.M. Review of the physician's orders for Resident #18 revealed a routine order for Senna (treats constipation) oral tablet 8.6 milligrams (mg) by mouth daily. The following orders were as needed for signs and symptoms of constipation: fleet enema 7-19 grams (gm) per 118 milliliters (ml) insert one applicator full rectally if suppository is ineffective; Milk of Magnesia 400 mg per 5.0 ml give 30 ml by mouth every day for constipation relief; Miralax 17 g one cupful every other day for constipation relief; and Biscolax suppository 10 mg insert one suppository rectally for constipation relief. Review of the Medication Administration Record (MAR) revealed Miralax 17 g was administered on 06/15/25 at 5:04 P.M. with unknown results, and a fleet enema 17-19 g per 118 ml was administered on 06/16/25 at 11:30 P.M. with unknown results. There was no documentation that Resident #18 was offered and/or refused any of her medications to relieve her signs and symptoms of constipation from 06/09/25 to 06/16/25. There was no documentation the physician was notified Resident #18 did not have a bowel movement for eight days from 06/09/25 through 06/16/25. Interview on 06/18/25 at 11:59 A.M. with Resident #18 stated she was not feeling well due to not having a bowel movement for eight days. Resident #18 stated she received an enema on 06/16/25 and when she receives enemas, it makes her nauseous. Resident #18 stated she did have a bowel movement on 06/17/25. Interview on 06/18/25 at 12:22 P.M. with Certified Nursing Assistant (CNA) #309 revealed the CNAs document bowel movements in in the electronic medical record and the system will trigger to the dashboard if a resident has not had a bowel movement in three days. CNA #309 stated the CNAs were able to put in a subnote in regards to bowel movements. CNA #309 stated the Director Of Nursing (DON) was the person who takes care of the bowel movement list. CNA #309 stated Resident #18 told her she had not had a bowel movement in eight days, and that Resident #18 did not want to keep getting enemas to go to the bathroom. CNA #309 stated she reported Resident #18's concerns to the nurse. Interview on 06/18/25 at 12:39 P.M. with Licensed Practical Nurse (LPN) #206 stated she would ask the resident after three days of no bowel movement, and if the resident refuses, then they would follow up with the resident at five days. LPN #206 stated a bowel assessment should be done when a resident has not had a bowel movement for three days, and confirmed Resident #18 had no recent bowel assessments documented. LPN #206 stated the Director of Nursing (DON) would get flagged within the electronic medical record when a resident has not had a bowel movement in three days. LPN #206 stated communication between nurses would be done verbally or through the progress notes for bowel interventions. LPN #206 stated the doctor should be updated for residents who have not had bowel movement after intervention was implemented. LPN #206 confirmed the physician was not updated about Resident #18 not having not having a bowel movement for eight days. Interview on 06/18/25 at 12:48 P.M. with the DON revealed she was responsible for getting alerts on dashboard from the electronic medical record. The DON has no response when asked why no bowel protocol was followed with Resident #18. The DON confirmed the doctor was not updated about Resident #18 not having a bowel movement, and further confirmed the staff should be implementing a bowel protocol after three days of no bowel movement. Review of the facility policy titled Bowel (Lower Gastrointestinal Tract) Disorders- Clinical Protocol dated September 2012 revealed the facility will check for diffuse or localized tenderness and listen for bowel sounds in areas of suspected obstruction, and in addition the nurse will assess vitals, and an abdominal assessment. The staff and physician will monitor the individuals response to interventions and overall progress.

Based on interview, record review, and review of the facility policy, the facility failed to ensure a resident was administered tube feeding through their percutaneous endoscopic gastrostomy (PEG) as physician ordered. This affected one (Resident #16) of one resident reviewed for tube feedings. The facility census was 21. Findings include: Record review for Resident #16 revealed an admission date of 09/14/22. Diagnoses included gastrostomy tube and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had gastrostomy, had a feeding tube, had weight loss and was not on a prescribed weight loss regimen. Review of the care plan dated 03/19/25 revealed Resident #16 was at risk for impaired nutritional status. Interventions included tube feedings and supplements via PEG tube as ordered by the physician. Review of the physician orders for Resident #16 dated 09/14/22 revealed an order for nothing by mouth (NPO) diet related to gastrostomy status. Vital 1.5 (tube feed formula) at 55 milliliters (ml) per hour via PEG tube. On 09/27/24, an order to check residual every shift, if greater than 500 cubic centimeters (cc) hold for two hours then resume per dietary recommendation. This indicated Resident #16's sole source of nutrition was through the tube feedings. Review of the Treatment Administration Record (TAR) for June 2025 revealed Resident #16's tube feed residual was 0 to 200 cc every shift. The TAR revealed no indication the tube feeding was held. Review of the progress note dated 06/06/25 revealed Resident #16 was moaning, checked residual prior to medication administration, noted 200 cc of residual, held tube feed at this time and gave medications. There was no indication the physician or registered dietitian (RD) was notified the facility held Resident #16's tube feed. Review of the Nutrition/Weight note for Resident #16 dated 06/09/25 at 10:14 A.M. completed by RD #302 revealed weight appeared on a trend with usual body weight stabilizing. At this time resident remains on appropriate nutrition prescription, no new recommendations. The progress note dated 06/13/25 completed by Primary Physician #301 revealed Resident #16's abdomen was soft, non-distended, and had a PEG tube present. Primary Physician #301 stated to continue with tube feeding via PEG tube. Resident #16 had no further episodes of nausea and vomiting and will continue to monitor. The progress note dated 06/13/25 revealed Resident #16 had small emesis, and the residual was 200 cc. The nurse turned off tube feeding at this time. There was no indication the physician or RD was notified the facility held Resident #16's tube feed. The progress note dated 06/13/25 at 4:22 A.M. completed by Licensed Practical Nurse (LPN) #199 revealed Resident #16 had a residual at 175 cc and the tube feed continues to be held. There was no indication the physician or RD was notified the facility held Resident #16's tube feed. The progress note dated 06/17/25 revealed the nurse held the tube feed from 8:30 P.M. to present (4:30 A.M.). The current residual was 50 cc, and restarted the tube feed. There was no indication the physician or RD was notified they held Resident #16's tube feed. Interview with the Director of Nursing (DON) on 06/17/25 at 2:15 P.M. confirmed the physician nor RD were notified of the nursing staff were holding Resident #16's tube feeding, including on 06/06/25 when the residual was 200 cc; 06/13/25 when Resident #16 had an emesis and the tube feeding was off for an undocumented amount of time, or 06/17/25 when the tube feeding was held for unknown reason. The DON stated it was obvious nursing was not following physician orders, and said Resident #16 had high residuals so they hold the tube feed. The DON verified the highest residual documented on the TAR was 200 cc. The DON verified the physician order and RD recommendation was to hold the tube feed if greater than 500 cc, and hold for two hours. The DON stated staff had been holding it for months when it was less than 500 cc because he had a history of vomiting and confirmed, but they did not notify the physician of the times they held it when they did not follow physician orders or when the resident vomited. Interview on 06/18/25 at 9:44 A.M. with RD #302 stated the facility does not notify her of holding Resident #16's tube feeding, and verified they should be. RD #302 stated what research shows for the limit for gastric residual, if there was no emesis, they should not hold the tube feeding. RD #302 stated shutting the tube feeding on and off could impact the resident's estimated energy needs of the tube feeding. Review of the facility policy titled Acute Condition Changes - Clinical Protocol revised December 2015 revealed the nursing staff and physician will discuss possible causes of the condition change. The physician will help identify and authorize appropriate treatments.

Based on observations, staff interview, record review, and review of the facility policy, the facility failed to ensure a resident was assessed for the need for oxygen use and receive oxygen per the physicians orders. This affected one (Resident #3) of one resident reviewed for oxygen use. The facility identified three current residents who received oxygen administration. The facility census was 21. Findings include: Record review for Resident #3 revealed an admission date of 03/01/24. Diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was severely cognitively impaired. Resident #3 was dependent for bed mobility and transfers and required staff assistance for all activities of daily living. Review of the care plan dated 05/15/23 revealed Resident #3 had COPD/seasonal allergies, acute respiratory failure with hypoxia and hypercapnia and obstructive sleep apnea. Interventions included to monitor for signs and symptoms of acute respiratory insufficiency and oxygen at two liters per nasal cannula as needed. Review of the physician order for Resident #3 dated 05/17/24 revealed oxygen via nasal cannula (NC) at two liters as needed (PRN) every one hour for shortness of breath (SOB) maintain saturation of peripheral oxygen (SP02) at 90% or above. Review of the Treatment Administration Record (TAR) for Resident #3 revealed the order for oxygen via NC at two liters PRN every one hour for SOB, maintain SP02 at 90% or above was initialed as used on 06/06/25 at 11:32 A.M. No further indication of oxygen use was documented for the month of June 2025. No oxygen saturations were documented on the TAR. Review of the weights and vital signs report for Resident #3 revealed no oxygen saturations were documented for the month of July 2025. Observations on 06/16/25 at 9:02 A.M. and 06/17/25 at 5:12 P.M. revealed Resident #3 was sitting up in her bedside chair resting. Resident #3 was receiving oxygen at 2.5 liters per minute via NC. Observation and interview on 06/17/25 at 5:16 P.M. with Registered Nurse (RN) #211 confirmed Resident #3 was receiving oxygen at 2.5 liters per minute via NC. RN #211 stated Resident #3 received oxygen continuously even when leaving her room for meals. RN #211 confirmed Resident #3's physician order was for oxygen via NC at two liters PRN every one hour for SOB, maintain SP02 at 90% or above. RN #211 confirmed no saturations were documented for the month of July 2024 to determine SP02 level. Interview on 06/17/25 at 5:28 P.M. with the Director of Nursing (DON) revealed Resident #3 wore her oxygen all the time. The DON confirmed nurses were not monitoring oxygen saturation levels and documenting the use of the oxygen and stated the nurses were obviously not following the physician's orders. The DON confirmed the oxygen saturation should be assessed every shift and as needed to ensure oxygen saturation was 90% or above per the physician orders. Review of the facility policy titled Oxygen Administration revised October 2010 revealed guidelines for safe oxygen administration which included to verify there is a physician's order for this procedure. The policy included assessing oxygen saturation if applicable. Document the date and time the procedure was performed and the rate of oxygen flow, route and rationale.

Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure medications ordered by the physician were ordered and available for administration. The affected one (Resident #4) of four residents reviewed for medications. The facility census was 21. Findings include: Review of the medical record for Resident #4 revealed an admission date of 07/16/21 with diagnoses including gastro-esophageal reflux disease (GERD) without esophagitis. Review of the care plan last revised on 12/13/24 revealed Resident #4 has GERD related to inappropriate diet. Interventions included giving medications as ordered. Review of Resident #4's physician order revealed an order dated 11/08/24 for magnesium oxide oral tablet 400 milligrams (mg) (an over-the-counter (OTC) supplement), give one tablet by mouth twice daily for GERD. Review of the Medication Administration Record (MAR) for June 2025 revealed Resident #4 did not receive her magnesium oxide as physician ordered on 06/10/25 at 5:00 P.M., 06/11/25 at 9:00 A.M. and 5:00 P.M., 06/12/25 at 9:00 A.M., and 06/13/25 at 9:00 A.M. Review of the medication order forms from 05/30/25 through 06/11/25 revealed magnesium oxide was not on the medication reorder form. The medication delivery receipt confirmed magnesium oxide was not delivered. Interview on 06/17/25 at 7:13 A.M. with the Director of Nursing (DON) revealed magnesium oxide was not available in the facility and she was unsure why. The DON stated if it was an OTC medication then she would go to the store and get it, if it was unavailable at the facility. The DON further stated the facility should notify the doctor if the residents do not receive their medication as physician ordered, and confirmed the facility did not update the physician after Resident #4 did not receive her magnesium oxide for multiple doses. Interview on 06/17/25 at 8:01 A.M. with Licensed Practical Nurse (LPN) #224 revealed house stock medications were ordered through a company called Medline. The nurse would mark down when a central supply medication needed reordered and activities orders them. LPN #224 further stated if the facility runs out of an OTC medication, they will go to a store and buy it. Interview on 06/17/25 at 11:25 A.M. with Activities Director #220 revealed there was a clip board with order sheets for central supply items, including medications. The nurse would go through and mark how many bottles of medication they needed and how many the facility had on hand. AD #220 would then order the medication from Procurement Partners. AD #220 stated if they did not have the OTC medication, either herself, the other activity aid, or the DON would go to the store and get the medication. AD #220 stated magnesium oxide was just ordered on 06/16/25 and would arrive in two to three days. Review of the undated facility policy titled Medication and Treatment Orders revealed drug and biological orders must be given as prescribed by the physician.

Based on observation, interview, record review, review of Medscape guidance, and review of the manufacturer directions, the facility failed to ensure the medication rate did not exceed five percent (%). There were two errors within 27 opportunities for an error rate of 7.41%. This affected two (Resident #16 and #24) of two residents reviewed for medication administration. The facility census was 21. Findings include: 1. Record review for Resident #24 revealed an admission date of 03/27/25. Diagnosis included type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 had diabetes mellitus and received insulin injections. Review of the care plan dated 03/28/25 revealed Resident #24 had diabetes mellitus type two with hyperglycemia. Interventions included accuchecks as ordered and administer medications. Review of the physician orders for Resident #24 dated 06/05/25 revealed insulin Lispro injection solution 100 units/milliliter (ml) solution inject 20 units subcutaneously three times a day every Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday for diabetes mellitus. Observation on 06/18/25 at 11:51 A.M. revealed Licensed Practical Nurse (LPN) #206 administered medications to Resident #24. LPN #206 placed a needle on Resident #24's Lispro insulin pen. LPN #206 then set the pen at 20 units. LPN #206 verified the 20 units and administered the insulin to Resident #24. Observation revealed LPN #206 never primed the insulin pen after applying the needle and before injecting the medication. LPN #206 returned to the medication cart, when asked about priming the insulin pen, LPN #206 stated, I thought you didn't need to prime for that, only the needles. LPN #206 pulled an insulin syringe out of the drawer revealing she believed those were the only needles requiring priming. LPN #206 then stated, Oh well, I did do it in the room before I gave it, one unit, didn't you see me. Surveyor confirmed she never took her eyes off the insulin pen and the pen was never primed. Review of the manufacturers directions titled, Instructions for Use of Insulin Lispro Kwikpen revealed always use a new needle for each injection. Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Review of Medscape guidance titled Intermittent Insulin Injections Insulin Overview dated 11/05/20 and located at https://emedicine.medscape.com/article/2049311-overview#a1 revealed to avoid air and to ensure proper dose, you will need to prime the syringe each time; to do this, dial two units; hold the pen with the needle pointing up and tap the cartridge gently a few times to get rid of any air bubble; press the push button all the way in until the dose selector returns to zero; a drop of insulin must appear at the needle tip; if not, change the needle and repeat the procedure. 2. Record review for Resident #16 revealed an admission date of 09/14/22. Diagnosis included acute and chronic respiratory failure and gastrostomy tube. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 had a feeding tube. Review of the physician orders dated 09/14/22 revealed Resident #16 was to receive nothing by mouth (NPO) diet related to gastrostomy status. An additional order dated 03/15/25 revealed cerovite advanced formula liquid (multivitamin) give five teaspoons (equivalent to 24.6 milliliters) one time a day. Observation of medication administration on 06/17/25 at 8:04 A.M. revealed Licensed Practical Nurse (LPN) #224 administered 30 milliliters (ml) of cerovite to Resident #16 via feeding tube. LPN #224 confirmed she administered 30 ml of cerovite. Interview on 06/18/25 at 9:20 A.M. with Director of Nursing (DON) confirmed there were five ml per teaspoon and Resident #16 should have received 25 ml of cerovite, not 30 ml.

Based on observation, interview, record review, review of Medscape guidance, and review of the manufacturer directions, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #24) of two residents reviewed for medication administration. The facility identified eight residents who receive insulin. The facility census was 21. Findings include: Record review for Resident #24 revealed an admission date of 03/27/25. Diagnosis included type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 had diabetes mellitus and received insulin injections. Review of the care plan dated 03/28/25 revealed Resident #24 had diabetes mellitus type two with hyperglycemia. Interventions included accuchecks as ordered and administer medications. Review of the physician orders for Resident #24 dated 06/05/25 revealed insulin Lispro injection solution 100 units/milliliter (ml) solution inject 20 units subcutaneously three times a day every Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday for diabetes mellitus. Observation on 06/18/25 at 11:51 A.M. revealed Licensed Practical Nurse (LPN) #206 administered medications to Resident #24. LPN #206 placed a needle on Resident #24's Lispro insulin pen. LPN #206 then set the pen at 20 units. LPN #206 verified the 20 units and administered the insulin to Resident #24. Observation revealed LPN #206 never primed the insulin pen after applying the needle and before injecting the medication. LPN #206 returned to the medication cart, when asked about priming the insulin pen, LPN #206 stated, I thought you didn't need to prime for that, only the needles. LPN #206 pulled an insulin syringe out of the drawer revealing she believed those were the only needles requiring priming. LPN #206 then stated, Oh well, I did do it in the room before I gave it, one unit, didn't you see me. Surveyor confirmed she never took her eyes off the insulin pen and the pen was never primed. Review of the manufacturers directions titled, Instructions for Use of Insulin Lispro Kwikpen revealed always use a new needle for each injection. Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Review of Medscape guidance titled Intermittent Insulin Injections Insulin Overview dated 11/05/20 and located at https://emedicine.medscape.com/article/2049311-overview#a1 revealed to avoid air and to ensure proper dose, you will need to prime the syringe each time; to do this, dial two units; hold the pen with the needle pointing up and tap the cartridge gently a few times to get rid of any air bubble; press the push button all the way in until the dose selector returns to zero; a drop of insulin must appear at the needle tip; if not, change the needle and repeat the procedure.

Based on policy review, observation, and staff interviews, the facility failed to ensure food was served at proper consistency for mechanical soft and ground meat diets. This had the potential to affect three residents (#4, #8, and #21) that were ordered either a mechanical soft or ground meat diet. The facility census was 21. Findings include: Observation on 06/18/24 at 7:37 A.M. revealed [NAME] #223 plated Resident #21's plate with sausage gravy and it was placed into the food cart. Dietary Manager (DM) #210 was asked to remove Resident #21's food tray from the food cart. Resident #21's sausage gravy was of regular consistency with the sausage cut into 1/2 inch pieces. DM #210 verified Resident #21's was on a mechanical soft diet and the meat should have been ground. DM #210 proceeded to put Resident #21's tray back into the food cart, then paused and grounded some sausage gravy for Resident #21 and the other mechanical and ground diets. The telephone interview on 06/18/25 at 11:49 A.M. with Speech Therapist #303 revealed it was her expectation to have ground meat like hamburger for mechanical soft and ground texture diets. The facility identified three residents (#4, #8, and #21) were on a mechanical soft or ground meat diet. Review of the undated facility policy titled Mechanical Soft Diet revealed the mechanical soft diet is modified in consistency to reduce the amount of chewing required to consume food. The mechanical soft diet included food modified in texture for the ease of mastication.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure accurate documentation in the medical record for one (Resident #16) of 28 medical records reviewed. Findings include: Record review for Resident #16 revealed an admission date of 09/14/22. Diagnosis included anoxic brain damage, gastrostomy tube, dysphagia, and paraplegia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 had gastrostomy tube. Review of the physician orders for Resident #16 revealed an order for nothing by mouth (NPO) diet related to gastrostomy status dated 09/14/22; Cerovite advanced formula liquid (multivitamin), give five teaspoons by mouth one time a day dated 03/15/25; Vitamin C 500 milligrams (mg) by mouth once daily dated 03/16/2; and Acetaminophen tablet 325 mg give two tablets by mouth every four hours as needed for pain dated 12/02/24. Observation of medication administration on 06/17/25 at 8:04 A.M. revealed LPN #224 administered Resident #16's cerovite and vitamin C via Percutaneous Endoscopic Gastrostomy (PEG) tube. LPN #224 then documented with her initials on the Medication Administration Record (MAR) under the order for the cerovite and vitamin C revealing the medication was administered per the orders. Interview with the Director of Nursing (DON) on 06/17/25 at 2:15 P.M. confirmed nurses documented daily on the Resident #16's MAR that Resident #16 received cerovite and vitamin C by mouth. The DON confirmed this was inaccurate documentation, Resident #16 was nothing by mouth (NPO), and in a continuous vegetative state since admission. Interview on 06/17/25 at 2:20 P.M. with Physician #301 confirmed Resident #16 was NPO and should not have any medications by mouth. Physician #301 stated Resident #16 was unresponsive and in a vegetative state since admission. Review of the facility policy titled Charting and Documentation revised July 2017 revealed documentation in the medical record will be objective, complete and accurate.

Based on observation, interview, record review, review of Centers for Disease Control and Prevention (CDC) guidance, and review of the facility policy, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) as ordered by the physician when completing high contact resident care activities with residents with indwelling medical devices and pressure ulcers. Additionally, the facility failed to follow the proper infection control practices during fingerstick checks and the shared glucometer was not properly cleaned and disinfected after use. This affected two residents (#16 and #24). The facility identified there were two residents who receive blood sugar checks utilizing the same glucometer and eight residents on EBP. The facility census was 21. Findings include: 1. Record review for Resident #16 revealed an admission date of 09/14/22. Diagnoses included acute and chronic respiratory failure, gastrostomy tube, pressure ulcer left and right buttocks stage four (Full thickness tissue loss with exposed bone, tendon or muscle), local infection of skin and subcutaneous tissue, dysphagia, and retention of urine. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #16 was dependent on staff for all activities of daily living. Resident #16 had an indwelling catheter, an ostomy, gastrostomy status, and pressure ulcers of the right and left buttocks. Review of the care plan for Resident #16 dated 04/02/24 revealed EBP related to indwelling medical device, wounds and/or infection or colonization with an Multidrug-resistant Organisms (MDROs) (when contact precautions do not apply) during high contact resident care activities. Review of the physician orders for Resident #16 dated 04/16/24 revealed an order for EBP related to indwelling medical device and/or wounds and/or infection or colonization with an MDRO during high contact resident care activities. Observation on 06/17/25 at 8:04 A.M. revealed Licensed Practical Nurse (LPN) #224 administered medications to Resident #16. LPN #224 confirmed Resident #16 had a feeding tube, indwelling catheter and stage four pressure ulcers. LPN #224 did not donn an isolation gown and administered 14 medications via Resident #16's feeding tube. LPN #224 confirmed she never donned an isolation gown and stated EBP were for wound care only. LPN #224 stated staff did not need to donn the isolation gowns unless providing the wound care. Observation on 06/17/25 at 9:10 A.M. revealed Certified Nursing Assistant (CNA) #215 provided catheter care for Resident #16. CNA #215 never donned an isolation gown and completed catheter care for Resident #16. CNA #215 confirmed she never wore an isolation gown during catheter care and she thought only the nurses had to were an isolation gown. CNA #215 stated 'they' never said anything to us. Interview on 06/17/25 at 10:00 A.M. with Regional Director of Clinical Services (RDCS) #300 stated the facility expects staff to follow CDC guidelines and wear Personal Protective Equipment (PPE) for high-risk activities including catheters, any tubes, lines, or drains. RDCS #300 confirmed the CNA and nurse worked throughout the day with all residents. Review of the facility policy titled Enhanced Barrier Precautions dated 04/01/24 revealed EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status. Review of CDC guidance titled Implementation of PPE Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html and dated 04/02/24 revealed MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. EBP are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds or indwelling medical devices, regardless of MDRO colonization status. 2. Record review for Resident #24 revealed an admission date of 03/27/25. Diagnosis included type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 had diabetes mellitus and received insulin injections. Review of the care plan dated 03/28/25 revealed Resident #24 had diabetes mellitus type two with hyperglycemia. Interventions included accuchecks as ordered and administer medications as ordered. Review of the physician orders dated 06/05/25 for Resident #24 revealed insulin lispro injection solution 100 units/milliliter (ml) solution inject 20 units subcutaneously (sq) three times a day every Tuesday, Wednesday, Thursday, Friday, Saturday, and Sunday for diabetes mellitus. Observation on 06/17/25 at 8:30 A.M. revealed LPN #224 assessed Resident #24's blood sugar via fingerstick and a glucometer. LPN #224 removed the uncovered glucometer from the top drawer of the medication cart. LPN #224 then entered Resident #24's room and assessed the fingerstick blood sugar. After assessing the blood sugar, LPN #224 returned to the medication cart with the glucometer. LPN #224 wiped off the glucometer with a sani wipe for less than eight seconds then returned the glucometer back to the top drawer of the medication cart uncovered. LPN #224 confirmed she used the same glucometer for all residents who required a fingerstick blood sugar. LPN #224 confirmed she wiped the glucometer off with the sani wipe for approximately eight seconds before returning it to the medication cart drawer and revealed she never wrapped the glucometer with a wipe. Observation on 07/17/25 at 4:53 P.M. revealed Registered Nurse (RN) #211 completed a fingerstick blood sugar assessment on Resident #24. RN #211 wiped Resident #24's finger off with an alcohol wipe, then pulled Resident #24's finger to her mouth, and blew her air from her mouth onto Resident #24's finger that she just wiped with alcohol. RN #211 then pricked the same finger with the lancet to draw blood to assess the blood sugar via the glucometer. RN #221 confirmed she cleaned Resident #24's finger with alcohol to prepare to lance it. RN #211 confirmed she blows her air onto the resident's skin to dry if off before completing a finger stick. Observation on 07/18/25 at 8:10 A.M. revealed LPN #206 removed the uncovered glucometer from the top drawer of the medication cart, then entered Resident #24's room, and assessed the fingerstick blood sugar. After assessing the blood sugar, LPN #206 returned to the medication cart with the glucometer. LPN #206 wiped off the glucometer with a microdot bleach wipe for less than 10 seconds, then returned the glucometer back to the top drawer of the medication cart uncovered. LPN #206 confirmed she wiped the glucometer off with the microdot wipe for approximately 10 seconds before returning it to the medication cart drawer. Review of the direction on the microdot container with LPN #206 confirmed the cleaning process of the glucometer included a wet time of three minutes with use of the microdot wipe. Interview on 06/18/25 at 9:05 A.M. with Regional Director of Clinical Services (RDCS) #300 confirmed the manufacturer recommendations for the sani wipe contact time while cleaning a glucometer was two minutes; when using the microdot bleach wipes, the contact time was three minutes. Review of the facility policy titled Blood Glucose Monitoring System revised 08/2015 revealed to minimize the risk of transmitting blood borne pathogens, the cleaning and disinfecting procedure should be performed as recommended in the instructions below. Disinfectants were validated separately and only one cleaning/disinfecting solution should be used on the device, as the effect of using more than one cleaner/disinfectant interchangeably has not been evaluated. Using a towelette wipe the entire surface of the meter three times horizontally and three times vertically, dispose of the towelette. Allow the exterior to remain wet for the appropriate contact time then wipe the meter using a dry cloth. For Super sani cloth contact time is two minutes. Review of the CDC's guidance titled Considerations for Blood Glucose Monitoring and Insulin Administration dated 08/07/24 and found at https://www.cdc.gov/injection-safety/hcp/infection-control/index.html revealed one of the key points was to assign blood glucose meters to a person unless the device is assigned for use in professional settings and is cleaned and disinfected after every use. The summary of recommendations included to clean and disinfect blood glucose meters after every use, per the manufacturer's instructions.

Based on observation, review of facility menus, and staff interview, the facility failed to ensure menus were followed. This affected all 19 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, and #22) residents who the facility identified as receiving meals from the kitchen. The facility census is 22. Findings include: Review of the lunch menu for Friday, 05/03/24, identified baked fish, macaroni and cheese, creamy coleslaw, bread and butter, and Jello poke cake were planned to be served. Observation of the kitchen meal service on 05/03/24 at 11:50 A.M. revealed Cook #5 was observed to plate resident meals with fish, macaroni and cheese, creamy coleslaw, and Jello. The observation identified meal cart #1 left the kitchen on 05/03/24 at 12:00 P.M. and none of the trays included bread and butter as listed on the menu. Interview with Cooperate Dietary Manager #10 was completed on 05/03/24 at 12:05 P.M. in the hallway as the staff started delivering meal trays to the residents. Corporate Dietary Manager #10 confirmed the meal trays did not include bread and butter as per the menu. The interview confirmed Cook #5 did not follow the dietician approved menus by not serving the bread and butter. This deficiency represents non-compliance investigated under Complaint Number OH00153014.

Based on observation, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure medications were not left unattended and unsecured in resident rooms. This affected one (#2) of three resident rooms observed. The facility census was 22. Findings include: Review of Resident #2's medical record identified her admission to the facility occurred on 12/19/20 with medical diagnosis including malnutrition, depression, pancreatic tumor, and esophageal stricture. The most recent comprehensive assessment completed on 03/04/24 identified Resident #2 was completely cognitively intact. Observation and interview with Resident #2 on 05/03/24 at 10:41 A.M. revealed a full cup of oral medications sitting on the resident's bedside stand with a cup of pudding. Interview with Resident #2 at that time confirmed the nursing staff usually set her medications down and leave them with her, and stated sometimes she just throws them in the trash. Review of Resident #2's medication administration record (MAR) for May 2024 revealed the residents morning medications for 05/03/24 were signed off as administered even though they were observed sitting on her bedside table and had not consumed them. Observation and interview with the Director of Nursing (DON) on 05/03/24 at 10:50 A.M. revealed Resident #2's oral medications sitting on her bedside stand. The DON confirmed the medication sitting on Resident #2's bedside stand at that time and stated no medications should be left in resident rooms unattended. Review of the facility policy titled, Administering Medications, dated December 2012, revealed the individual administering the medications must initial the medication administration record (MAR) on the appropriate line after giving the resident the medication and before administering the next one. This deficiency was based on an incidental finding discovered during the course of complaint investigation.

Based on observations, staff interview, and review of the menu and whiteboard, the facility failed to follow the prepared menus and failed to ensure the changes to the menu were approved by a qualified clinical nutrition professional for nutritional adequacy. This affected four of four meals reviewed during the survey. This had the potential to affect the 22 residents who received meals from the kitchen. The facility census was 24. Finding include: Review of the facility's menu for Fall and Winter 2023 to 2024 revealed they menu was signed but it was unknown who the person was because it was not the Registered Dietitian (RD) for the facility. The lunch menu for Wednesday 03/13/24 was chicken barbeque, macaroni and cheese, baked beans, and a peanut butter bar. The white board (located in the hallway near the residents' rooms) revealed the residents would be receiving hamburger gravy, mashed potatoes, green beans, and pudding. The dinner menu for Wednesday 03/13/24 was taco salad, refried bean, lettuce and tomato, crackers, and cream pie. The white board revealed the residents were to receive barbeque chicken nuggets, baked beans, mixed vegetables, and fruit. The lunch menu for Thursday 03/14/24 was baked ziti, garlic bread, green beans, and fruit salad. The white board revealed the residents were to receive breaded chicken with gravy, macaroni and cheese, bean and carrot medley, and apple pie. The dinner menu for Thursday 03/14/24 was pork riblet, creamed corn vegetable medley, dinner roll, and sherbert. The white board revealed the residents would receive stuffed pepper soup, grilled cheese, and fruit. Observations on 03/13/24 and 03/14/24 at lunch and dinner revealed the residents were served the meals which were noted on the whiteboard and not what listed in the menu for these days. Interview with Cook #600 on 03/13/24 at 12:01 P.M. verified he did switch the lunch and dinner menu for this day. Cook #600 was unsure if the RD was aware of changes made to the menu, because he does not notify anyone of the changes. Cook #600 stated he does not do the ordering and it was the dietary manager who does the ordering. When he makes changes to the menu, he writes it on the whiteboard first thing in the morning for the residents to see and if they may want a substitution. Interview with Dietary Manager (DM) #700 on 03/14/24 at 9:15 A.M. verified he usually works on Wednesday and was completing the menu for Wednesday. DM #700 did not want to serve the residents the taco salad due to the residents having received salad on Monday when he changed the menu from pork loin to chili because he did not have the pork loin. DM #700 stated he was sick and had corporate make out the food order. DM #700 said the facility did not receive the pork loin. DM #700 verified he substitutes for other foods because he does not have time to look through all the search through the facility's online food order guide. The residents do not like pork riblets, so another pork item was substituted. DM #700 does not know if the RD was aware of the changes and he does try to substitute meat for meat and a potato for potato, like fries because the residents do not like them. DM #700 does not speak to the RD and does not report to anyone when he makes changes to the menu. DM #700 stated he did not know why the cook yesterday substituted the lunch and supper meals because the food for those meals was here. DM #700 does not document the food substitutions. Telephone interview on 03/14/24 at 10:33 A.M. with RD #800 verified she does not review the menus or approve the menus. The menus were approved in the the corporate office. Interview with Director of Culinary for Ohio #900 on 03/14/24 at 1:29 P.M. verified Food Contract Company #750 develops the menus and the RD at the Food Contract Company approves the menus. Director of Culinary for Ohio #900 said there should be a substitution log and the RD should be aware of changes to the menu and be approved by the RD. This deficiency represents non-compliance investigated under Complaint Number OH00151649.

Based on medical record review, resident interview, and staff interview, the facility failed to treat Resident #17 with dignity and respect by completing a urinary drug test without consent or physician's orders. This affected one (Resident #17) of three residents reviewed for dignity and respect. The facility census was 25. Findings included: Review of Resident #17's medical record revealed an admitted [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease, bipolar disease, and diabetes mellitus. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. She required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent upon staff for transfers. Review of Resident #17's most recent care plan revealed the resident was prescribed antidepressant medications. There was no care plan regarding drug addiction. Further review of Resident #17's medical record revealed a urine drug test was completed on 05/17/23 by the Director of Nursing (DON). The test was recorded on a hand-written form and revealed the resident tested positive for amphetamines, cocaine, and opiates. Review of Resident #17's physician's orders revealed there was no order for the urine drug test completed on 05/17/23. Review of the urine drug test form dated 05/17/23 revealed the DON completed the form that came with the test kit. The resident information and results were handwritten, which included being positive for amphetamines, cocaine, and opiates. The urine sample was taken from a Foley catheter bag and was between 90 and 100 degrees Fahrenheit. The drug test was completed due to Resident #17's behavior was very tired, snoring, and difficult to arouse. Review of Resident #17's medical record revealed a serum blood drug test was ordered by the physician per the resident's request. Review of the serum blood drug test dated 05/18/23 revealed the results were negative for drugs. Review of the blood serum drug test completed on 05/18/23 revealed the physician ordered test was negative for drugs. Interview on 06/22/23 at 8:56 A.M. with Resident #17 revealed on 05/17/23, the DON informed the resident that a urine test was needed and drew a urine sample out of the resident's Foley catheter bag. The DON failed to ask permission to run the test nor informed the resident the urine was being tested for drugs. The resident revealed on 05/17/23, the local police arrived at the facility after being called by the DON. The police searched the resident's husband in front of staff and other residents. Resident #17 stated the action was humiliating and embarrassing. She stated she cried for several days after. In addition, Resident #17 was awaiting a court case and was on parole. She stated the DON also notified the parole officer who visited the facility, but the resident was able to prove she was drug free by showing the parole officer the negative blood test results. Interviews on 06/22/23 at 10:24 A.M. and 2:02 P.M. with the DON verified she completed a urine drug test for Resident #17 without a physician's order. She ran the test due to being suspicious of the resident's actions due to going outside frequently with her husband. On the afternoon of 05/17/23, Resident #17 was observed being tired, sleeping, and was difficult to arouse, which she decided to complete a drug test. This deficiency represents non-compliance investigated under Complaint Numbers OH00143403 and OH00143388.

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to obtain a physician's order prior to completing a urine test. This affected one (Resident #17) of one resident reviewed for laboratory orders. The facility census was 25. Findings included: Review of Resident #17's medical record revealed an admitted [DATE]. Diagnoses included paraplegia, chronic obstructive pulmonary disease, bipolar disease, and diabetes mellitus. Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. She required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene and was totally dependent on staff for transfers. Review of Resident #17's medical record revealed a urine drug test was completed on 05/17/23 by the Director of Nursing (DON). The test was recorded on a hand-written form and revealed the resident tested positive for amphetamines, cocaine, and opiates. Review of Resident #17's physician orders revealed no orders for the urinary drug test completed on 05/17/23. Interview with Resident #17 on 06/22/23 at 8:56 A.M. revealed on 05/17/23 the DON informed the resident a urine test was needed and drew a urine sample out of the resident's Foley catheter bag. Interview with the DON on 06/22/23 at 10:24 A.M. and 2:02 P.M. verified she completed a urine drug test for Resident #17 without a physician's order. Review of the facility policy titled, Request For Diagnostic Services, revised April 2007 revealed all requests for diagnostic services must be ordered by the resident's attending physician. This deficiency is based on incidental findings discovered during the course of the investigation.