Every finding on record at Crystal River Health and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program to eradicate common household pests.Findings include: During an observation on 03/30/2026 at 9:32 AM, a live brown-colored insect was observed crawling on the wall, and a dead brown-colored insect was observed on the windowsill of the training room adjacent to the kitchen and dining area. (Photographic evidence obtained) During an observation on 04/01/2026 at 8:48 AM, a live brown-colored insect was observed crawling under a cabinet in the dining area. (Photographic evidence obtained) During an observation on 04/01/2026 at 9:02 AM, a live brown-colored insect was observed crawling on the floor immediately outside of Resident #45's doorway in the [NAME] Wing, down the hallway from the kitchen entrance. During an observation on 04/01/2026 at 11:48 AM, a dead brown-colored insect was observed on the floor near the exit door leading from the kitchen food preparation area. (Photographic evidence obtained) During an observation on 04/01/2026 at 1:29 PM, a live brown-colored insect was observed crawling around the drain area of the dishwashing machine in the dish room, an area where food contact items are processed. (Photographic evidence obtained) During an interview on 04/02/2026 at 10:29 AM, the Dietary Manager stated the Maintenance Department is notified of pest control concerns and is responsible for contacting the pest control company. During an interview on 04/02/2026 at 11:25 AM, the Maintenance Director stated each wing maintains a pest log for reporting concerns and that a contracted pest control company conducts weekly visits to review logs and address reported issues. He stated service reports are reviewed and corrective actions are taken as needed. However, ongoing pest activity observed during the survey indicated the facility's pest control program was not effective in identifying, correcting, and preventing pest presence. During an interview on 04/02/2026 at 12:55 PM, the Facility Administrator confirmed the expectation for the facility is to maintain a pest-free environment. Review of the [Name of exterminator company] reports dated 04/11/2025, 04/28/2025, 05/30/2025, 07/30/2025, 10/14/2025, 12/09/2025, and 02/20/2026 documented repeated identified concerns in the kitchen, all three resident wings. During an interview on 4/02/2026 at 10:23 AM Staff R, LPN stated that she knew they came around and sprayed for roaches every week, but it didn't seem to be helping. She did see roaches on the unit. During an observation on 3/30/2026 at 10:01 AM Resident #99's bathroom there was a live brown color insect by the base board. (Photographic evidence obtained) During an observation on 4/1/2026 at 4:12 PM with the Maintenance Director when entering Resident #38's room, when the resident's bathroom door was opened and the light was turned on there were three small dark brown insects running toward the baseboard of the bathroom. Review of the facility policy and procedure titled Resident Environment Quality with a last review date of 1/13/2026 read, Standard: Maintain an effective pest control program so the facility is free of pest and rodents.

Based on observation, interview, and record review the facility failed to ensure the residents' environment remained free of accident hazards for the main dining room by failing to secure hazardous cleaning chemicals in a resident non-accessible area. Findings include:During an observation on 4/1/2026 at 8:48 AM, a lower cabinet located in the main dining room was observed unlocked and accessible. Inside the cabinet, two bottles of cleaning chemicals were observed: Virex II 256 One-Step Disinfectant Cleaner and Deodorant and Virex TB Ready-to-Use Disinfectant Cleaner. There was no locking mechanisms or other security measures observed to restrict access to the chemicals.Review of the Safety Data Sheet (SDS) information for Virex II 256 documented the product is classified as corrosive and may cause eye and skin burns, and may be harmful if inhaled, absorbed through the skin, or swallowed. The product is labeled for industrial/institutional use and is intended to be handled with appropriate precautions and stored safely to prevent exposure.Review of the SDS for Virex TB Ready-to-Use Disinfectant Cleaner documented the product contains chemical agents intended for institutional disinfecting and may cause irritation to the eyes, skin, and respiratory tract with exposure routes including inhalation, ingestion, skin, and eye contact. The product is labeled for industrial/institutional use and is intended to be handled with appropriate precautions and stored safely to prevent exposure.During an interview on 4/1/2026 at 9:41 AM the Administrator stated cleaning products observed in the lower cabinet of the main dining room were not secured and should always be secured when not in use by facility staff. The dining room is open for access throughout the day to ambulatory residents. His expectations are that all cleaning chemicals are stored in a secure manner to prevent accidental ingestion or exposure to residents at the facility.

Based on observation, interview, and record review, the facility failed to ensure the implementation of person-centered comprehensive care plans for 1 of 6 residents, Resident #89, reviewed for safety concerns. Findings include: Review of Resident #89's clinical record documented re-admission on [DATE] with medical diagnosis that included foot drop right foot, bradycardia (slow heart rate), heart failure (fluid buildup in heart), dementia, abnormal auditory perceptions, psychotic disturbance, mood disturbance and anxiety, and absence epileptic syndrome (seizures). Review of Resident #89's physician orders dated 6/2/2025 read, BL [bilateral] floor mats at bedside when in bed Review of Resident #89's Care Plan documented the care plan was initiated 4/11/2025 and updated 3/23/2026. Focus: Problem potential for falls, seizure disorder, foot drop. Interventions: Encourage bed in lowest position while occupied, BL [bilateral both sides of the bed] floor mats at bedside when in bed. During an observation on 3/30/2026 09:20 AM Resident #89 was lying in bed. The bedside rails were in the up position, and the bed was in the low position. There was one floor mat on the right side of the bed. (Photographic evidence obtained). During an observation on 3/30/2026 2:23 PM Resident #89 was lying in bed side. The beside rails were in the up position, and the bed was in the low position. A floor mat was observed lying on the floor on the right side of Resident #89's bed. There was no floor mat observed to the left side of the bed. During an observation on 3/31/2026 at 10:15 AM with Staff J, CNA (Certified Nursing Assistant) of Resident 389's room a floor mat was observed on the floor on the right side of the bed only. During an interview on 3/31/2026 at 10:15 AM Staff J, CNA stated that he knows his residents but does not know if she [Resident #89] should have fall mats on both sides of the bed, she has always had just one. During an observation on 3/31/2026 at 10:30 AM with Staff I, RN a floor mat was observed on the floor by the right side of the bed only. During an interview 3/31/2026 at 10:30 AM Staff I, Registered Nurse (RN) stated that she will have to check the orders and see [if bilateral floor mats are ordered]. During an interview on 3/31/2026 at 1:30 PM the Director of Nursing stated, I expect the staff to follow physician orders and the resident [Resident #89] should have fall mats on each side of her bed Review of the policy and procedures titled Person Centered Care Plans last reviewed dated 1/13/2026 read, Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest(s) rights. Standard: According to federal regulations, the facility develops and implements a baseline plan of care within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident/guest. f) Upon completion of baseline care plan or comprehensive care plan and when reviewed quarterly/significant change, the MDSC [Minimum Data Set Coordinator] will ensure care plan intervention(s) are entered into Care Guide ADLs/intervention [ADLs = activities of daily living] in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the resident's care needs.

Based on interview and record review the facility failed to ensure all residents were free from unnecessary medications for 1 of 5 residents, Resident #80, reviewed for unnecessary medications.Findings include:Review of Resident #80's physician order dated 3/2/2026 read, Midodrine tablet, 5 mg [milligrams], 1 tablet oral, three times a day (8:00 AM, 12:00 PM, 5:00 PM), special instructions: Hold for systolic BP [blood pressure] over 110.Review of Resident #80's Medication Administration Record (MAR) for March 2026 documented 13 administrations of midodrine outside of the physician ordered parameters. During an interview on 4/1/2026 at 3:10 PM Staff L, LPN (Licensed Practical Nurse) stated, The documentations for administration of Midodrine was a documentation error, I always check the resident's blood pressure prior to administration of a medication with parameters and would not have administered the medication if the blood pressure was outside the ordered parameters.During an interview on 4/1/2026 at 3:20 PM Staff M, LPN stated, I always check the blood pressure prior to administering the medication, if the blood pressure was outside parameters I would not have administered the medications and I believe that I made a documentation error.During an interview on 4/1/2026 at 9:38 AM the DON stated, My expectations are that the nursing staff would follow the physicians' orders including specific parameters before administering the medications.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection for respiratory equipment for 3 of 4 residents, Residents #2, #12, and #54, reviewed for respiratory services. Findings include: 1) During an observation on 3/30/2026 at 10:26 AM of Resident #2's room, the resident was not in the room. In the room there was an oxygen concentrator and coiled on top of the concentrator was oxygen tubing dated 3/14/2026 and the tubing was not bagged. During an observation on 03/31/2026 at 8:15 AM Resident #2 was lying in bed. Oxygen was being administered via nasal cannula at 2 liters per minute. The oxygen tubing was dated 3/14/2026. Resident #2's wheelchair was in front of the bed. On the wheelchair there was nasal cannula tubing that was not bagged and coiled around the arm rest. During an interview on 3/31/2026 at 1:44 PM Staff Q, Licensed Practical Nurse (LPN) stated, Oxygen tubing should be bagged when not in use. I am not sure how often the tubing is changed. That is supposed to be done on the night shift. During an interview 3/31/2026 at 1:44 PM Staff A, Registered Nurse Unit Manager stated, Tubing is changed every Friday. During an observation on 3/31/2026 at 1:49 PM with Staff Q, LPN Resident #2 was in bed with oxygen being administered via nasal cannula. The date on the tubing was 3/14/2026. During an interview on 3/31/2026 at 1:49 PM Staff Q, LPN confirmed the tubing was dated 3/14/2026 and Resident #2 was being administered oxygen through the tubing. Review of Resident #2's physician order dated 2/2/2026 read, O2 [oxygen] at 2L/min [2 liters per minute] via nc [nasal cannula] for shortness of breath as needed. During an interview on 4/2/2026 at 9:48 AM the Director of Nursing stated, Tubing is changed weekly and dated and stored in a bag when not in use. 2) During an observation 3/30/2026 at 10:22 AM of Resident #54's room a nebulizer machine was lying on the floor behind the bed. The nebulizer mask and tubing were lying across the nebulizer machine on the floor. The tubing attached to the nebulizer was not dated. During an observation on 3/31/2026 9:15 AM of Resident #54's room a nebulizer machine was lying on the floor behind the bed. The nebulizer mask and tubing were lying across the nebulizer machine on the floor, and the tubing was not dated. (Photographic evidence obtained). During an interview on 3/30/2026 at 10:22 AM Resident #54 stated I have not used that [nebulizer] in forever. During an interview on 3/31/2026 at 1:24 PM the Director of Nursing stated the mask must be covered when not in use and tubing has to be dated when changed. She [Resident #54] does not even have orders for nebulizer treatments and has not been receiving nebulizing treatments. The machine and mask should have been removed, cleaned and stored. 3) During an observation on 3/30/2026 at 09:40 AM of Resident #12's room an uncovered nebulizer mask was lying across the nebulizer machine that was on the bedside table. The tubing to the nebulizer machine was not dated. During an observation on 3/31/2026 at 08:45 AM of Resident #12's room an uncovered nebulizer mask was lying across the nebulizer machine that was on the bedside table, and the tubing was not dated. During an interview on 3/31/2026 at 08:48 AM Staff I, Registered Nurse (RN) stated, the nebulizer should be covered after each use. Tubing is changed weekly and should be dated. If the resident no longer has orders for nebulizing treatments we should remove the machine, clean and store it for future use. The tubing is thrown away. She [Resident #12] does not have orders for nebulizing treatments. During an interview on 3/31/2026 at 1:24 PM the Director of Nursing stated, the mask must be covered when not in use and tubing has to be dated when changed. She [Resident #12] has not received nebulizing treatments since October 2025 and the machine and mask should have been removed. Review of the policy and procedure titled Oxygen Administration dated 1/13/2026 read 11. Cannulas and masks should be changed weekly. 14. 02 cannula/mask should be stored in a plastic bag when not in use.

Based on observation, interview, and record review the facility failed to ensure residents had a clean, homelike environment for 1 of 3 units. Findings include:During an observation on 3/30/2026 at 10:04 AM of Resident #38's room the base boards were missing on the left side of the bathroom doorway, the wall was peeling and had black stains. Inside of the bathroom there were tiles lifting around the toilet seat and some were missing. The bathroom sink wall had cracks and gaps and the bathroom vent was covered in a gray matter. [Photographic evidence obtained]During an observation on 3/30/2026 at 10:24 AM of Resident #24's room the wall paint was missing exposing the wall. [Photographic evidence obtained]During an observation on 3/30/2026 at 10:25 AM of Resident #2's room the wall pain was peeling and had holes near the base board. [Photographic evidence obtained]During an observation on 3/30/2026 at 10:28 AM of Resident #15's room the door handle was loose, the toilet paper holder was missing one of the mounts, and the sink wall had gaps and cracks. [Photographic evidence obtained]During an observation on 3/30/2026 at 10:31 AM of Resident #57's room the door handle to the bathroom was loose. [Photographic evidence obtained]During an observation on 4/1/2026 at 4:12 PM with the Maintenance Director of Resident #38's room the base board was missing on the left side of the bathroom doorway, the wall was peeling and had black colored stains. Inside the bathroom tiles around the toilet there was a brown substance, the tiles were lifting, and there were missing portions from some of the tiles. The bathroom sink wall had visible cracks and gaps. The bathroom vent was covered with gray matter.During an interview on 4/1/2026 at 4:12 PM the Maintenance Director stated, This is horrible this is the room [Resident #38's room] I was looking for the plumbing company to come out and fix. They told me about this room about a month ago, but I couldn't figure out what room it was. The vent looks filthy.During an observation on 4/1/2026 at 4:20 PM with the Maintenance Director, the Maintenance Director confirmed Resident #2's room the wall paint was peeling exposing the wall and had holes near the base board. During an observation on 4/1/2026 at 4:22 PM with the Maintenance Director of Resident #15's the room the door handle was loose, the toilet paper holder was missing one of the mounting brackets, the floor tiles were heavily stained, and the bathroom sink wall had cracks and gaps in the paint.During an interview on 4/1/2026 at 4:22 PM the Maintenance Director stated, The sink is coming off maybe the resident put pressure on it. The door handle needs to be adjusted, and the toilet paper holder needs to be replaced.During an observation on 4/1/2026 at 4:24 PM with the Maintenance Director, the Maintenance Director confirmed Resident #57's room bathroom door handle was loose.During an interview on 4/1/2026 at 4:25 PM the Maintenance Director stated, Normally I try to go around and fix stuff when I see it. I just took over in January 19 [2026]. I am doing mostly large projects right now. The smaller details I will tell my assistant to do. When asked for documentation of these repairs being reported the Maintenance Director stated, Normally I will get calls or text messages to my phone of things to be repaired. I am waiting on a laptop to have access to it [maintenance repair log]. I do not have access to it on my phone. It is really hard to be able to look back and see if these rooms have been reported. I was going to do boards on each unit, but it was a daunting task. I would not be able to look back.Review of the [maintenance system] work history report for the months of January 2026 through March 2026 did not contain any information regarding these residents' room repairs or need of repair. During an interview on 4/2/2026 at 10:00 AM the Director of Nursing stated, Typically I am entering into the maintenance repair log. I also communicate verbally with maintenance as I am going down the hall or shoot a message and let them know. I also report to the unit manager and any leadership if I identified anything that needs to be repaired. No reports are given to me about any pending repairs.During an interview on 4/2/2026 at 12:30 PM the Administrator stated, When staff go around in their angel rounds, they put any repairs needed in [the maintenance repair log] and maintenance will follow up. They can also communicate with the Maintenance Director to let him know. There has been a delay in getting his laptop in order for his use [maintenance repair log]. This way we could put it in [maintenance repair log] and have a paper trail. I would expect that these areas would have been corrected. I know he is always walking the unit and never sits at his desk. He is newer to the building.Review of the facility policy and procedure titled Resident Environment Quality with a last review date of 1/13/2026 read, Purpose: The facility should be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. Standard: According to federal regulation, the facility must: Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents. Process: Preventive maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment.

Based on record review and interview the facility failed to ensure the provision of necessary care and services of medication administration to maintain appropriate blood pressure control for 1 of 1 resident, Resident #111, reviewed for surgical coordination. Findings include: Review of Resident #111's clinical record documented an admission 1/29/2024 with diagnosis including but not limited to hypertension, anxiety, depression, and anemia. During an interview on 3/30/2026 at 10:20 AM Resident #111 stated I did not receive my medications before surgery and the surgery was cancelled because my blood pressure was too high. I still do not have a date scheduled for my surgery. Review of Resident #111's pre-operative instructions from [surgical center name] read Surgery date 3/23/2026, no food, drink or water after midnight. Medications: day of surgery, Take heart medications, blood pressure medications, thyroid medications, with a small amount of water. Do not take diuretics or water pills. If you use an inhaler, bring it with you. Review of Resident #111's physician orders dated 1/29/2024 read Amlodipine [used to treat high blood pressure] 10 mg [milligrams] daily 1 tablet every day 09:00 AM. Review of Resident #111's Medication Administration Record (MAR) documented medication was held on the morning of 3/23/2026 due to NPO (nothing by mouth) status. Review of Physician orders for Resident #111 dated 2/19/2025 read, Metoprolol Tartrate [used to treat high blood pressure] 50 mg twice daily 9:00 AM and 8:00 PM. Review of Resident #111's MAR documented Metoprolol Tartrate was held on the morning of 3/23/2026 due to NPO status. Review of Resident #111's physician orders dated 10/10/2025 read, Hydralazine [used to treat moderate to severe high blood pressure] 50 mg four times daily 09:00AM, 01:00 PM, 05:00 PM and 09:00 PM. Review of Resident #111's MAR documented Hydralazine was held on the morning of 3/23/2026 due to NPO status. Review of Resident #111's physician orders dated 3/9/2026 read Lisinopril [used to treat high blood pressure] 40 mg daily every day 09:00 AM. Review of Resident #111's MAR documented Lisinopril was held on the morning of 3/23/2026 due to NPO status. Review of Resident #111's physician orders did not have NPO orders documented in the system. Review of Resident #111's MAR for March 2026 read, Eye Center for right cataract surgery on 3/23/2026 at 10:30 AM. Review of Resident #111's nursing progress note dated 3/5/2026 1:11 PM read, Resident out of facility this AM to [name of eye center] for consultation for right eye cataract surgery on 3/23/26 at 10:30 am. Orders received: NPO after midnight day before surgery. Continue medication as ordered except diuretics. Review of Resident #111's nursing progress note dated 3/23/2026 read, The resident returned from the surgery center without undergoing surgery due to elevated systolic blood pressure ranging from 198–202 mmHg. During an interview on 4/1/2026 at 9:57 AM Staff K, Licensed Practical Nurse (LPN) stated, I held his [Resident #111] morning medication including his blood pressure medications because I was told in shift report that he was NPO. I was not told that he was supposed to get his AM hypertension medications. I did not review the physician orders or MAR. I did not contact the physician for clarification. During an interview on 3/31/2026 at 09:40 AM Staff I, Registered Nurse (RN) stated, I received the pre-operative instructions verbally from the eye center when I called for a time. I did not enter the orders into the computer and do not recall being told to administer the hypertensive medications. I only remember that he was NPO after midnight. I shared his NPO status with the nurses and aids and they shared with the oncoming shift during report. A Shift report is utilized but not retained. The written instructions were found only after the surgery cancellation. They were in his [Resident #111] room. The surgery was cancelled because of his blood pressure being too high and he required a medical follow-up and clearance. I am just waiting for the surgery center now to call me back to reschedule. During an interview on 4/1/2026 at 12:44 PM the Director of Nursing stated, There are no orders in the system for NPO status or continue medication except for Lasix. Physician orders should have been entered and followed as directed from the surgery center.

Based on interview, observation, and record review, the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 7 residents, Resident #11, reviewed for medication pain management.Findings include:During an interview on 3/30/2026 at approximately 3:00 PM, Resident #11 stated he has pain in his right shoulder. He received medication for the pain, but he continued to have pain. He used his feet to push himself in his wheelchair because he was not able to use his hands/arms.During an observation on 3/30/2026 at approximately 3:00 PM Resident #11 was propelling himself backwards in his wheelchair using only his feet. He held his right arm against his body in a protective manner. Review of Resident #11's physician orders documented dated 1/10/2026 Lyrica (pregabalin) [a nerve medication used to treat neuropathic pain) tablet 25 mg [milligrams] oral: 1 tablet Twice A DayReview of Resident #11's medical record documented the resident was admitted on [DATE] with medical diagnoses that included Epilepsy, unspecified, not intractable, without status epilepticus; Personal history of traumatic brain injury; Contracture of muscle, multiple sites; Parkinsonism, unspecified; Other: chronic painReview of Resident #11's MAR (Medication Administration Record) for the period of 3/01/2026 through 4/01/2026 documented an entry which read, Lyrica (pregabalin)- [used for pain management] capsule; 25 mg; 1 tablet; oral twice a day - 01/10/2026 - 04/01/2026 [to be administered from 01/10/2026 to 04/01/2026 and then discontinued]. There was no documentation on the MAR of Lyrica being administration on 3/26/2026 through 3/31/2026, resulting in 12 doses of Lyrica not being administered as order by the physician. The MAR documented nine of the doses of Lyrica were not administered due to Drug/Item Unavailable, one of the doses not administered due to Drug/Item Unavailable OOS [out of stock], one of the doses not administered due to Drug/Item Unavailable - Comment: awaiting on approval from insurance dated 3/30/2026, and one does not administered due to Not Administered: Other - Comment: awaiting approval, dated 4/01/2026.During an interview on 4/01/2026 at 8:50 AM Resident #11 stated he had been having more pain in his right arm recently. He had not received pain medications routinely for the last several days. During an observation on 4/01/2026 at 8:50 AM Resident #11 was sitting in his wheelchair in his room. He was holding his right arm against his body.During an interview on 4/01/2026 at 8:54 AM Staff A, Unit Manager, stated she had not charted anything regarding discussions with the pharmacy about not being able to get the Lyrica approved or any other measures regarding finding an alternative option.During an interview on 4/01/2026 at approximately 10:00 AM the DON (Director of Nursing) stated the expectation was for nurses to contact the pharmacy if a resident was out of a medication to see if it was on the way. If there was a problem with obtaining the medication, the nurses should contact the physician.During an interview on 4/01/2026 at 3:22 PM APRN (Advanced Practice Registered Nurse) 2 stated Pain Management [a group that specializes in pain management control] had been managing Resident #11's prescription for Lyrica, and she did not know anything about insurance coverage for the medication. She had not received a call regarding Resident #11's pain or an alternate medication for his Lyrica.During an interview on 4/01/2026 at 5:45 PM the PA (Physician's Assistant) #2 stated he had raised Resident #11's Lyrica about one month after he started the prescription. There was a Lyrica prescription sent [to the pharmacy] on 3/25 [2026]. There was no telephone encounter [from the facility] regarding Resident #11 being out of Lyrica. He did not see a request for a prior authorization [for Resident #11's Lyrica]. He was in the facility on Friday [3/27/2026] and spoke with Staff A, Unit Manager, but there was no discussion or request about Lyrica or an alternative medication for Resident #11's pain. The prn analgesic he had ordered would not be effective for his neuropathic pain.During an interview on 4/01/2026 at 6:06 PM PA #2 stated the pharmacy informed him that Resident #11 should have had one dose of Lyrica still available through the e-kit [emergency medication kit designed to provide medications in the facility]. He was concerned that no one had called him from the facility, as they were usually able to get prescriptions out the next day after a request was made.During an interview on 4/02/2026 at 2:00 PM Staff S, LPN (Licensed Practical Nurse) stated he had called PA #2 on 3/25/2026 regarding Resident #11's Lyrica prescription and PA #2 put in a script [prescription]. Staff S, LPN called the pharmacy, and the pharmacy faxed a code [to get into the e-kit in the automated medication dispensing machine] and a sheet stating the medication was not covered by Resident #11's insurance and the facility would need to pay for the medication. He did not withdraw or administer the Lyrica. He left the sheet for the Unit Manager. He did not attempt to get an alternative pain medication for Resident #11.During an interview on 4/02/2026 at 2:41 PM Staff T, LPN stated on 3/26/2026 she had called the pharmacy and asked if Resident #11's Lyrica was on its way. She was informed that it was not, and it was something to do with insurance. She did not write a note about the phone call with pharmacy, but she thought it would be an expectation for her to write such a note. She believed that she had been told that the doctor had been told [about Resident #11 not having his Lyrica] and there was nothing comparable. She did not contact the doctor herself.During an interview on 4/02/2026 at 3:55 PM Staff U, LPN stated on 3/29/2026 when she did not administer a scheduled dose of Lyrica for Resident #11, she was in training, working with Staff S, LPN. Basically, when it came to medications not being available, Staff S, LPN told her just to press the button [in the electronic medical record] for a refill. She was just following what she was told to do by Staff S, LPN.Review of Resident #11's medical record progress notes for the period of 3/25/2026 through 3/31/2026 did not contain documentation regarding Resident #11's Lyrica not being administered or an alternative for the scheduled pain medication.Review of Resident #11's most recent MDS (Minimum Data Set) Assessment, a quarterly assessment dated [DATE] documented his BIMS [Brief Inventory of Mental Status] Score as 10 out of 15 which indicated he had some cognitive deficit. He received scheduled and PRN pain medications. He frequently had pain which occasionally interfered with his sleep and that frequently limited his day-to-day activities. He received opioid and anticonvulsant medications which were documented to be high-risk medications.Review of Resident #11's Care Plan documented, Problem: Resident has complaints of chronic pain. Start Date: 01/12/2026. Last Reviewed/Revised 03/18/2026. Goal: Resident will verbalize reduction of pain. Approaches included: Administer medications: Start Date 01/12/2026; refer to pain management team. Problem: Requires pain management. Additional Information: R/T [related to] impaired mobility, contracture and dx [diagnosis] of muscle spasms. Start Date 02/01/2026. Goal: I will not have unrelieved pain X 90 days AEB [as evidenced by] no moaning, groaning, or facial grimaces {sp}. Approaches included: Medications as ordered.Review of a report titled Item Expiration Tracking Report dated 3/30/2026 documented that Pregabalin (Lyrica) 25mg capsule was available in the automated medication dispensing machine and had an expiration date of 10/31/2026.Review of the policy and procedure titled Pain Management and Assessment, last reviewed on 1/13/2026 read, Purpose: The detection of the presence of pain, determining the frequency and intensity of pain, and identification of effective pain management interventions can help to avoid adverse outcomes that impact the resident/guests functional status and quality of life. Process: I. General Information - a) pain is any type of physical pain or discomfort in any part of the body. It may be localized to one area or may be more generalized. It may be acute or chronic, continuous or intermittent, or occur at rest or with movement. Pain is very subjective; pain is whatever the experiencing person says it is and exists whenever he or she says it does. b) Pain can be suffering and is associated with inactivity, social withdrawal, depression, and functional decline. f) Most resident/guests with moderate to severe pain will require regularly dosed pain medications, and some will require additional PRN pain medications for breakthrough pain. III. Pain Management - b) If the resident's/guess pain is not controlled by the current treatment regimen, the physician should be notified.

Based on interview and record review the facility failed to provide a bed hold notice for 1 of 3 residents, Resident #138, reviewed for hospitalizations. Findings include:Review of Resident #138's progress note dated 01/28/2026 read, Physician office requested for patient to go [Hospital Name]. Reached out to hospital and ortho floor stated unable to take patient without direct admit. Called office back and got in touch with [Doctor's Name] who stated to send her to closest hospital to assess right hip. Called non-emergent transport [Name of the transport company] and they picked up patient at 5:45 PM and taking to [Hospital Name]. Son at bedside and agreeable with POC [Plan of Care].Review of Resident #138's Nursing Home Transfer and Discharge Notice Resident was sent to hospital on [DATE]Review of Resident #138 Hospital Transfer Form dated 1/28/2026 read, send to ER [emergency room] to eval [evaluate] and treat.During an interview on 03/31/2026 at 3:37 PM Staff O, Licensed Practical Nurse Medical Records stated, We have no 3 day bed hold policy stating bed reserve payment for Resident #138 in her paper chart. It must not have been done.During an interview on 04/02/2026 at 10:05 AM with the Director of Nursing stated, The floor nurse or unit manager gets bed holds completed if the resident goes out of the facility. If family is at bedside staff should have family sign the bed hold form.

Based on observation, interview, and record review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 4 residents, Resident #2, reviewed for respiratory services. Findings include:During an observation 3/31/2026 at 8:15 AM Resident #2 was lying in bed. Oxygen was being administered via nasal cannula at 2 liters per minute.Review of Resident #2's physician order dated 2/2/2026 read, O2 [oxygen] at 2L/min [2 liters per minute] via nc [nasal cannula] for shortness of breath as needed.Review of Resident #2's Minimum Date Set titled Significant Change dated 2/23/2026 in Section O Special Treatments, Procedures, Programs did not document oxygen was in use by the resident.During an interview on 3/31/2026 at 3:52 PM Staff G Licensed Practical Nurse MDS stated, Oxygen use was documented in the notes a few times. It should have been coded as in use, it will need to be corrected.Review of Resident #2's progress note date 2/22/2026 read, Pulmonary/Respiratory Service: Oxygen Therapy (indicate L/P/M [liters per minute] and delivery) 2L-95% [two liters- 95 percent].Review of Resident #2's progress note date 2/21/2026 read, O2 [oxygen] - 90% via nasal cannula 2 L [liter].Review of the facility policy and procedure titled Resident Assessment Instrument [RAI] with a last review date of 1/13/2026 read, Purpose: Resident are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care. Standard: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the state.

Based on observations, interviews, and record reviews, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen's walk-in cooler, walk- in freezer, and in 2 of 3 nutrition rooms and appliances for preparing food were kept in a clean, sanitary manner in 1 of 3 nutrition rooms. Findings include: On 10/21/2024 at 9:15 AM, a tour of the main kitchen was conducted with the Certified Dietary Manager (CDM). During an observation of the walk-in cooler, there was 1 opened, undated, container of potato salad, 1 opened, undated container of ricotta cheese, and 1 opened container of sour cream with an expiration date of 10/18/24. There was three 1-inch-deep trays of unlabeled, undated vegetables sitting on the 3rd shelf. In the walk-in freezer there were 3 frozen pizzas with no opened, use by, or expiration date sitting on top of a box located on the top shelf. (Photographic evidence obtained) During an interview on 10/21/2024 at 9:30 AM, the CDM confirmed the unlabeled, undated foods, and stated, Those should be labeled and dated. On 10/21/2024 at 9:40 AM, a tour of the nutrition rooms was conducted with the CDM. In nutrition room [ROOM NUMBER], located on the south wing, there were three (3) opened, unlabeled, bottles of purple sport hydration drink sitting in the side shelf of the refrigerator door. There were two (2) unlabeled, undated, take-out sandwich bags with a 1/2 eaten sandwich wrapped in a paper towel in the bottom left drawer of the refrigerator. There was an unlabeled, undated, grocery store bag with a 1/2 lb. container of chicken salad, a plastic bag of pistachio nuts, and a plastic bag with homemade cookies. The microwave had a brown sticky-like substance on the door and the top of the microwave and there was also red splattered particles on the back wall of the microwave. In nutrition room [ROOM NUMBER], located on the west wing, there was one (1) opened, unlabeled, undated pint of cookie dough ice-cream, an opened, unlabeled, undated bag of frozen vegetables, and one (1) unlabeled frozen dinner meal sitting in the freezer's door shelf. During an interview on 10/21/2024 beginning at 10:00 AM, the CDM confirmed the unlabeled, undated items in the refrigerators in both nutrition rooms. The CDM stated, All foods should have the resident's name, room number, and the date it was brought in. The kitchen staff along with the nurses are responsible for keeping the nutrition rooms cleaned. Review of the policy titled, Food Preparation Guideline, last reviewed 1/9/2024, read, Process: d. Frozen foods should be properly thawed .Frozen fruits and vegetables should NOT be thawed before cooking. Allow extra time for preparation of these frozen products. Review of the policy titled, Food from Families and Friends, last reviewed 1/9/2024, read Purpose: To preserve the resident/guest(s) right to receive gifts of food from family and friends, while reducing the potential for food borne illnesses. Process: b. If food is to be stored, it should be labeled with resident/guest(s) name, dated and stored in airtight container. c. If refrigeration is necessary, food items should be stored in the nursing unit refrigerator or resident/guest(s) room refrigerator, and leftover cooked items discarded after 3 days, open items discarded after 7 days. A policy and procedure was requested for food storage in the kitchen related to unlabeled and undated foods. None was provided.

Based on interview and record reviews, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for 1 (Resident #54) of 3 residents reviewed for skin conditions. Findings include: Review of Resident #54's resident face sheet showed Resident #54 was first admitted on [DATE] with diagnoses that included chronic venous hypertension with ulcer and inflammation to right and left lower extremity. Review of Resident #54's wound assessment report dated 8/24/2024, documented a venous ulcer identified on 5/22/2024 with an unchanged status and a note that read, Wound IDT [interdisciplinary team] note. Resident has open areas to lower extremities that is unchanged. The measurements for left lower leg are 4.0 x 4.0 x 1.0 CM [centimeters] with scant serous drainage. Review of Resident #54's physician order dated 8/28/2024, read, Left lower leg open areas. Cleanse wound with N/S (normal saline), pat dry with 4x4 gauze, apply Dressing Wound Silicone to wound bed, apply Calcium Alginate with Silver, cover with ABD (abdominal) pads, wrap with rolled gauze . Review of Resident #54's physician order dated 8/28/2024, read Right lower leg open areas. Cleanse wound with N/S, pat dry with 4x4 gauze, apply Dressing Wound Silicone to wound bed, apply Calcium Alginate with Silver, cover with ABD pads, wrap with rolled gauze . Review of Resident #54's Quarterly MDS dated [DATE] documented no venous or arterial wounds were present. During an interview on 10/23/2024 at 8:30 AM, Staff E, MDS License Practical Nurse, stated I overlooked the wound assessment done by the nurse here in the facility and was guiding myself by the hospital documentation. Review of the policy and procedure titled Resident Assessment Instrument (RAI), last review date of 1/9/2024 read, Purpose: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care. Standards: According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the state.

Based on interview and record reviews, the facility failed to ensure 2 of 7 residents, (Resident #83 and Resident #107) reviewed for Preadmission Screening and Resident Review (PASRR) documented all diagnoses relevant to the screening. Findings include: 1. Review of Resident #83's Level I PASRR screening, dated 7/17/2023, showed no entries documented on page 2 in Section I: PASRR Screen Decision-Making under Section A. MI [Mental Illness] or suspected MI. Review of Resident #83's face sheet, admitted [DATE], revealed Resident #83 had diagnoses that included generalized anxiety disorder, brief psychotic disorder and other specified persistent mood disorders. 2. Review of Resident #107's Level I PASRR screening, dated 8/18/2024, showed schizophrenia documented on page 2 in Section I: PASRR Screen Decision-Making under Section A. MI [Mental Illness] or suspected MI. Review of Resident #107's face sheet, admitted [DATE], revealed diagnoses that included other specified anxiety disorders. During an interview on 10/24/2024 at 7:48 AM, the Director of Nursing confirmed Resident #83's diagnoses of generalized anxiety disorder, brief psychotic disorder and other specified persistent mood disorders had not been included on his Level I PASRR screening dated 7/17/2023. She confirmed Resident #107's diagnoses of other specified anxiety disorders had been included on her Level I PASRR screening dated 8/18/2024.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #10) of 3 residents reviewed for skin conditions. Findings include: During an observation on 10/21/2024 at 9:59 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. (photographic evidence obtained) During an interview on 10/21/2024 at 9:59 AM, Resident #10 stated I got a skin tear when we went for the storm. During an observation on 10/22/2024 at 7:50 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. Review of Resident #10's physician order, dated 10/14/2024, read, Skin tear site___Change dressing___Cleanse W(with)/___Apply___Cover W/___ Observe Area Daily. Frequency: Once a day. Special Instructions: Remove old dressing, cleanse wound with NS (normal saline) and cover with medipore dressing. During an interview on 10/22/2024 at 1:30 PM, Staff C, License Practical Nurse, (LPN), stated I changed [Resident #10's Name] dressing today. The old dressing was dated 10/19. I believe [Resident #10's Name] has wound care orders for daily dressing changes. During an interview on 10/22/2024 at 1:11 PM, Staff D, Wound Care Nurse, stated, As soon as my day starts, I let the nurses know what I will be doing as to wound care. I usually do the big wounds, and they [nurses] will do the rest. Some days I help and do them all. During an interview on 10/23/2024 at 10:26 AM, the Director of Nursing, (DON), stated, My expectation is for the nurse assigned to the resident with daily wound care orders would be completing that [wound care] daily and signing off on it. Review of the policy and procedure titled Dressing-Clean, last review date of 1/9/2024, read Purpose: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. Each wound site should be treated individually. Standard: Physician's orders should specify type of wound, frequency of change, type of dressing or products to be used.

Based on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals were stored in a secured manner for 2 of 3 halls. Findings include: 1. During an observation on 10/21/2024 at 09:30 AM of Resident #243's room, one bottle of nasal spray (Oxymetazoline HCI 0.05% nasal decongestant), and 1 bottle of 4% lidocaine was sitting on bedside table not secured. (Photographic Evidence Obtained) During an interview on 10/21/2024 at 11:30 AM, Resident #243 stated, I usually have my nasal spray and my [Name Brand of 4% lidocaine] all the time because I need it so often. During an observation on 10/22/2024 at 1:20 PM of Resident #243's room, one bottle of nasal spray (Oxymetazoline HCI 0.05% nasal decongestant), and 1 bottle of 4% lidocaine was sitting on bedside table not secured. During an observation on 10/23/2024 at 7:57 AM with Staff F, License Practical Nurse (LPN) acknowledged the one bottle of nasal spray (Oxymetazoline HCI 0.05% nasal decongestant), and 1 bottle of 4% lidocaine was sitting on Resident #243's bedside table not secured. During an interview on 10/23/2024 at 7:57 AM, Staff F, LPN, stated Medications are not supposed to be at the bedside unless the resident has been accessed for self-administration and the medication still needs to be secured. During an interview on 10/24/2024 at 8:12 AM, the Director of Nursing stated, Per our policy, patients are not to have medication in their room unless they have been assessed for self-administration and the physician writes an order for self-administration. 46523 2. During an observation on 10/23/2024 at 8:20 AM, Resident #61 was eating breakfast in his room. On his meal tray there was a medication cup with a thick brown liquid inside another plastic cup. (photographic evidence obtained) During an interview on 10/23/2024 at 8:20 AM, Resident #61 stated, That is medication. The nurse will bring it to me, and I drink it after breakfast. I will not drink that [brown liquid in medication cup] today. During an interview on 10/24/2024 at 8:12 AM with the Director of Nursing stated, Medication should not be left at bedside. Nurse should take the medication with her and bring it back when resident is able to take it, and she is able to watch the resident take the medication. During an interview on 10/23/2024 at 8:25 AM with Staff C, LPN stated, There is medication in his room. If I wait for him [Resident #61] to take his medication he will start cursing me out. I try not to push. He likes to take his medication after breakfast. I will go back and check on him after breakfast. Review of the facility policy and procedure titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles, last review date of 1/9/2024 read, 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a physician/prescriber order and approval by the Interdisciplinary Care Team and Facility Administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room.

Based on observations, interviews, and record reviews, the facility failed to accurately document wound care dressing changes for 1 (Resident #10) of 3 residents reviewed for skin conditions. Findings include: During an observation on 10/21/2024 at 9:59 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. (photographic evidence obtained) During an interview on 10/21/2024 at 9:59 AM, Resident #10 stated, I got a skin tear when we went for the storm. During an observation on 10/22/2024 at 7:50 AM, Resident #10 was sitting in a chair in her room. There was a pink gentle border foam dressing dated 10/19/2024 on Resident #10's right lower leg. Review of Resident #10's physician order, dated 10/14/2024, read, Skin tear site___Change dressing___Cleanse W(with)/___Apply___Cover W/___ Observe Area Daily. Frequency: Once a day. Special Instructions: Remove old dressing, cleanse wound with NS (normal saline) and cover with medipore dressing. Review of Resident #10's treatment administration history for the month of October 2024 for Skin tear site___Change dressing___Cleanse W(with)/___Apply___Cover W/___ Observe Area Daily. Frequency: Once a day. Special Instructions: Remove old dressing, cleanse wound with NS (normal saline) and cover with medipore dressing documented staff initials as treatment being done on 10/20/2024 and 10/21/2024. During an interview on 10/22/2024 at 1:30 PM, Staff C, License Practical Nurse, (LPN) stated I changed Resident #10's dressing today. The old dressing was dated 10/19. I believe Resident #10 has wound care orders for daily dressing changes. During an interview on 10/23/2024 at 10:26 AM, the Director of Nursing (DON) stated, My expectation is for the nurse assigned to the resident with daily wound care orders would be completing that [wound care] daily and signing off on it. Staff should document when they are completing the task and if they are not able to complete the dressing change, document and readdress. The documentation should be accurate. During an interview on 10/24/2024 at 7:45 AM, the DON stated, The nurses did not document accurately the dressing changes [for 10/20/2024 and 10/21/2024]. Review of the policy and procedure titled, Charting and Documentation Guidelines, last reviewed 1/9/2024, read, Purpose: Documentation in medical records of residents, by the interdisciplinary team, should provide: A source to support charges to the resident for services rendered. Process: I. Rules for Charting and Documentation: b) Be concise, accurate and complete and use objective terms. c) Document only the facts .

Based on observations, interviews and record reviews, the facility failed to perform hand hygiene during wound care for 1 (Resident #10) of 3 residents reviewed for skin conditions and during meal delivery. Findings include: 1. During an observation on 10/21/2024 at 1:24 PM, Staff A, Certified Nursing Assistant (CNA), entered Resident #22's room and placed a meal tray on the bedside table. Staff B, CNA, was in the room and assisted Staff A to readjust Resident #22 in his bed to set him up for lunch. Staff A, CNA, exited Resident #22's room and without performing hand hygiene removed another tray from the meal cart and entered Resident #72's room without performing hand hygiene. Staff A, CNA, started to feed Resident #72. During an interview on 10/22/2024 at 1:32 PM, Staff A, CNA, stated I should have used hand sanitizer in between residents when passing out meal trays. 2. During an observation on 10/22/2024 at 1:20 PM, Staff C, License Practical Nurse (LPN), came to Resident #10's doorway and Staff D, Wound Care Nurse, asked Staff C to come in and explain to Resident #10 she needed to change her dressing. Staff C stated to Staff D she was texting a provider and would come in. Staff C finished texting with a cellular phone and put it away in her pocket. Staff C, without performing hand hygiene, donned a pair of gloves and removed the dressing on Resident #10's right lower leg. Staff C, without performing hand hygiene, proceeded to place a new dressing on Resident #10's lower leg. During an interview on 10/22/2024 at 1:30 PM, Staff C, LPN, stated I should have washed my hands before putting on the gloves. During an interview on 10/23/2024 at 9:20 AM, the Infection Control Preventionist stated Staff should perform hand hygiene upon entering a resident's room and of course in between clean and dirty bandages. Gloves don't substitute hand hygiene. Staff should perform hand hygiene always before entering and upon exiting a room during meal delivery. During an interview on 10/23/2024 at 10:29 AM, the Director of Nursing (DON) stated Staff are expected to wash hands in between each resident encounter. The staff should wash their hands before donning gloves. Putting on gloves does not substitute hand hygiene. Review of the policy and procedure titled Hand Hygiene, with a last review date of 1/9/2024, read, Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. Process: III. Hand Hygiene. Hand Hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. When hands are visibly soiled (hand washing with soap and water); before and after direct resident/guest contact (for which hand hygiene is indicated by acceptable professional practice. Before and after direct resident/guest contact. Before and after assisting a resident/guest with meals. Before and after changing a dressing. Review of the policy and procedure titled Dressing-Clean, with a last review date of 1/9/2024 read, Purpose: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. Each wound site should be treated individually. Standard: Physician's orders should specify type of wound, frequency of change, type of dressing or products to be used. Process: 5. Wash hands and put on clean gloves. 6. Loosen the tape and remove the existing dressing, moisten with prescribed cleansing solution if needed to remove dressing. 7. Pull your glove off the hand and over the dressing; discard into appropriate receptacle. 8. Wash hands and put on clean gloves.

Based on observation, interview, and record review, the facility failed to ensure residents received respiratory care services consistent with professional standards for 2 of 3 residents, Residents #90 and #105. Findings include: During an observation on 6/20/2023 at 9:31 AM, Resident #90 was lying in bed. Her nebulizer mask was observed sitting on the top of the nebulizer on her nightstand and was not bagged or dated. During an observation on 6/20/2023 at 9:56 AM, Resident #105 was lying in bed. Her nebulizer mask was observed sitting on top of the nebulizer on her nightstand and was not bagged. During an observation on 6/21/2023 at 8:04 AM, Resident #90 was lying in bed. Her nebulizer mask was observed to be on top of the nebulizer and was not bagged or dated. (Photographic evidence obtained) During an observation on 6/21/2023 at 8:16 AM, Resident #105 was lying in bed. Her nebulizer mask was observed to be on her nightstand and was not bagged or dated. Review of the physician's order for Resident #90 dated 6/19/2023 read, Albuterol SUL [sulfate] 2.5 mg/ml soln [milligrams per milliliter solution] one UD [unit dose] inhaled via neb tx [nebulizer treatment] every 6 hours as asa [sic] needed dfro [sic] sob [shortness of breath]/ wheezing. Review of the physician's order for Resident #105 dated 3/6/2023 read, Albuterol SUL 0.63 mg/3 ml soln inhale one UD via nebulizer tx every 4 hours as needed for sob/ wheezing. Review of the care plan for Resident #90, dated 5/21/2023, read Administer nebulizer treatment as directed. Change tubing as ordered. Review of the care plan for Resident #105, dated 3/7/2023, read Administer nebulizer treatments as ordered. Change nebulizer tubing as directed. During an interview on 6/22/2023 at 9:49 AM, Staff A, Registered Nurse (RN), stated, The nebulizer masks are to be bagged and dated. [Resident #90's name] nebulizer mask is not bagged or dated. During an interview on 6/22/2023 at 9:56 AM, Staff A, LPN stated, Nebulizer masks are to be bagged and dated. [Resident #105's name] nebulizer mask is not bagged or dated. During an interview on 6/22/2023 at 10:17 AM, the Director of Nursing stated, My expectation is that all nebulizer masks are to be bagged and dated. Review of the facility policy tilted Nebulizer, last reviewed 1/102023 read, V. After completion of therapy: a) Remove nebulizer container. b) Rinse container with fresh tap water. c) Dry with clen paper towel or gauze sponge. d) Wipe mouth piece or mask with damp paper towel or gauze sponge. e) Store in plastic bag. VI. Documentation should include length of therapy. VII. Discard administration setup every seven (7) days.

Based on observation, interview, and record review, the facility failed to ensure all drugs were stored and labeled in accordance with currently accepted professional principles and manufacturers' recommendations and under proper temperature in 4 of 6 medication carts and failed to ensure medications were stored in locked compartments to permit only authorized personnel to have access. Findings include: 1) During an observation of the North Wing Back Hall medication cart on 6/20/2023 at 8:58 AM, with Staff D, Registered Nurse (RN) there was one Levemir vial with no open or expiration date and a Novolog vial with an expiration date of 6/5/2023. During an interview on 6/20/2023 at 9:01 AM, Staff D, RN stated, Medication should be labeled with an open and expiration date when the medication is first opened. Expired medications should be disposed and not kept in the medication cart. Review of the manufacturer's recommendations for Detemir injection (Levemir) read, Pen or vial, vial - throw away after 42 days. During an observation of the South Wing Back Hall medication cart on 6/20/2023 at 9:05 AM, with Staff E, License Practical Nurse (LPN) there was an unopened vial of Novolog and one bottle of Timolol eye drops with an expiration date of 5/12/2023. During an interview on 6/20/2023 at 9:09 AM, Staff E, LPN stated, Unopened insulin vials should be kept refrigerated until it is opened. Expired medication should be thrown away and new medication ordered. Review of the manufacturer's recommendations Novolog read, Unused vials of Novolog should be stored under refrigeration between 36 and 46 degree Fahrenheit. During an observation of the South Wing Front Hall medication cart with Staff F, LPN there was one unopened Lantus Solostar insulin pen labeled, Refrigerate till open then room temperature. During an interview on 6/20/2023 at 9:21 AM with Staff F, LPN stated Insulin should be refrigerated until it is opened. Review of the manufacturer's recommendations for Lantus Solostar pen read, Always store UNOPENED Lantus Solostar pens in the refrigerator. During an observation on 6/20/2023 at 9:25 AM of the [NAME] Wing Back Hall medication cart with Staff C, LPN, there was one expired Lispro insulin pen with an opened date of 5/9/2023, one expired Basaglar insulin pen with opened date of 5/13/2023, one expired Novolog insulin pen with an opened date of 5/15/2023, one expired opened bottle of Latanoprost eye drops with an expiration date of 6/4/2023, two opened bottles of Timolol with no opened date and expiration date, and one opened bottle of Brinzolamide eye drops with no opened or expiration date. During an interview on 6/20/2023 at 9:30 AM Staff C, LPN stated Medication should be labeled when first opened with the opened date and expiration date. Medication that is expired should be returned to the pharmacy or disposed of. Review of the manufacturer's recommendations for Lispro insulin pen read, Insulin Lispro: Throw away pen/vials after 28 days of use, even if there is still insulin left. Review of the manufacturer's recommendations for Basaglar read, Store your opened Pen at room temperature up to 86 degrees Fahrenheit and throw it away after 28 days. Review of the manufacturer's recommendations for Novolog insulin pen read, Insulin Name: Novolog. Expiration upon opening or removing from refrigerator: 28 days. Review of the manufacturer's recommendations for Timolol read, Use the timolol eye drops within the expiry date shown on the bottle and within 4 weeks of opening. This will help to lower the risk of eye infections and make sure the eye drops work properly. Review of the manufacturer's recommendations for Brinzolamide read, Use the timolol eye drops within the expiry date shown on the bottle and within 4 weeks of opening. This will help to lower the risk of eye infections and make sure the eye drops work properly. During an interview on 6/22/2023 at 12:50 PM, the Director of Nursing stated, Staff should be labeling medications as per protocol. If the medication is expired, it should be removed from the medication cart. I do not think insulin needs to be refrigerated until it is opened. I think we refrigerate insulin for longer shelf life. 46288 2) During an observation on 6/20/2023 at 10:19 AM, Resident #31 was lying in bed. Several medications were observed in a small cup sitting on resident #31's over the bed table. (Photographic evidence obtained). During an interview with Resident #31 on 6/20/2023 at 10:19 AM stated, My Parkinson's medicine is in that cup and the nurse left it this morning. During an interview with Staff A, Registered Nurse (RN) on 6/22/2023 at 9:52 AM, That is [Resident # 31's name] medications and she should not have that at her bedside. During an interview with the Director of Nursing (DON) on 6/22/2023 at 10:17 AM stated, My expectation is that no medications are to be left at a resident's bedside. Review of policy and procedure titled Storage and Expiration of Medications, Biologicals, Syringes and Needles last reviewed on 1/10/2023 reads, Procedure: 3. General Storage Procedures: 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. 4. facility should ensure that medications and biologicals: 4.2 Have not been retained longer than recommended by manufacturer or supplier. 5. Once any medication or biologicals package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 11. Facility should ensure medications and biologicals are stored at their appropriate temperature according to the United States Pharmacopeia guidelines for temperature ranges. 16. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other Applicable Law, and in accordance with Policy 8.2 (Disposal/Destruction of Expired or Discontinued Medication). 18. Facility should request that Pharmacy perform a routine nursing unit inspection for each nursing station in Facility to assist Facility in complying with its obligations pursuant to Applicable Law relating to the proper storage labeling, security and accountability of medications and biologicals.

Based on observation, interviews and record review, the facility failed to ensure cleaning of equipment per policy guidelines to maintain sanitary standards of equipment. Findings include: A walk-through tour of the kitchen was conducted on 6/21/23 at 07:16 AM with the Certified Dietary Manager (CDM). There was a built-up black substance on the interior door of the ice machine. The microwave was observed to have numerous dried food particles inside on the sides, top and base. The robot coupe (chopper/grinder) was observed to have water nesting in the bottom of the base. The mixer was observed to have food particles on the base and bowl of the mixer. The can opener was observed to have a buildup of dried food particles on and around the blade and base of the can opener. (Photographic evidence obtained). An interview was conducted with the CDM on 6/21/23 at 9:20 AM. The CDM verified the presence of a black built-up substance on the interior door of the ice machine, the microwave had numerous food particles on the sides, top and base of the equipment, the mixer was covered, was to be clean and there were food particles on the base and the bowl, the can opener had dried food particles on the blade and base, the robot coupe bowl (chopper/grinder) was clean and should have been inverted to prevent wet-nesting; the robot coupe bowl had water standing in the bottom from being washed and placed back on the base. The CDM stated the dietary department has a cleaning schedule for assigned daily, weekly, monthly, and as needed duties. The CDM confirmed the cleaning schedule was not being followed. Review of the policy and procedure titled Cleaning Schedules with an effective date of 2/1/2022 read, To prevent the spread of bacteria that may cause food borne illnesses. Process: e. The Dietary Manager should supervise adherence to the cleaning schedule, and inspect the kitchen weekly for cleanliness. Review of the policy and procedure titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of 04/17/214 read, 24. Ice Machine, Dispensers, Chests: (at least monthly) Wash machine, inside and outside, including legs and handle. 27. Meat Grinder/Buffalo Chopper: (after each use) Air dry on clean surface or dry with clean paper towels or cloth to prevent rust. 28. Mixer: (after each use) Take out bowl and beater. Wash in pot and pan sink or dish machine. Thoroughly scrub machine (include motor housing), air dry. 35. Microwave Oven: (daily and as needed) Wash walls inside and out.