Every finding on record at Davis Health and Wellness Center at Cambridge Vill

Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 9 of 172 days reviewed for sufficient staffing (4/12/25, 4/25/25, 4/26/25, 5/9/25, 6/7/25, 6/8/25, 8/2/25, 8/3/25 and 9/21/25).Finding included:The Payroll Based Journal (PBJ) report for the Federal Fiscal third quarter of 2025 (April, May, June) and the Federal Fiscal fourth quarter of 2025 (July, August, September) reported the facility was without RN coverage for eight consecutive hours per day.A review of the daily census posting sheets for the months of 4/12/25 to 9/30/25, indicated a consistent census less than 60 residents in the facility and no RN coverage for eight consecutive hours for the following dates: 4/12/25, 4/25/25, 4/26/25, 5/9/25, 6/7/25, 6/8/25, 8/2/25, 8/3/25, 9/21/25. A review of the daily nursing staffing sheets for the months of 4/1/25 to 9/30/25 indicated there was no RN scheduled for at least eight consecutive hours for the following dates: 4/12/25, 4/25/25, 4/26/25, 5/9/25, 6/7/25, 6/8/25, 8/2/25, 8/3/25, 9/21/25. There was no RN recorded as working eight consecutive hours on the timecard records reviewed for the following dates 4/12/25, 4/25/25, 4/26/25, 5/9/25, 6/7/25, 6/8/25, 8/2/25, 8/3/25, 9/21/25.During an interview with the Administrator on 3/26/26 at 8:55 AM, she stated that she was responsible for ensuring that an RN was scheduled to work eight consecutive hours each day in the facility. She acknowledged that since beginning her role last year, she had been aware of ongoing difficulties in maintaining this required RN coverage. She explained that the facility relied on agency nurses for RN shifts, and when an agency RN failed to report for a scheduled shift, she was often unable to secure a replacement and the previous Director of Nursing was unavailable, resulting in gaps in the required eight consecutive hours of RN coverage. The Administrator reported that she had since hired additional Registered Nurses and had a new Director of Nursing who understood the responsibility to ensure consistent RN coverage.

Based on record review, and staff and Physician interviews the facility failed to obtain consent and inform the resident or Responsible Party in advance of the risks and benefits of psychotropic medications (medications that alter brain chemicals and are used to treat conditions such as anxiety and depression and include the medications classified as antidepressants) prior to initiation for 7 of 7 residents reviewed for unnecessary medications (Residents #13, #4, #16,#1,#26, #12, #3). Findings included: a). Resident #13 was admitted on [DATE] with a diagnosis of depression. Review of Resident #13's physician orders revealed an order dated 2/13/26 for the antidepressant medication duloxetine delayed release 30 milligrams (mg) twice per day for depression. A review of Resident #13's electronic medical record (EMR) indicated no documentation that the resident or resident representative was informed in advance of the risks or benefits of initiating the psychotropic antidepressant medication duloxetine prescribed for depression. Review of Resident #13's admission Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was cognitively intact and received an antidepressant medication. A review of Resident #13's electronic Medication Administration Record from February 2026 and March 2026 revealed that the resident received the antidepressant duloxetine as ordered. b). Resident #4 was admitted on [DATE] with diagnosis which included stroke and depression. A review of Resident #4's physician orders revealed an order dated 8/24/24 for the psychotropic antidepressant medication sertraline (antidepressant) 75 milligrams at bedtime for depression. Review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] indicated that the resident had mild cognitive impairment and received an antidepressant on a regular basis during the assessment period. A review of Resident #4's physician orders revealed an order dated 3/11/26 for the psychotropic antidepressant medication amitriptyline 25 milligrams at bedtime for insomnia. A review of Resident #4's electronic medical record (EMR) indicated no documentation that the resident or resident representative was informed in advance of the risks or benefits of initiating the psychotropic antidepressant medications sertraline or amitriptyline. A review of Resident #4's electronic Medication Administration Record for March 2026 revealed that the resident received the psychotropic antidepressant medication amitriptyline daily as ordered. c). Resident #16 was admitted on [DATE] with diagnosis which included stroke and depression. A review of Resident #16's physician orders revealed an order dated 8/25/25 for the psychotropic antidepressant medication sertraline 150 milligrams daily for recurrent depressive disorder. The order was discontinued on 1/19/26. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was cognitively intact and received an antidepressant during the past 7 days. A review of Resident #16's electronic Medication Administration Record from 8/25/25 through 1/19/26 revealed that the resident received the psychotropic antidepressant medication sertraline daily as ordered. A review of Resident #16's physician orders revealed an order dated 1/19/26 for the psychotropic antidepressant medication sertraline 100 milligrams daily. A review of Resident #16's electronic Medication Administration Record for 1/19/26 through 3/24/26 revealed that the resident received the psychotropic antidepressant medication sertraline daily as ordered. A review of Resident #16's electronic medical record (EMR) indicated no documentation that the resident or resident representative was informed in advance of the risks or benefits of initiating the psychotropic antidepressant medication sertraline. d). Resident #1 was admitted on [DATE] with diagnosis which included major depressive disorder, anxiety, falls and muscle weakness. Review of Resident #1's electronic health record revealed a physician order dated 3/4/26 for the psychotropic antidepressant medications trazadone 50 milligrams at bedtime as needed for insomnia and bupropion hydrochloride sustained release 12 hour 150 milligrams once per day for depression. A review of Resident #1's electronic medical record (EMR) indicated no documentation that the resident or resident representative was informed in advance of the risks or benefits of initiating the psychotropic antidepressant medications trazadone and bupropion. Review of Resident #1's electronic Medication Administration Record for March 2026 revealed that resident received the psychotropic antidepressant medications bupropion 150 milligrams once per day daily and received trazadone as needed on 3/4/26, 3/5/26, 3/9/26, 3/17/26 and 3/18/26. A review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident was cognitively intact and received an antidepressant during the last 7 days. e.) Resident #26 was admitted to the facility on [DATE] with diagnoses including dementia and insomnia. A physician's order dated 3/13/26 for Resident #26 revealed to continue Trazodone (an antidepressant medication) 50 milligrams (mg) at bedtime for insomnia. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #26 was cognitively intact and received an antidepressant medication. A review of the Medication Administration Record (MAR) dated March 2026 revealed Resident #26 received Trazodone 50 mg tablets as ordered by the Physician from 3/13/26 through 3/24/26. A review of the electronic medical record contained no documentation that Resident #26 or his Responsible Party (RP) was provided information regarding: the name of the medication, the purpose of the medication, risks and benefits, alternatives, and the right to refuse. There was no signed informed consent form and no progress note documenting an informed consent discussion. f). Resident #12 was admitted to the facility on [DATE] with a diagnosis of major depression. A physician's order dated 3/10/26 for Resident #12 revealed to continue Prozac (an antidepressant medication) 10 mgs by mouth once a day. The Minimum Data Set admission assessment dated [DATE] revealed Resident #12 was cognitively intact and received an antidepressant medication. A review of the Medication Administration Record dated March 2026 revealed Resident #12 received Prozac 10 mg tablets as ordered by the Physician from 3/11/26 through 3/24/26. A review of the electronic medical record contained no documentation that Resident #12 or his Responsible Party (RP) was provided information regarding: the name of the medication, the purpose of the medication, risks and benefits, alternatives, and the right to refuse. There was no signed informed consent form and no progress note documenting an informed consent discussion. g). Resident #3 was admitted to the facility on [DATE] with a diagnosis of major depression. A physician's order dated 3/23/25 for Resident #3 revealed Duloxetine (an antidepressant medication) 20 mg tablets by mouth twice a day for major depressive disorder. The Minimum Data Set annual assessment dated [DATE] revealed Resident #3 was cognitively intact and received an antidepressant medication. A review of the Medication Administration Record dated March 2025 through March 2026 revealed Resident #3 received Prozac 10 mg tablets twice a day as ordered by the Physician. A review of the electronic medical record contained no documentation that Resident #3 or her Responsible Party (RP) was provided information regarding: the name of the medication, the purpose of the medication, risks and benefits, alternatives, and the right to refuse. There was no signed informed consent form and no progress note documenting an informed consent discussion. During an interview on 3/23/26 at 3:15 PM the Case Manager stated that she was not aware that consents were required for psychotropic medications and she did not obtain consents prior to the medications being initiated. During an interview with the Director of Nursing (DON) on 3/23/26 at 3:30 PM she stated that she was not aware that consent was required for psychotropic medications. The DON stated that the facility had not been obtaining informed consent prior to initiating psychotropic medications, and they did not currently have consent forms in place. During a phone interview on 3/25/26 at 3:45 PM the Physician stated that she was unaware that consent had not been obtained prior to initiating a psychotropic medication. The Physician stated that obtaining informed consent from the resident and/or the Responsible Party was essential prior to initiating psychotropic medications.

Based on observations and staff interviews, the facility failed to discard expired food items stored in 1 of 2 reach in refrigerators. This deficient practice had the potential to affect the safety of food served to residents. Findings included: During the initial tour of the Kitchen on 03/22/26 at 10:20 AM along with [NAME] #1 the following expired food items were observed in the reach-in refrigerator: - A plastic container of sauerkraut that was opened with a discard date of 2/24/26.- A plastic container of canned pears that was opened with a discard date of 3/12/26.- A plastic container of canned tuna that was opened with a discard date of 3/19/26.- A plastic container of canned pork and beans that was opened with a discard date of 3/21/26. During an interview on 3/22/26 at 10:25 AM [NAME] #1 stated all kitchen staff were responsible for checking for and discarding expired foods. He stated he was the weekend cook and had not gone through the refrigerator this morning (3/22/26) to check it. He stated he also worked yesterday (3/21/26) and the expired food items were overlooked. During an interview on 03/24/26 at 12:42 PM the Dietary Manager stated perishable foods were to be discarded after 3 days and staff should have removed the foods from the refrigerator on the discard date. He stated the kitchen staff were aware of this. During an interview on 03/24/26 at 12:52 PM the Administrator stated she expected the kitchen staff to check for expired foods daily and remove any foods by the discard date.

Based on record review and staff and Physician interviews, the facility failed to notify the Physician when Resident #13 missed 8 doses of the antibiotic doxycycline for 1 of 1 resident reviewed for notification (Resident #13). Findings included: Resident #13 was admitted on [DATE] with diagnosis which included chronic osteomyelitis (bone infection) and diabetes. Review of a physician order dated 2/13/26 indicated Resident #13 was ordered doxycycline 100 milligrams (mg) by mouth twice per day indefinitely for chronic osteomyelitis. Review of Resident #13's Medication Administration Record (MAR) for March 2026 revealed the following documentation for the medication doxycycline 100 mg twice a day. On 3/9/26 the lunch dose was documented by Nurse #6 as the medication was unavailable and the medication was not administered. On 3/9/26 PM (evening) dose was documented by Nurse #1 as the medication was unavailable and the medication was not administered. There was no documentation in the nursing progress notes that the physician was notified of the missed medication.On 3/10/26 lunch dose was documented by Nurse #7 as the medication was unavailable and the medication was not administered. There was no documentation in the nursing progress notes that the physician was notified of the missed medication.On 3/10/26 PM dose was documented by Nurse #1 as waiting pharmacy delivery and the medication was not administered. On 3/11/26 lunch dose was documented by Nurse #5 as the medication was unavailable, awaiting pharmacy refill and the medication was not administered. On 3/11/26 PM dose was documented by Nurse #2 as the medication was unavailable and the medication was not administered. On 3/12/26 lunch dose was documented by Nurse #7 as medication was unavailable and the medication was not administered. On 3/12/26 PM dose was documented by Nurse #2 as medication was unavailable and the medication was not administered. An interview conducted with Nurse #6 on 3/23/26 at 11:20 AM revealed that she was assigned to Resident #13 on 3/9/26 from 7:00 AM to 7:00 PM and she did not administer the prescribed antibiotic. Nurse #6 stated that she did not call the physician to report the medication was not administered and she did not recall why she did not report this to the physician. Attempts were made to interview Nurse #1 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received. Attempts were made to interview Nurse #7 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received. An interview with Nurse #5 on 3/25/26 at 1:50 PM revealed that she was assigned to Resident #13 on 3/11/26 from 7:00 AM to 7:00 PM. She stated that the doxycycline was not available for Resident #13 on 3/11/26, and she did not notify the physician that the resident did not receive the prescribed dose. Nurse #5 stated that she did not think it was necessary to inform the physician that the resident did not receive the prescribed antibiotic. An interview was conducted with Nurse #2 on 3/25/26 at 12:15 PM. Nurse #2 was assigned to resident #13 on 3/11/26 and 3/12/26 from 7:00 PM to 7:00 AM. Nurse #2 stated that the medication doxycycline was unavailable for Resident #13 on 3/11/26 so she did not administer it. Nurse #2 stated that she did not inform the physician that the antibiotic doxycycline was not administered as ordered on 3/11/26 and 3/12/26. Nurse #2 acknowledged that she should have informed the physician of the missed doses of antibiotic, but at the time she did not realize it was necessary. An interview with the Director of Nursing (DON) on 3/25/26 at 2:30 PM revealed that she expected medications to be administered as ordered by the physician. The DON stated she would expect nursing staff to notify the provider when a medication was not available so that an alternate medication could be prescribed, if necessary. An interview conducted with the Physician on 3/25/26 at 3:45 PM revealed that she was unaware that Resident #13 had missed 8 doses of the prescribed antibiotic. The Physician stated that medications should be available and administered as ordered. The Physician further stated that if a medication was not available the provider should be notified to determine if another medication should be ordered.

Based on record review and interviews with staff, the Pharmacy Manager and the Physician, the facility failed to obtain the antibiotic doxycycline, which was prescribed for Resident #13 twice daily for the treatment of chronic osteomyelitis (a bone infection). As a result, Resident #13 missed a total of eight doses of the medication on 3/9/26, 3/10/26, 3/11/26, and 3/12/26. According to the Physician, the resident did not experience an adverse outcome; however, the failure to provide the prescribed antibiotic placed the resident at risk for potential complications. This occurred for 1 of 1 resident reviewed for pharmacy services.Findings included:Resident #13 was admitted on [DATE] with diagnosis which included chronic osteomyelitis and diabetes. Review of a physician order dated 2/13/26 indicated Resident #13 was ordered doxycycline 100 milligrams (mg) by mouth twice per day indefinitely for chronic osteomyelitis.Review of Resident #13's Medication Administration Record (MAR) for March 2026 revealed the following documentation for the doxycycline 100 mg twice a day. On 3/9/26 the lunch dose was documented by Nurse #6 as the medication was unavailable and the medication was not administered. On 3/9/26 PM (evening) dose was documented by Nurse #1 as the medication was unavailable and the medication was not administered. On 3/10/26 lunch dose was documented by Nurse #7 as the medication was unavailable and the medication was not administered.On 3/10/26 PM dose was documented by Nurse #1 as waiting pharmacy delivery and the medication was not administered. On 3/11/26 lunch dose was documented by Nurse #5 as the medication was unavailable, awaiting pharmacy refill and the medication was not administered. On 3/11/26 PM dose was documented by Nurse #2 as the medication was unavailable and the medication was not administered. On 3/12/26 lunch dose was documented by Nurse #7 as medication was unavailable and the medication was not administered. On 3/12/26 PM dose was documented by Nurse #2 as medication was unavailable and the medication was not administered. An interview conducted with Nurse #6 on 3/23/26 at 11:20 AM revealed that she was assigned to Resident #13 on 3/9/26 from 7:00 AM to 7:00 PM and she did not administer the prescribed antibiotic. She stated that the doxycycline was not available for Resident #13 on 3/9/26 in the resident's medication cabinet. She acknowledged that she did not check the automated medication dispensing machine and she did not contact the pharmacy to obtain the medication from the local back up pharmacy. Nurse #6 stated that she did not recall why she did not call the pharmacy to obtain the medication doxycycline for Resident #13.Attempts were made to interview Nurse #1 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received.Attempts were made to interview Nurse #7 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received.An interview with Nurse #5 on 3/25/26 at 1:50 PM revealed that she was assigned to Resident #13 on 3/11/26 from 7:00 AM to 7:00 PM. She stated that the doxycycline was not available for Resident #13 on 3/11/26 in the resident's medication cabinet, and she did not check the automated medication dispensing machine and did not contact the pharmacy to obtain the medication from the local back up pharmacy. Nurse #5 stated that she documented awaiting pharmacy refill as she assumed that the medication would be delivered later that day or the next day.An interview was conducted with Nurse #2 on 3/25/26 at 12:15 PM. Nurse #2 reported that she was assigned to Resident #13 on 3/11/26 and 3/12/26 for the 7:00 PM to 7:00 AM shift. She stated that the doxycycline was unavailable on 3/11/26 and therefore she did not administer it. Nurse #2 stated that when she determined the doxycycline was not in Resident #13's medication cabinet, she checked the automated medication dispensing machine however the correct dose of the medication was not available in the machine. Nurse #2 acknowledged that she did not contact the pharmacy on 3/11/26 to obtain the medication but did place a call on 3/12/26. She also stated that she did not request that the medication be sent through the backup system. Nurse #2 reported that she informed the pharmacy the medication was not available in the facility and was told that the pharmacy had the order listed as once per day instead of twice daily. She acknowledged that she should have requested immediate delivery to ensure that Resident #13 did not miss any doses. She further stated that she did not report to the Director of Nursing or Physician that there was a discrepancy with the frequency of the medication between the pharmacy and the facility.Attempts were made to interview Nurse #7 with voicemail messages left with no return call received.An interview with the Director of Nursing (DON) on 3/25/26 at 2:30 PM revealed that she expected medications to be administered as ordered by the physician. The DON stated she would expect nursing staff to notify the pharmacy when a medication was not available in the facility so that the medication could be obtained through the local backup pharmacy. The DON further explained that the facility utilized an automated medication dispensing machine that housed an emergency supply of select medications. She stated that once the nurses determined the medication was not in the resident's medication cabinet, they should have checked the automated dispensing machine. If the medication was not available there, the next step should have been to contact the pharmacy to obtain the medication from the local backup pharmacy. The DON stated that she had since learned that the automated medication-dispensing machine did not contain the correct dose of doxycycline.An interview conducted with the Physician on 3/25/26 at 3:45 PM revealed that she was unaware that Resident #13 had missed 8 doses of the prescribed antibiotic. The Physician stated that medications should be available and administered as ordered. The Physician indicated that there was a potential for the infection that the antibiotic was ordered to treat to worsen if it was not administered for several days. An interview with the Pharmacy Manager was conducted on 3/26/26 at 12:00 PM. The Pharmacy Manager stated that the pharmacy had systems in place to ensure medications were available daily, including twice daily deliveries and backup processes when necessary. The Pharmacy Manager indicated that if the pharmacy was notified that the doxycycline was not available in the facility, it would have been sent to the facility through the backup system. The Pharmacy Manager was unable to explain why the pharmacy had entered the order for doxycycline as once daily rather than twice daily. He stated that the pharmacy reconciled the orders sent to the pharmacy with what was entered by the nursing staff into the computer, after which a label was generated and the prescription was filled. He indicated that although missing eight doses of doxycycline was not expected to result in a significant clinical outcome, there was a potential risk for worsening of the infection for which the medication had been prescribed.

Based on record review, and staff interviews the facility failed to act on the Consultant Pharmacist's monthly medication regimen review and change the frequency of Resident #8's hydroxyzine 25 milligrams (an antihistamine used to treat anxiety, allergic reactions, and induce sleep) from three times a day to twice a day after the physician signed to change the medication order. This occurred for 1 of 2 residents reviewed for medication administration (Resident #8). Findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses including pruritus (persistent itching). A physician's order dated 7/10/23 for Resident #8 revealed hydroxyzine 25 milligram tablets three times a day for pruritus. The Consultant's Pharmacist's Medication Regimen Review dated 1/12/26 noted that the Physician signed the pharmacy consult report on 12/12/25 to change Resident #8's hydroxyzine to 25 milligrams every morning and midday and discontinue three times a day. This order was not changed in the electronic medical record. Please correct and report the medication error. Review of Resident #8's Medication Administration Record (MAR) dated 12/12/25 through 1/18/26 revealed Resident #8 continued to receive hydroxyzine 25 mgs three times a day as evidenced by the nurse's signatures. The physician's order was updated by the Director of Nursing on 1/19/26 and entered into Resident #8's electronic medical record for hydroxyzine 25 mgs twice a day morning and midday. During an interview on 3/25/26 at 2:35 PM the Director of Nursing (DON) stated the Consultant Pharmacist emailed her the medication regimen reviews each month. The DON stated the process now included that once she received the monthly Pharmacy reports, she would address the nursing recommendations and place the physician recommendations in the Physician's notebook for review unless there was something that needed immediate attention then she would call the Physician. Once the Physician signed off on any medication order changes from the Pharmacy recommendations the DON would make the order change in the resident's electronic medical record. The DON stated she was new to the facility in December 2025 and did not realize the importance of addressing the pharmacy reviews promptly and therefore there was a delay in addressing the December (2025) reports. She stated she did not implement the new order to reduce the hydroxyzine 25 mg dose to twice a day until she was notified by the Consultant Pharmacist the following month (January 2026) that she had not changed the frequency. The DON stated she should have acted on the Pharmacy reports once she received them. During an interview on 3/26/26 at 11:00 AM the Clinical Compliance Administrator stated that the Consultant Pharmacist's medication regimen reviews should be addressed as soon as the DON received the monthly reports. She indicated the DON had received education on the importance of addressing the medication regimen reviews promptly. The Consultant Pharmacist was on leave during the survey and unavailable for an interview.

Based on record review, and residents, staff, Physician and Pharmacy Manager interviews, the facility failed to ensure residents were free from significant medication errors when 1.) Eight doses of the antibiotic doxycycline, prescribed twice daily for the treatment of chronic osteomyelitis (bone infection), were omitted on 3/9/26, 3/10/26, 3/11/26 and 3/12/26 for Resident #13. 2.) Resident #5 received 15 milligrams (mg) of mirtazapine (a psychotropic medication primarily prescribed for depression) instead of the physician ordered 7.5 mg dose. 3.) Resident #8 continued to receive hydroxyzine 25 mg (an antihistamine that directly affects the central nervous system and used to treat anxiety, allergic reactions, and induce sleep) three times a day instead of the reduced dose of twice a day. The residents did not experience any significant outcome, however this failure placed Resident #13 at risk for potential complications, and the potential for altered sedation levels, and an increased risk of adverse effects for Resident #5 and Resident #8. This occurred for 3 of 3 residents reviewed for medication administration (Resident #13, Resident #5, and Resident #8). Findings included: 1.) Resident #13 was admitted on [DATE] with diagnosis which included chronic osteomyelitis and diabetes. Review of a physician order dated 2/13/26 indicated Resident #13 was ordered doxycycline 100 milligrams (mg) by mouth twice per day indefinitely for chronic osteomyelitis. Review of Resident #13's admission Minimum Data Set assessment dated [DATE] indicated the resident was cognitively intact and received an antibiotic. Review of Resident #13's Medication Administration Record (MAR) for March 2026 revealed the following documentation for the medication doxycycline 100 mg twice a day. On 3/9/26 the lunch dose was documented by Nurse #6 as the medication was unavailable and the medication was not administered. On 3/9/26 PM (evening) dose was documented by Nurse #1 as the medication was unavailable and the medication was not administered. On 3/10/26 lunch dose was documented by Nurse #7 as the medication was unavailable and the medication was not administered. On 3/10/26 PM dose was documented by Nurse #1 as waiting pharmacy delivery and the medication was not administered. On 3/11/26 lunch dose was documented by Nurse #5 as the medication was unavailable, awaiting pharmacy refill and the medication was not administered. On 3/11/26 PM dose was documented by Nurse #2 as the medication was unavailable and the medication was not administered. On 3/12/26 lunch dose was documented by Nurse #7 as medication was unavailable and the medication was not administered. On 3/12/26 PM dose was documented by Nurse #2 as medication was unavailable and the medication was not administered. An interview conducted with Nurse #6 on 3/23/26 at 11:20 AM revealed that the pharmacy normally delivered to the facility in the afternoon and at night. Nurse #6 acknowledged that she was assigned to Resident #13 on 3/9/26 from 7:00 AM to 7:00 PM and did not administer the prescribed antibiotic. Nurse #6 stated that she did not recall why she did not call the pharmacy to obtain the ordered medication for Resident #13. Attempts were made to interview Nurse #1 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received. Attempts were made to interview Nurse #7 via telephone with voicemail messages left on 3/24/26 and 3/25/26 with no return call received. An interview with Nurse #5 on 3/25/26 at 1:50 PM revealed that she was assigned to Resident #13 on 3/11/26 from 7:00 AM to 7:00 PM. She stated that the medication doxycycline was not available for Resident #13 on 3/11/26, and she did not contact the pharmacy to obtain the medication. An interview was conducted with Nurse #2 on 3/25/26 at 12:15 PM. Nurse #2 was assigned to Resident #13 on 3/11/26 and 3/12/26 from 7:00 PM to 7:00 AM. Nurse #2 stated that the medication doxycycline was unavailable for Resident #13 on 3/11/26 so she did not administer it. Nurse #2 stated that she thought that the medication would come from the pharmacy and indicated that the medication was not available in the facility's back up medication system. Nurse #2 stated that on 3/12/26 when the medication was again not available, she called the pharmacy to find out where it was. Nurse #2 stated that the pharmacy stated that they thought the medication was ordered once per day and did not think that the prescription should have run out. Nurse #2 stated that she informed the pharmacy that the medication was ordered twice per day. An interview with the Pharmacy Manager was conducted on 3/26/26 at 12:00 PM. The Pharmacy Manager stated that the pharmacy had systems in place to ensure medications were available daily, including regular deliveries and backup processes when needed. He indicated that although missing eight doses of the antibiotic doxycycline was not expected to result in a significant clinical outcome, there was a potential risk for worsening of the infection for which the medication was prescribed. An interview with the Director of Nursing (DON) on 3/25/26 at 2:30 PM revealed that she expected medications to be administered as ordered by the physician. The DON stated she would expect nursing staff to contact the pharmacy to obtain any medication that was not available. An interview conducted with the Physician on 3/25/26 at 3:45 PM revealed that she was unaware that Resident #13 had missed 8 doses of the prescribed antibiotic. The Physician stated that not administering prescribed doses of an antibiotic was a significant medication error that needed to be addressed. The Physician stated that medications should be available and administered as ordered. The Physician indicated that there was a potential for the infection that the antibiotic was ordered to treat to worsen if it was not administered for several days. 2.) Resident #5 was admitted to the facility on [DATE] with diagnoses including major depression and Parkinson's disease. Resident #5's hospital Discharge summary dated [DATE] revealed medication orders for Mirtazapine 15 milligrams (mg) take one half tablet by mouth at 11:00 PM. A review of Resident #5's electronic medical record revealed on 2/27/26 the Director of Nursing entered an order for Mirtazapine 15 mgs by mouth at bedtime for dementia associated with Parkinson's disease. The Medication Administration Record (MAR) dated 2/27/26 through 3/10/26 revealed that Mirtazapine 15 mg tablets were administered to Resident #5 nightly as evidenced by the nurses' signatures. Review of Resident #5's electronic medical record from 2/27/26 through 3/10/26 contained no documentation indicating the mirtazapine dose had been changed, clarified, or corrected by the prescriber. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #5 was cognitively intact and received antidepressant medication. During an interview on 3/23/26 Resident #5 stated he felt pretty good, he was scheduled to discharge home tomorrow (3/24/26). He indicated he was not aware of the dosage of his medications and stated he had no concerns regarding his medications. During an interview on 3/24/26 at 2:00 PM the Director of Nursing (DON) stated she entered the order for Resident #5's mirtazapine. She entered one tablet (15 mg) of mirtazapine instead of one-half tablet (7.5 mg). The DON stated they had a two-step system to verify that physician orders were entered accurately. This included that the admission nurse entered medication orders from the hospital discharge summary, if the admission nurse was not available the DON would enter the medication orders which was what happened when Resident #5 was admitted . Then a second nurse, which was typically the residents assigned nurse, was responsible for double checking the orders to ensure accuracy. The DON stated she transcribed the order wrong, and the two-step process was missed, and a second check was not done for this order. She stated she did not know who the second nurse was who should also have verified the orders. She was notified of the medication error by the Consultant Pharmacist and corrected the dose on 3/10/26. The DON stated Resident #5 has had no change in condition and was to be discharged home today. During a phone interview on 3/26/26 at 12:00 PM the Pharmacy Manager stated receiving 15 mgs of mirtazapine instead of 7.5 mgs was generally considered safe and 15 mgs was considered to be a low dose. He stated mirtazapine had dose dependent effects and sometimes lower doses were more sedating than higher doses. During a phone interview on 3/25/26 at 3:30 PM the Physician stated Resident #5 receiving mirtazapine 15 mgs instead of 7.5 mgs would cause no concern and Resident #5 had not experienced any outcome from receiving the medication. 3.) Resident #8 was admitted to the facility on [DATE] with diagnoses including pruritus (persistent itching). A physician's order dated 7/10/23 for Resident #8 revealed hydroxyzine 25 milligrams (mg) three times a day for pruritus. The Consultant Pharmacist's Medication Regimen Review dated 1/12/26 noted that the Physician signed the pharmacy consult report from 12/12/25 to change Resident #8's hydroxyzine to 25 mg every morning and midday and discontinue three times a day. This order was not changed in the electronic medical record. Please correct and report the medication error. Review of Resident #8's Medication Administration Record (MAR) dated 12/12/25 through 1/18/26 revealed Resident #8 continued to receive hydroxyzine 25 mgs three times a day as evidence by the nurses' signatures. The physician's order was updated by the Director of Nursing on 1/19/26 and entered into Resident #8's electronic medical record for hydroxyzine 25 mgs twice a day morning and midday. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #8 had moderately impaired cognition. During an interview on 3/25/26 at 10:00 AM Resident #8 stated she took hydroxyzine for itching. She indicated she did not know the dosage or how often it was given but stated the medication helped with itching. Resident #8 stated she did not feel the medication made her excessively drowsy. During an interview on 3/25/26 at 2:35 PM the Director of Nursing (DON) stated she started working in the facility in November 2025 and was new to the role of DON. She received the medication regimen reviews monthly that were done by the Consultant Pharmacist. The DON stated she did not realize the importance of addressing the pharmacy reviews promptly and therefore there was a delay in addressing the December (2025) reports. She stated she did not implement the new order to reduce the hydroxyzine 25 mg dose to twice a day until she was notified by the Consultant Pharmacist the following month (January 2026) that she had not changed the frequency. The DON stated Resident #8 continued to receive hydroxyzine 25 mg three times a day until she corrected the order on 1/19/26. The DON stated Resident #8 has had no change in her condition from receiving the medication. The Consultant Pharmacist was on leave during the survey and unavailable for an interview. During a phone interview on 3/26/26 at 12:00 PM the Pharmacy Manager stated due to the length of time Resident #8 had received the hydroxyzine 25 mgs it would have no clinical effects on the resident for continuing to receive the medication three times a day. He stated a dose reduction was indicated due to the length of time Resident #8 had been receiving the medication. During a phone interview on 3/26/26 at 3:30 PM the Physician stated Resident #8 was a long-term care resident and had received hydroxyzine for itching for a long period. She stated Resident #8 had not experienced any outcome and had no change in condition.

Based on record review and staff interviews, the facility failed to develop a person-centered care plan in the area of falls for 2 of 3 residents reviewed for falls (Resident #1 and Resident #2).The findings included:1. Resident #1 was admitted to the facility on [DATE] with diagnoses which included a left knee fracture.The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 was cognitively intact and required partial to moderate assistance for transfers. Resident #1 was coded for a fall with fracture prior to admission and one fall without injury since admission to the facility. The MDS admission assessment further noted the care area assessment (a standardized assessment tool to identify potential problems and need in specific areas, such as falls, used to develop individualized care plans) for falls was triggered for a care plan to be initiated.Review of Resident #1's care plan initiated on 9/01/25 and last revised on 9/16/25 revealed no care plan was in place for fall risk.The nursing progress note dated 9/08/25 at 6:21 am revealed Resident #1 was observed on the floor near the room door. Resident #1 denied any pain or discomfort and had no injuries noted.The nursing progress note dated 9/09/25 at 6:30 am revealed Resident #1 was observed by the Nurse Aide (NA) to be on the floor next to the bed. The bed was noted to be in the lowest position possible. Resident #1 reported left knee pain and was administered acetaminophen for the pain.The event report dated 9/21/25 at 8:38 am revealed Resident #1 had an unwitnessed fall in the room. The event report further noted Resident #1 did not report any pain and did not have any injury noted.A telephone interview was conducted with the MDS Nurse on 10/07/25 at 2:24 pm. The MDS Nurse revealed when she completed the MDS assessment she would look at nursing progress notes, therapy notes, and provider notes to determine if a specific care area required a care plan to be initiated. The MDS Nurse further stated she normally would do the care plan for the items triggered by the CAA (care area assessment) at the same time as she completed the MDS assessment. The MDS Nurse confirmed the CAA for falls was triggered to have a care plan initiated for Resident #1. The MDS Nurse stated she was not sure why she did not enter a fall risk care plan for Resident #1, but she stated she must have just missed it. The MDS Nurse stated the facility conducted a weekly interdisciplinary team (IDT) meeting that she did not attend, and the facility would have been able to update the care plan as needed at the meeting.An interview was conducted with the Interim Director of Nursing (DON) on 10/08/25 at 12:21 pm, who revealed the IDT team had a weekly meeting at which time each resident was discussed and the goal was to ensure that the care plan reflected what was discussed for each resident. The Interim DON stated the care plan should have been updated during the weekly IDT meeting by the MDS Nurse, but she stated the MDS Nurse was not present for the weekly IDT meetings to ensure the care plans reflected the needs of the resident.During an interview on 10/08/25 at 1:00 pm with the Administrator she revealed the MDS Nurse was responsible to develop the fall risk care plan for Resident #1.2. Resident #2 was admitted to the facility on [DATE] with diagnoses which included dementia.The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #2 had severe cognitive impairment and required partial to moderate assistance for transfers. Resident #2 was coded for a fall prior to admission and one fall without injury since admission to the facility. The MDS admission assessment further noted the care area assessment (CAA) for falls was triggered for a care plan to be initiated.Review of Resident #2's care plan initiated on 9/17/25 revealed no care plan was in place for fall risk.The nursing progress note dated 9/18/25 at 8:04 am revealed Resident #2 was found on the floor in room with no apparent injury.The nursing progress note dated 10/02/25 at 3:30 pm revealed Resident #2 had a witnessed fall with no injury noted.The nursing progress note dated 10/03/25 at 7:00 pm revealed Resident #2 had a witnessed fall in room with no injury noted.A telephone interview was conducted with the MDS Nurse on 10/08/25 at 12:26 pm who confirmed Resident #2 did not have a care plan for fall risk in place. She stated she would normally have developed the fall risk care plan when she completed the MDS and care area assessment, but she must have missed it. An interview was conducted with the Interim Director of Nursing (DON) on 10/08/25 at 12:21 pm, who revealed the IDT team had a weekly meeting at which time each resident was discussed and the goal was to ensure that the care plan reflected what was discussed for each resident. The Interim DON stated the care plan should have been updated during the weekly IDT meeting by the MDS Nurse, but she stated the MDS Nurse was not present for the weekly IDT meetings to ensure the care plans reflected the needs of the resident.During an interview on 10/08/25 at 1:00 pm with the Administrator she revealed the MDS Nurse was responsible to develop the fall risk care plan for Resident #2.

Based on record review and staff interviews, the facility failed to implement a facility-wide system to monitor the use of antibiotics. This was evident for 12 of 12 months (January 2024, February 2024, March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, September 2024, October 2024, November 2024, December 2024) that surveillance data was reviewed. This practice had the potential to affect 18 of 18 residents in the facility. Findings included: The facility's Antibiotic Stewardship Program policy last revised on February 27, 2023, documented the antibiotic stewardship program will review essential data including antibiotic orders, clinical documentation, infection surveillance logs, microbiology testing, other tests to confirm infections, and trends in infection. A review of the monthly antibiotic summary reports for January 2024 through December 2024 revealed that no information for antibiotic monitoring was included. The monthly reports indicated the number of each type of infection including urinary tract infection, pneumonia, central line associated blood stream, gastrointestinal, skin, wound, conjunctivitis, or other type of infections but did not include surveillance logs, microbiology testing results or other tests to confirm infection, trends in infection. The monthly reports did not include the antibiotics ordered. The Compliance Coordinator was interviewed on 1/24/25 at 10:00 AM. The Compliance Coordinator explained that she was SPICE (Statewide Program for Infection Prevention and Control for Long Term Care) trained and was responsible for overseeing the Infection Control Program for this facility. The Compliance Coordinator stated the Infection Preventionist position was vacated in November 2024 and there was no system for compiling the information for antibiotic stewardship. The Compliance Coordinator stated although she was responsible for overseeing the Infection Control Program, the Infection Preventionist was responsible for the compilation of the necessary data for antibiotic stewardship. The Compliance Coordinator stated she was not aware that the previous Infection Preventionist had not completed the surveillance or tracking or trending of infections for the past year. The Compliance Coordinator revealed she had difficulty maintaining the Infection Control program and stated she reviewed the Antibiotic Summary Reports but was unable to locate any other antibiotic information that was completed by the previous Infection Preventionist. An interview was conducted with the Director of Nursing (DON) on 1/24/25 at 11:00 AM. The DON indicated that since she started in the position in December 2024, she was aware she was to function as the Infection Preventionist and was to complete these duties in addition to the duties of the DON. The DON stated she received a list of the antibiotics provided by the pharmacy, but she had not completed any documentation of antibiotic use in the facility and had not done any tracking or trending of the infections. An interview was conducted with the Administrator on 1/24/25 at 1:00 PM. The Administrator stated she was the interim Administrator and was in the position since 1/17/25. The Administrator stated the Infection Control Program should be a comprehensive program that included surveillance, tracking and trends. The Administrator stated unfortunately she had only been in the position for a short time and did not know why the infection control tracking trends of infections and use of antibiotics had not been completed. The Administrator stated she expected the Infection Preventionist to follow the facility protocol, complete the tasks for the antibiotic stewardship program including surveillance and tracking and trends of antibiotic use and infections.

Based on record review and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week for 17 of 332 days reviewed for sufficient staffing 8/27/22, 9/17/22, 9/18/22, 10/30/22, 12/10/22, 12/24/22, 12/25/22, 2/19/23, 3/4/23, 4/1/23, 4/2/23, 4/15/23, 4/16/23, 5/27/23, 5/28/23, 6/10/23, and 6/24/23. This deficient practice had the potential to affect all facility residents. The findings included: The Payroll Based Journal (PBJ) data report for fiscal year 2022 Quarter 4 from August 1 to September 30, 2022, was reviewed. The report indicated that the facility had 3 days within the quarter with no registered nurse (RN) hours. The dates were 8/27/22, 9/17/22, and 9/18/22. Review of the facility's nursing schedule revealed no RN was scheduled to work on 8/27/22, 9/17/22, and 9/18/22. The time sheets revealed no RN, including the Director of Nursing (DON), had worked any shift on 8/27/22, 9/17/22, and 9/18/22. The PBJ data report for fiscal year 2023 Quarter 1 from October 1 to December 31, 2022, was reviewed. The report indicated that the facility had 4 days within the quarter with no RN hours. The dates were 10/30/22, 12/10/22, 12/24/22 and 12/25/22. Review of the facility's nursing schedule revealed the RN called out on 10/30/22 and 12/10/22 and was replaced with a Licensed Practical Nurse (LPN). There was no RN scheduled on 12/24/22 and 12/25/22. Review of the time sheets revealed no RN, including the DON, had worked any shift on 10/30/22, 12/10/22, 12/24/22, and 12/25/22. The PBJ data report for fiscal year 2023 Quarter 2 from January 1 to March 31, 2023, was reviewed. The report indicated that the facility had 2 days within the quarter with no RN hours. The dates were 2/19/23 and 3/14/23. Review of the facility's nursing schedule revealed no RN was scheduled to work on 3/4/23 and the RN scheduled on 2/19/23 called out and was replaced with a LPN. The time sheets revealed no RN, including the DON, had worked any shift on 2/19/23 and 3/14/23. The PBJ data report for fiscal year 2023 Quarter 3 from April 1 to June 30, 2023, was reviewed. The report indicated that the facility had 8 days within the quarter with no RN hours. The dates were 4/1/23, 4/2/23, 4/15/23, 4/16/23, 5/27/23, 5/28/23, 6/10/23, and 6/24/23. Review of the facility's nursing schedule revealed no RN was scheduled to work on 4/1/23, 4/2/23, 4/15/23, 4/16/23, 5/27/23, 5/28/23, 6/10/23, and 6/24/23. The times sheets revealed no RN, including the DON, had worked any shift on 4/1/23, 4/2/23, 4/15/23, 4/16/23, 5/27/23, 5/28/23, 6/10/23, and 6/24/23. An interview was completed with the Clinical Nurse Administrator on 11/29/2023 at 1:01 PM. The Clinical Nurse Administrator stated that she had worked for the facility as the Director of Nursing (DON) until the current DON was hired in August 2023. She further stated that since the facility was small and only had 20 beds, the DON could be counted as the RN hours for the day. The Clinical Nurse Administrator stated that weekend staffing was always a challenge, and all of dates listed were on the weekend. She indicated that an RN was always available on-call for the nursing staff. An interview was conducted with the Director of Nursing (DON) on 11/30/2023 at 7:33 AM. The DON stated she had only been the DON since August 2023. She further stated that the facility had no days without RN coverage for 8 hours a day since she had been the DON. The DON indicated that she was available by phone for the nursing staff if they had questions or concerns when she was not in the facility. An interview was conducted with the Administrator on 11/30/2023 at 1:58 PM. The Administrator stated that the dates listed were days that the facility did not have any RN coverage for 8 hours a day. She further stated that she had only been the Administrator since September 2023, and did not know why the facility did not have RN coverage for the days listed. The Administrator stated that getting a consistent staff for the facility was one of the first things she did when she started working at the facility. She indicated that there had not been any days without RN coverage for 8 hours a day since she became the Administrator.

Based on record review, and staff interviews, the facility failed to have a documented water management program and failed to develop a program to assess/identify where legionella and other opportunistic waterborne pathogens could grow and spread, and measures to prevent the growth of opportunistic waterborne pathogens and how to monitor them that could affect 9 of 9 residents. The findings included: Review of the facility's Emergency Preparedness Plan (effective 11/29/23) and Infection Prevention and Control Program Policy dated 02/27/23; revealed no information related to a facility water safety management program. An interview was conducted on 11/29/23 at 11:30 AM with the Maintenance Technician. He said a water safety management program was not in place to monitor legionella or other waterborne pathogens, and that they needed to develop a program. An interview was conducted on 11/29/23 at 1:15 PM with the Administrator. She stated she was unaware of the requirement to develop a water management program. She stated that she spoke with the facility Maintenance Technician, and he was also unaware of the requirement. The Administrator said they should have had a water management policy and program in place and didn't. A follow-up interview was conducted on 11/29/23 at 2:25 PM with the Administrator and Clinical Compliance Administrator. They both said the facility did not have a water management policy or had a water management program in place and should have. The Administrator said she and the Maintenance Technician would develop a water management policy and water safety management program.

Based on observation, record review and staff interview the facility failed to provide a nutritional supplement ordered by the physician for 1 of 9 sampled residents (Resident #10) reviewed for nutrition. The Findings included: Resident #10 was admitted to the facility on [DATE] and had diagnoses of protein malnutrition, chronic kidney disease, and dysphagia. A review of Resident #10's diet orders dated 11/03/23 revealed the resident to receive a fortified nutritional supplement 237 milliliters (ml) once a day in the morning, with a start date of 11/03/23. A review of Resident #10's November/2023 Medication Administration Record (MAR) was conducted on 11/30/23. The MAR revealed from 11/04/23 through 11/30/23 nurses checked off the morning fortified nutritional supplement was given to the resident. The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a memory problem and was severely impaired in cognitive skills for daily decision making. Resident #10 needed set up help and supervision for meals. A review of Resident #10's weight record revealed that on 10/31/23 her weight was 116.8 pounds and on 11/21/23 her weight was 111 pounds, a weight loss of 5.8 lbs. in 10-days. Resident #10's most recent Care Plan dated 11/03/23 revealed she was at risk for potential alteration of nutrition and/or weight status related to cognitive decline and poor appetite. Interventions included monitoring by mouth (PO) intake of meals, offering alternates/substitutes and snacks as needed, and providing diet and supplement per physician order. An interview was conducted on 11/27/23 at 1:10 PM with Resident #10 and visitor #1. The resident was in her room with her sitter and had just finished lunch. Both the resident and her visitor #1 said they knew what the fortified nutritional supplement looked like and had not received fortified nutritional supplement on her breakfast tray or lunch tray that day (11/27/23), or at any time during resident's stay at the facility. A review of resident's meal card, served with this resident's breakfast and lunch meal trays, did not list a fortified nutritional supplement as something that needed to be provided with the breakfast or lunch meal. An interview was conducted on 11/30/23 at 1:00 PM with Nurse #1. The nurse said she passed out morning medications to Resident #10 that morning (11/30/23). The nurse said she did not know where they kept nutritional supplements like the fortified nutritional supplement ordered and did not provide Resident #10 her morning fortified nutritional supplement per Physician order because she was new and did not know where supplements were kept and did not think to ask the Director of Nursing (DON). She said she signed off in the resident's MAR that she gave the fortified nutritional supplement to the resident, but she had not, saying she signed in error. An interview was conducted on 11/30/23 at 1:20 PM. with Resident #10's Physician. She said she ordered fortified nutritional supplement one time per day in the morning for Resident #10 and expected the facility to follow that order to provide the supplement daily in the morning and did not. She said she also expected the facility to document the amount of fortified nutritional supplement the resident drank or refused, so she wound know if additional supplements were needed or type of supplement needed changing per resident preference. The Physician indicated that she did not feel that Resident #10's five-pound weight loss was detrimental to her. She indicated that Resident #10 was very old and that some weight loss was expected. An interview was conducted on 11/30/23 at 1:50 PM with the Administrator. She said Resident #10 had a Physician order for fortified nutritional supplement to be given to the resident once a day in the morning. She said the facility should have provided the fortified nutritional supplement as ordered, and then document in the resident's chart amount consumed or refused. The Administrator said she expected nursing staff to follow the Physician's order for fortified nutritional supplement as given, which they did not. An interview was conducted on 11/30/23 at 2:35 PM with the Registered Dietician (RD). She stated that she had been working in the facility and had assessed Resident #10 on 11/03/23, who reported that she had had poor appetite for a while, so she recommended fortified nutritional supplements every day related to poor appetite. She indicated she had not been contacted regarding Resident #10's nutritional status. She indicated that if a supplement, such as fortified nutritional supplements, was ordered it needed to be given to the resident. The RD indicated that the facility should have provided the Physician ordered fortified nutritional supplement and did not. In an interview on 11/30/23 at 3:40 PM the Director of Nurses (DON) stated that Resident #10's ordered morning fortified nutritional supplement to be given during the morning medication pass, was never ordered to be delivered, and none were ever in stock to provide to the resident. She said she had reviewed resident's current Medication Administration Record (MAR), which revealed nursing had checked off that resident's fortified nutritional supplement was given, but she said the nurses shouldn't have because no fortified nutritional supplements were ever ordered to be delivered, and none were in stock. Also, she indicated that if nursing was not providing the supplement to the resident, then no one, including kitchen staff or Nursing Aides (NAs) would know the resident was supposed to be given the RD ordered fortified nutritional supplement, and by whom. The DON stated no one ordered Resident #10's fortified nutritional supplement to be delivered, and that she expected all residents to receive nutritional supplements if ordered by the RD or Physician, especially if there was a weight loss.

Based on observations, record review, and resident, staff, and Physician interviews the facility failed to assess a resident's ability to self-administer medications. This deficient practice occurred for 1 of 1 resident (Resident #3) reviewed for medication self-administration. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses to include hypertension and major depressive disorder, recurrent, moderate. The quarterly Minimum Data Set (MDS) assessment 10/27/2023 for Resident #3 revealed she was cognitively intact and required extensive assistance of 1 staff for activities of daily living (ADL) care. The Care Plan for Resident #3 last reviewed on 11/16/2023, revealed a plan of care with a start date of 5/16/2023 which read in part, She has history of pocketing medications and then reporting that nurse didn't give to her, and reporting being given prn medications without asking for them. Interventions included administering medications as ordered and to document refusals. There was no plan of care for self-administration of medications. Review of the electronic medical record (EMR) for Resident #3 did not reveal an assessment for medication self-administration. The physician's orders for Resident #3 did not reveal an order for Resident #3 to self-administer her oral medications. An observation and interview with Resident #3 were completed on 11/27/2023 at 11:33 AM. A medication cup containing several pills was observed sitting on Resident #3's overbed table. Resident #3 stated the nurse must have left the pills in the room while she was sleeping. Resident #3 was observed immediately swallowing the medications. The November 2023 Medication Administration Record (MAR) for Resident #3 revealed she was administered aspirin 81milligrams (mg) tablet by mouth, vitamin D3 1000 units 1 capsule by mouth, duloxetine 20mg 1 capsule by mouth, fexofenadine 60 mg take 1 1/2 tablets to equal 90 mg by mouth, tizanidine 4mg 1 pill by mouth, potassium chloride 20 milliequivalents (meq) 1 tablet by mouth, vitamin B complex 1 capsule by mouth, multivitamin 1 tablet by mouth, and fluticasone propionate 1 spray each nostril on 11/27/2023 by Nurse #3. An interview was completed with Nurse #3 on 11/28/2023 at 3:12 PM. Nurse #3 stated that she was the nurse that left Resident #3's morning medications on her bedside table on 11/27/2023. She further stated that Resident #3 would not take her medications before she eats, so she left them on the bedside table. Nurse #3 indicated Resident #3 was allowed to self-administer some of her medications. An interview was conducted with the Physician on 11/28/2023 at 3:14 PM. The Physician stated that she trusted Resident #3's judgment for self-administration of most of her medications, just not her fentanyl pain patch. She further stated that she wanted to allow Resident #3 some autonomy in her care. An interview with Nurse #4 was completed on 11/29/2023 at 09:33 AM. Nurse #4 stated she always observed Resident #3 taking her oral medications. She further stated Resident #3 did not have an order to self-administer her oral medications. An interview was conducted with the Director of Nursing (DON) on 11/30/2023 at 07:42 AM. The DON stated that she could not find any assessments for medication self-administration for Resident #3. She further stated that Resident #3 did not have a physician's order for self-administration of oral medications. The DON indicated that pills should not be left in resident's rooms without the resident being assessed and a physician's order for self-administration. An interview was conducted with the Clinical Nurse Administrator on 11/30/2023 at 3:14 PM. The Clinical Nurse Administrator stated that she was unable to find any evidence to support that any Medication Self Administration Assessments were completed for Resident #3. She further stated that there was not a physician's order for Resident #3 to self-administer her oral medications.

Based on record review and staff interview the facility failed to maintain an accurate Medication Administration Record (MAR) for the administration of fortified nutritional supplement for 1 of 1 resident reviewed (Resident #10). The Findings included: Resident #10 was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a memory problem and was severely impaired in cognitive skills for daily decision making. A review of Resident #10's diet orders dated 11/03/23 revealed the resident to receive a fortified nutritional supplement 237 milliliters (ml) once a day in the morning, with a start date of 11/03/23. A review of Resident #10's November/2023 Medication Administration Record (MAR) was conducted on 11/30/23. The MAR revealed from 11/04/23 through 11/30/23 nurses checked off the morning fortified nutritional supplement was given to the resident. An interview was conducted on 11/27/23 at 1:10 PM with Resident #10 and visitor #1. The resident was in her room with Visitor #1 and had just finished lunch. Both the resident and her visitor #1 said they knew what the fortified nutritional supplement looked like and had not received fortified nutritional supplement on her breakfast tray or lunch tray that day (11/27/23), or at any time during resident's stay at the facility. An interview was conducted on 11/30/23 at 1:00 PM with Nurse #1. The nurse said she passed out morning medications to Resident #10 that morning (11/30/23). She said she signed off in the resident's MAR that she gave the fortified nutritional supplement to the resident, but she had not, saying she signed in error. An interview was conducted on 11/30/23 at 1:50 PM with the Administrator. She said the facility should have provided the fortified nutritional supplement as ordered, and then document in the resident's chart amount consumed or refused. In an interview on 11/30/23 at 3:40 PM the Director of Nurses (DON) stated that Resident #10's ordered morning fortified nutritional supplement to be given during the morning medication pass, was never ordered to be delivered, and none were ever in stock to provide to the resident. She said she had reviewed resident's current Medication Administration Record (MAR), which revealed nursing had checked off that resident's fortified nutritional supplement was given, but she said the nurses shouldn't have because no fortified nutritional supplements were ever ordered to be delivered, and none were in stock. Also, the DON revealed nursing staff were expected to accurately document on a resident's MAR that medications, treatments, or nutritional supplements were completed per the physician order only when they were the ones who administered the medication, treatment, or nutritional supplement.

Based on record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee previously put in place. This was for one repeat deficiency in the area of Resident Records (F842) originally cited on 3/26/2021 during the recertification and complaint investigation survey and subsequently recited on 11/30/2023 during the recertification and complaint survey. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA. Findings included: This tag cross referenced to: F842 Based on record review and staff interview the facility failed to maintain an accurate Medication Administration Record (MAR) for the administration of fortified nutritional supplement for 1 of 1 resident reviewed (Resident #10). During the recertification and complaint investigation survey of 3/26/2021, the facility failed to provide consistent information regarding a resident's code status. An interview was completed with the Administrator on 11/30/2023 at 4:15 PM. The Administrator stated that she did not know why the QAA committee had failed to maintain compliance because she was not the Administrator 2021.

Based on observations, and family and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional which resulted in the facility ' s failure to develop, implement, supervise, and provide ongoing evaluation of the activities ' program. This deficient practice had the potential to effect 19 of 19 residents that were residing in the facility. Findings included: Observations on 07/10/22 from 12:00 PM till 6:00 PM revealed there were no structured activities being conducted in the facility. An interview was conducted with a family member (FM) of Resident #68 on 07/10/22 at 4:45 PM. The FM stated Resident #68 was confused and could not make his needs known at all times. The FM revealed she was concerned that whenever she would come to visit Resident #68 during the day hours or around dinner time, he was always in his room and not participating in any activities. The FM stated she visited daily during the afternoon hours and stayed through dinner, and she had not ever seen any activities occur during her visits. The FM indicated she thought Resident #68 was lonely and needed more stimulation. Observations on 07/11/22 from 8:30 AM through 5:00 PM revealed there were no structured activities being conducted in the facility. An interview was conducted with Nurse #2 on 07/12/22 at 11:10 AM. Nurse #2 stated he had been working at the facility for a couple of years. He stated he was not agency staff. He reported that he was not sure how the activities program worked at the facility, but he believed various staff went into the residents ' rooms to talk with the residents. He did not explain who the various staff were. Nurse #2 stated there were no group activities in the dining/common area that he was aware of. Nurse #2 stated he did not bring residents to any activities since COVID-19 started. An interview was conducted with Nurse Aide (NA) #1 on 07/12/22 at 1:33 PM. NA #1 stated she had been employed with the facility for about 6 years. She stated there used to be an Activities Director at the facility but that was a couple of years ago. NA #1 stated she would try to do 1:1 activities with the residents if she had time such as reading them a book, sitting with the resident, or playing music in their room, whatever interested the resident. NA #1 stated there were not any group activities. NA #1 stated it was difficult to incorporate group activities with the long-term care residents and the rehab residents due to the workload of the aides and the nurses. An interview was conducted with Administrator #1 on 07/12/22 at 11:00 AM. Administrator #1 reported there was no designated Activities Director at the facility. She explained that the facility utilized the household model whereas everyone participated with the activities program and there was not one person who was responsible to direct the provision of activities to the residents. Administrator #1 stated there were no structured activities and the household was predicated on social interaction either in their rooms or in groups; adding, whatever the resident wanted it to be. Administrator #1 stated the facility was going to have to make changes with the household model as it pertained to activities. She did not explain what changes were going to be made. During a follow up interview via phone with Administrator #1 on 07/26/22 at 1:07 PM she provided conflicting information from her previous interview (07/12/22 at 11:00 AM) reporting the facility previously had a qualified activities professional employed from 10/29/2014 to 05/02/2022. Administrator #1 indicated a new employee was promoted to the Wellness Guide position (the job title the facility utilized for the activities professional position) on 05/26/22, but the new employee had not been enrolled in the activities professional class. She explained that staff at the facility were not aware that the activities director position was referred to as a Wellness Guide and not an Activities Director. Administrator #1 stated she believed that was why the staff were saying there was no Activities Director.

Based on record review and staff interviews, the facility failed to develop comprehensive care plans according to the care area assessments (CAA) for 3 of 16 residents reviewed. (Resident #8, #9, and #10). Findings included: 1) Resident #8 was readmitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS admission assessment dated [DATE] revealed the resident was moderately cognitively impaired, demonstrated behaviors of rejection of care, and was always incontinent of bowel and bladder. She received 2 insulin injections, 3 days of antipsychotic medication, 3 days of antidepressant medication, and 3 days of antibiotic medication during this assessment. The care area assessments (CAAs) for the MDS assessment dated [DATE] revealed urinary incontinence, behaviors, falls and [CONDITION(S)] drug use were selected to have a care plan in place. Resident #8 ' s care plan dated 05/05/22 revealed there was no care plan for urinary incontinence, behaviors, falls or [CONDITION(S)] drug use. An interview with the MDS Nurse on 07/13/22 at 1:45 PM revealed the CAAs trigger for a care plan to be developed as a result of the information that she would put into the electronic record based on orders, progress notes, and medication review. The MDS Nurse stated Resident #8 should have a care plan in place for cognition, urinary incontinence, falls and [CONDITION(S)] use since they triggered on the CAAs. The MDS nurse stated she should have developed the care plans and overlooked it. An interview with the Administrator on 07/13/22 at 6:00 PM revealed if any care plans were indicated to be developed in the CAA section, she would expect the MDS Nurse to develop and implement those care plans, so the plan of care accurately reflects the residents. 2) Resident #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's admission assessment dated [DATE] revealed the following care area assessments (CAAs): cognition, communication, incontinence, falls and pressure ulcers. The care plan decision was checked to proceed to care plan to address the following areas: cognition, communication, incontinence, falls and pressure ulcers. Review of Resident #9's care plan with a start date of 9/27/21 revealed the following problems were addressed in the care plan: cognitive loss, falls, psychosocial wellbeing, pressure ulcer, activity of daily living, nutrition and pain. Communication and incontinence were not addressed. An interview was conducted with the MDS Nurse on 07/13/22 01:53 PM. The MDS Nurse revealed that if a CAA was triggered by the MDS and the decision was made to proceed to care plan, that a problem, goal, and interventions should be in the care plan. After reviewing Resident #10's care plan with the MDS Nurse, she confirmed that communication and incontinence were still active problems for this resident, and she did not know why the areas listed in the CAA's that were to be included in the care plan were not there. An interview with the Administrator on 07/13/22 at 5:55 PM revealed if the CAA section indicated that an area was to be addressed in the care plan, she would expect the MDS Nurse to develop and implement those care plans. She added that she expected the plan of care to accurately reflect each resident. 3). Resident #10 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's 5/9/22 Admission Minimum Data Set assessment revealed resident had minimal difficulty with hearing, had minimal cognitive impairment, required limited assistance of 2 people with bed mobility, transfers and toileting. Resident #10 was able to feed herself with set up assistance and was occasionally incontinent of bowel and bladder. Review of the Significant Change in Status Assessment (SCSA) dated 5/26/22 revealed Resident #10 had minimal difficulty hearing, was cognitively intact, and required assistance with bed mobility, transfers, and toileting. Resident #10 demonstrated rejection of care and was not interested in activities with groups of people. She received 3 days of antianxiety medication and 7 days of antidepressant. The care area assessments from the SCSA MDS assessment dated [DATE] revealed cognition, vision, communication, Activity of Daily Living (ADL), incontinence, psychosocial, behavior, activities, falls, pressure ulcers, and [CONDITION(S)] medication. The care plan decision was marked as proceed to care plan for the following areas: cognition, communication, ADL, incontinence, psychosocial, behavior, activities, falls, pressure ulcers, and [CONDITION(S)] medication. Review of Resident #10's care plan dated 5/26/22 revealed that there was no care plan for incontinence, behavior, activities and [CONDITION(S)] medication. An interview was conducted with the MDS Nurse on 07/13/22 01:53 PM. The MDS Nurse revealed that if a CAA was triggered by the MDS and the decision was made to proceed to care plan, that a problem, goal, and interventions should be in the care plan. After reviewing Resident #10's care plan with the MDS Nurse, she stated she did not know why the areas listed in the CAA's that were to be included in the care plan were not there. An interview with the Administrator on 07/13/22 at 5:55 PM revealed if the CAA section indicated that an area was to be addressed in the care plan, she would expect the MDS Nurse to develop and implement those care plans. She added that she expected the plan of care to accurately reflect each resident.

Based on observations and staff interviews, the facility failed to date 2 of 2 insulin pens that were opened and kept inside the medication storage cabinet in the resident ' s room (Resident #119), discard expired nasal spray for Resident #67, and ensure medication storage cabinets inside of each resident room contained medication ordered for the resident who resided in the room (Resident #67) for 2 of 2 medication cabinets observed. Findings included: a. An observation 07/12/22 at 8:30 AM with Nurse #2 in Resident #119 ' s medication storage cabinet located inside the resident ' s room revealed 2 insulin pens that were opened and not dated. An interview with Nurse #2 on 07/12/22 at 8:30 AM revealed the resident received his insulin early this morning. Nurse #2 stated the insulin pens should have been dated when they were opened because they were only good for 28 days and if there was no date on the insulin pens, nurses would not know when to discard them. Nurse #2 stated all nurses and medication aides were responsible for checking the medication storage cabinets each time they administered medications to ensure medications including insulin pens were dated when they were opened and there were no expired medications in the cabinet. b. An observation on 07/12/22 at 8:55 AM with Nurse #2 in Resident #67 ' s medication storage cabinet located inside the resident ' s room revealed nasal spray that was expired on 02/22/22. It was also noted there were two blister cards of potassium supplement medication in the medication storage bin that was for another resident An interview with Nurse #2 on 07/12/22 at 8:55 AM revealed he was not aware the nasal spray had expired, and he had no idea how another resident ' s medication got into Resident #67 ' s cabinet. Nurse #2 stated all nurses and medication aides were responsible for checking the medication storage cabinets each time they administered medications to ensure they had the right patient, right drug, right dose, right route, and right time and to make sure there were no expired medications in the cabinet. An interview with the Director of Nursing (DON) on 07/13/22 stated nursing staff were responsible for labeling the insulin pens with an opened date as soon as it was opened. The DON added, the nursing staff should be checking that insulin pens are dated, there are no expired medications in the cabinet and checking each medication card before they administer the medication to ensure the nurses have the right patient, right drug, right dose, right route, and right time on the medication card.

Based on observations and staff interviews, the facility ' s Quality Assurance (QA) program failed to maintain implemented procedures and monitor interventions put into place following the recertification and complaint investigation survey of [DATE] to prevent the reoccurrence of deficient practice related to not labeling insulin pens with an open date which resulted in a repeat deficiency on the current recertification survey of [DATE] at F761 Label/Store Drugs and Biologicals. The continued failure of the facility during 2 federal surveys showed a pattern of the facility ' s inability to sustain an effective QA program. Findings included: This tag is cross referenced to: F761: Based on observations and staff interviews, the facility failed to date 2 of 2 insulin pens that were opened and kept inside the medication storage cabinet in the resident ' s room (Resident #119), discard expired nasal spray for Resident #67, and ensure medication storage cabinets inside of each resident room contained medication ordered for the resident who resided in the room (Resident #67) for 2 of 2 medication storage cabinets. Review of the facility ' s survey history revealed F761 was cited during the facility ' s [DATE] annual recertification and complaint survey for not labeling insulin pens with an open date once opened. The facility was re-cited during the current annual recertification for the same issue of not labeling insulin pens with an opened date. An interview was conducted with the Director of Nursing on [DATE] at 8:10 AM. The DON stated the previous plan of correction was for audits was done weekly for 4 weeks and then monthly for 3 months. The DON indicated that a longer period in QA may have allowed the facility to monitor and audit medication storage and to provide further education to the nurses if needed.

Based on record review and staff interviews, the facility failed to complete the Minimum Data Set (MDS) comprehensive admission assessment for 1 of 16 residents (Resident #68) reviewed. Findings included: Resident #68 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The MDS admission assessment date was dated 07/05/22 and indicated in process. An interview with the MDS Nurse on 07/13/22 at 1:45 PM was conducted. The MDS Nurse stated she was aware the assessment needed to be completed within 14 days of the day of admitted [DATE] and she was working on it. The MDS nurse stated she has been having to work between the two campus ' s and she got behind on her assessments and added the assessment should have been completed on 07/12/22. An interview was conducted with the Administrator on 07/13/22 at 6:00 PM. The Administrator stated her expectation of the MDS Nurses was to complete the comprehensive assessments on time. The Administrator added the timeliness of the assessments drives the care area assessments and care plans, so the assessments needed to be completed on time to accurately reflect the care of the residents.