Every finding on record at Freedom Pointe Health Center

Based on observation, interview, and record review the facility failed to ensure wound care and treatment was provided according to professional standards for 3 of 6 residents, Residents #4, #15, and #40, reviewed for skin conditions.Findings include:1) During an observation on 1/26/2026 at 9:45 AM Resident #15 had a wound gauze dressing wrapped to the left upper arm that was not dated.During an interview on 1/26/2026 at 9:45 AM Resident #15 stated, The wound vac [vacuum, used to treat wounds] is not connected because when they were going to change it, they realized they did not have supplies for the suction.Review of Resident #15's physician order dated 1/9/2026 read, Cleanse: NPWT [Negative Pressure Wound Therapy] to Left Axilla @ 125 mmhg [at 125 millimeters of mercury] pressure. Remove dressing, cleanse wound with Dakins, apply skin prep to peri-wound area, apply drape to peri-wound area. Fill wound space with black foam, cover with drape. Do not apply foam directly to skin without drape barrier. Change dressing 3x [times] weekly. every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] and as needed for compromised drg [dressing] seal. Monitor NPWT to left axilla and canister. Notify MD [Medical Doctor] for s/s [signs/symptoms] of bleeding. If dressing is unable to maintain pressure, check for leakage and reinforce. If problem persists, remove and change entire dressing. When machine malfunctions and unable to fix it: remove granufoam, pack wound loosely with moist gauze, secure with secondary dressing and notify wound team every shift. Do not leave granufoam longer than 2 hours without a well functioning wound vac machine.Review of Resident #15's Treatment Administration Record for the month of January 2026 read, Cleanse NPWT to left Axilla. Documented on 1/23/2026 the order was coded with a 9 [other/see nurse notes].Review of Resident #15's progress noted dated 1/23/2026 read, Awaiting Supplies.During an interview on 1/27/2026 at 3:45 PM Staff A, Licensed Practical Nurse (LPN) stated, We had to change the dressing, and we needed the suction and there were no supplies for the wound vac. The wound nurse is responsible for ordering supplies for the vacuum. I went to look and the wound care nurse was on vacation, and I went to his office. I notified both Unit Managers that we did not have the supplies to change her [Resident #15] dressing. My Unit Manager told me not to remove the dressing and wait for the supplies. The dressing was intact, that is why we did not remove it and the vacuum was working properly. We left the vacuum connected with the suction. [Staff B Registered Nurse's name] is the Unit Manager. The resident agreed to leave the dressing as is because if I remove it, we would not be able to put the vacuum back on and it would be a regular dressing. I don't know if she [Staff B] notified the provider.During an interview on 1/27/2026 at 4:00 PM the Director of Nursing (DON) stated, I was not aware of that [wound vac dressing was not changed due to not having supplies]. The wound care nurse is on vacation. It is not likely they did not have supplies, not normal here. Typically, the staff would have let me know. I need to look into what happened.During an interview on 1/28/2026 at 7:48 AM the DON stated, Supplies were here in the overflow storage, and the nurse was not sure where the supplies were located. I would expect them to notify the provider.During an interview on 1/29/2026 at 9:50 AM Staff B, RN (Registered Nurse) Unit Manager, stated, We were going to change [Resident #15's name] wound vac dressing and we did not have supplies to do the dressing change. We went to the supply room and were unable to locate the supplies. I did not call the provider, the 3-11 supervisor was aware, and we spoke to the resident, and she was okay with leaving the dressing how it was. It was functioning correctly at that time. The supervisor was going to follow up after that.During an interview on 1/29/2026 at 10:07 AM Medical Doctor #1 stated, I did not know what was going on with the wound vac. If they did not have supplies, they would need to keep it closed until they have supplies again. I was not aware of it.During an interview on 1/29/2026 at 10:17 AM the Advance Practice Registered Nurse (APRN #1) stated, The staff called me and I gave instructions to change the dressing that Friday evening [01/23/2026] to a wet to dry dressing.During an interview on 1/29/2026 at 12:14 PM the DON stated, The staff did not change the dressing on Friday [1/23/2026]. The dressing was changed on Saturday [1/24/2026] because the suctioning was malfunctioning and the staff changed the dressing to moist dressing. They should have called me and double checked for the supplies. The supplies were available but in the overflow storage. If the staff were unable to change the dressing they should have contacted the provider. The night shift nurse did not contact the provider on Friday [1/23/2026]. The dressing should also have been dated when it was changed on 1/24/2026.Review of the facility policy and procedure titled Negative Pressure Wound Therapy with a last review date of 9/23/2025 read, Purpose: The purpose of this procedure is to provide guidelines for establishing and maintain negative pressure wound therapy (NPWT). General Guidelines: 3. Change dressings per physician orders and manufacturer guidelines.2) During an observation on 1/26/2026 at 11:00 AM Resident #4 had a wound dressing to the left forearm. The wound dressing was not dated. [Photographic evidence obtained]During an interview on 1/26/2026 at 11:00 AM Resident #4 stated, This happened [dressing on left forearm] while I was in the exercise room and it [the wound dressing] has not been changed in about a week.Review of Resident #4's physician orders did not document a wound care order for the resident's left forearm.Review of Resident #4's medical record, the record did not contain documentation of the resident having suffered an injury resulting in a wound to the left forearm. During an observation on 1/27/2026 at 3:55 PM Staff C, RN of Resident #4, the resident was lying in bed and to his left arm there was a dressing dated 1/26/2026. Staff C peeled off the left corner of the dressing and there was a skin tear. Staff C placed the dressing back on Resident #4's arm.During an interview on 1/27/2026 at 4:00 PM Staff C, RN stated, I do not see any wound care orders for [Resident #4's name] left arm.During an interview on 1/29/2026 at 12:52 PM Medical Doctor #2 stated, No one had brought to my attention [Resident #4's name] had a skin tear in his left forearm.3) During an observation on 1/26/2026 at 10:24 AM Resident #40 had a wound dressing to the left forearm dated 1/25/2026 with staff Initials.During an observation on 1/27/20256 at 10:40 AM Resident #40 had a wound dressing dated 1/25/2026 to the left arm. [Photographic evidence obtained]Review of Resident #40's physician orders did not contain an order for wound care for the resident's left arm.During an interview on 1/27/2026 at 3:50 PM Staff D, LPN (Licensed Practical Nurse) stated, I did not pay attention to the date on the dressing. I did see that the dressing looked old. I checked; there are no dressing change orders.During an interview on 1/27/2026 at 4:00 PM the Director of Nursing stated, Typically, we complete a risk and incident report. The nurse would do a skin assessment, let the wound care nurse know and put in orders in the system; making sure the wound care nurse sees it to make sure that no other treatment is required. The dressings should be dated. The incident report has a check list and notifying the doctor is part of it and depending on the circumstances family is also notified.During an interview on 1/29/2026 at 12:15 PM Medical Doctor #3 stated, I have not been informed of a skin tear to the left arm of [Resident #40's name]. There should be orders for wound care and treatment provided. The nurse should write a progress note documenting the notification.Review of the facility policy and procedure titled Care of Skin Tears-Abrasion and Minor Breaks with a last review date of 9/23/2025 read, Purpose: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Preparation. 1. Obtain a physician's order as needed. Document physician notification in medical record. Steps in the Procedure:18. Apply the ordered dressing and secure with tape or border dressing per order. (Note: Use non-allergenic tape as indicated.) Label with date and initials to top of dressing.

Based on observation, interview, and policy and procedure review the facility failed to ensure hot food items were maintained at the proper temperatures during meal service. Findings include:During an observation on 01/27/26 at 7:32 AM of the breakfast service on the [NAME] Wing, the Assistant Dietary Director was beginning to serve the breakfast meal. A review of the temperatures for the bacon, sausage patties, and hashbrowns the temperatures were 117 to 118 degrees Fahrenheit (F) on the steam table. During an interview on 01/27/26 at approximately 7:33 AM the Assistant Dietary Director verified the temperatures of the bacon, sausage patties, and hashbrowns.During an interview on 1/27/26 at approximately 8:00 AM the Dietary Director stated, The temperatures of 117 and 118 for hot food items are within the danger zone area.Review of the policy and procedure titled, Temperatures and Safe Food Handling last reviewed on 09/23/26 read, Objective: Participants will be able to understand the importance of proper temperatures and food handling procedures when handling food for residents. 2. e. Failure to reheat to 165 F or hold food at appropriate temperatures-cold food less than or equal to 41 F and hot foods more than or equal to 140 F.

Based on interview and record review the facility failed to ensure residents' records were complete and accurate for documentation of provider notification when physician orders are not followed as prescribed for 2 of 6 residents, Residents #5 and #15, reviewed for medication management. Findings include: 1) Review of Resident #5's physician order dated 12/15/2025 read, Carvedilol Oral Tablet 12.5 MG [Milligram] (Carvedilol) Give 1 tablet by mouth two times a day for HTN [Hypertension].Review of Resident #5's Medication Administrator Record (MAR) for the month of January 2026 for Carvedilol 12.5 MG documented on 1/10/2026 at 1700 [5:00PM] blood pressure 119/58, Pulse 84, coded 4 (vital signs outside of parameters), dated 1/17/2026 at 1700 no blood pressure or pulse was documented, coded 5 (Hold/See Nurse Note), dated 1/18/2026 at 1700 blood pressure 109/52, pulse 84, coded 5, dated 1/22/2026 at 1700 blood pressure 100/73, Pulse 82, coded 4, dated 1/24/2026 at 0900 [9:00AM] no blood pressure or pulse documented, coded 4 and at 1700 blood pressure 104/57, pulse 82, coded 4, and dated 1/25/2026 at 0900 no blood pressure or pulse documented, coded 4.Review of Resident #5's progress note dated 1/17/2026 read, Held medication, BP [Blood Pressure] 108/50.Review of Resident #5's progress note dated 1/18/2026 did not contain documentation related to the resident's Carvedilol not being administered.Review of Resident #5's progress notes for the period of 01/10/2026 through 01/25/2026 did not contain documentation the physician was notified the resident's Carvedilol was not administered.During an interview on 1/28/2026 at 7:52 AM the Director of Nursing (DON) stated, I would expect nursing staff If they were going to hold a medication that does not have parameters and they have spoken to the provider they should document it in the record that they spoke to the provider.During an interview on 1/28/2026 at 1:59 PM Staff E Licensed Practical Nurse (LPN) stated, If the resident's blood pressure is low, I will hold the medication and notify the provider. I should have documented in the progress notes that I contacted the provider, but I do not think I did.During an interview on 1/28/2026 at 5:00PM with Staff F, LPN, stated, Sometimes [Resident #5's name] representative will not want the medication to be administer and if the blood pressure is to low, I will hold the medication. I will always contact her [Resident #5's] provider to let him know. I do not think I documented the notification in the system.During an interview on 1/29/2026 at 10:43 AM Medical Doctor #4 stated, The staff call me to notify when they are going to hold [Resident #5's name] medication. 2) Review of Resident #15's physician order dated 1/8/2026 read, Oxycodone HCI Oral Tablet 5 MG [Milligram] give 1 tablet by mouth every 8 hours as needed for Acute Pain (7-10).Review of Resident #15's MAR for the month of January 2026 documented Oxycodone 5 mg was administered on 1/6/2026 at 1248 [12:48 PM] pain level 6, dated 1/17/2026 at 1757 [5:57PM] pain level 6, dated 1/20/2026 at 2110 [9:10 PM] pain level 6, dated 1/21/2026 at 0652 [6:52 AM] pain level 5, dated 1/24/2026 at 1929 [7:29 PM] pain level 2, dated 1/25/2026 at 1236 [12:36 PM] pain level 4, and dated 2117 [9:17 PM] pain level 4.Review of Resident #15's progress notes did not contain documentation of provider notification regarding oxycodone being administered when the pain level was below the physician ordered parameters.During an interview on 1/27/2026 at 3:45 PM Staff A, LPN, stated, I was giving her oxycodone before her wound care changes. She [Resident #15] likes to take that medication to handle the pain. The doctor is aware that this is the resident's preference.During an interview on 1/28/2026 at 7:48AM the Director of Nursing stated, If the medication is outside parameters the staff need to speak to the provider and write a note and document they spoke to the provider.During an interview on 1/28/2026 at 1:159 PM Staff E, LPN, stated, I cannot recall , but I normally will not hold a medication that does not have parameters without contacting the provider.During an interview on 1/28/2026 at 5:00 PM Staff F, LPN, stated, I am new and still learning the system. I think I wrote the pain level wrong in that section.During an interview on 1/29/2026 at 10:17AM APRN # 1 stated, The staff call me about Resident #15's pain medication and request from the patient.Review of the facility policy and procedure titled Administering Medications with a last review date of 9/23/2025 read, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation. 4. Medication are administered in accordance with prescriber orders, including any required time frame.Review of the facility policy and procedure titled Charting and Documentation with a last review date of 9/23/2025 read, Policy Statement: All services provided to the resident, progress toward the care pan goals, or any changes in the resident's medical physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review the facility failed to prevent the possible spread of infection when not performing hand hygiene during wound care for 1 of 6 residents, Resident #15, reviewed for skin conditions.Findings include: Review of Resident #15's physician order dated 1/9/2026 read, Cleanse: NPWT [Negative Pressure Wound Therapy] to Left Axilla @ 125 mmhg [at 125 millimeters of mercury] pressure. Remove dressing, cleanse wound with Dakins, Apply skin prep to peri-wound area. Apply drape to peri-wound area. Fill wound space with black foam, Cover with drape. Do not apply foam directly to skin without drape barrier. Change dressing 3x [times] weekly. every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] AND as needed for compromised drg [dressing] seal.During an observation on 1/29/2026 at 11:45 AM the Wound Care Nurse performed hand hygiene, don a gown and two sets of gloves. The Wound Care Nurse entered Resident #15's room and placed the wound care supplies on top of Resident #15's cabinet without placing a barrier underneath. The Wound Care Nurse proceeded to clean Resident #15's bedside table, throwing away a water cup in the garbage, placing a newspaper on top of the resident's recliner, sanitized the bedside table, and placed the wound care supplies on the table. The Wound Care Nurse removed the top pair of gloves leaving the first original pair of gloves on, did not perform hand hygiene, put a new pair of gloves on, on top of the first original gloves. The Wound Care nurse removed the dressing from Resident #15's left arm, removed the top pair of gloves leaving the first original gloves on, did not perform hand hygiene, and put another pair of gloves on. The Wound Care Nurse cleansed the wound, pat dried the wound, removed the top pair gloves leaving the original pair of gloves on, did not perform hand hygiene, and put another pair of gloves on. The Wound Care Nurse applied a drape to the peri wound area, filled the wound with a black foam covering with a transparent drape, removed the top pair of gloves leaving the original pair on, did not perform hand hygiene, put a new set of gloves on, cut a hole in the barrier, and placed tubing with an adhesive pad over the wound. The wound care nurse proceeded to look for a new disposable canister for the wound vacuum system. One was not located in the resident's room. The Wound Care Nurse removed both sets of gloves, performed hand hygiene, and exited the room. The Wound Care Nurse returned to the room, performed hand hygiene, put two sets of gloves on, connected the canister tubing, and initiated the negative pressure on the pump for the wound vacuum as ordered. The wound care nurse dated the wound dressing, removed both sets of gloves, and performed hand hygiene.During an interview on 1/29/2026 at 12:15 PM the Wound Care Nurse stated, I should have performed hand hygiene when I took my gloves off.During an interview on 1/28/2026 at 1:00 PM the Director of Nursing stated, Staff should wash their hands in between each wound care step. The staff should take their gloves off and wash their hands and put a new pair of gloves on.During an interview on 1/28/2026 at 3:54 PM the Infection Preventionists stated, I would expect the staff to perform hand hygiene. I don't know why they are putting two sets of gloves on. They would need to remove both sets of gloves and put new gloves back on after washing their hands.Review of the facility policy and procedure titled Handwashing/Hand Hygiene with a last review date of 9/23/2025 read, 9. The use of gloves does not replace hand washing/hand hygiene.Review of the facility policy and procedure titled Negative Pressure Wound Therapy with a last review date of 9/23/2025 read, Steps in the procedure: 1. Identify and size the wound to be treated. 2. Wash hands and apply gloves. 3 Clean wound according to facility protocol, or as ordered. 4. Remove gloves. 5. Wash Hands and apply clean gloves. 6. Cut sponge dressing to size.

Based on interview and record review the facility failed to ensure antibiotic medications were administered based on culture and sensitivity results for 1 of 6 residents, Resident #61, reviewed for medication management. Findings include:Review of Resident #61's physician order dated 1/21/2026 read, Cipro Oral Tablet 500 MG [milligram] (Ciprofloxacin HCI [Hydrochloride]) give 1 tablet by mouth two times a day for E. Coli UTI [Escherichia coli urinary tract infection] for 7 Days.Review of Resident #61's Medication Administration Record (MAR) for the month of January 2026 documented Cirpo 500 mg was administered from 1/21/2026 to 1/27/2026.Review of Resident #61's Urine Culture [a lab test that will identify the bacteria causing the infection] with a reported date of 1/21/2026 read, Results: Escherichia coli (Isolate 1). Sensitivity Analysis. Ciprofloxacin R [Resistant/ineffective].Review of Resident #61's physician follow up note dated 1/21/2026 read, Patient observed ambulating with physical therapy and doing well. Reviewed urine culture and sensitivity. Will have to discontinue Bactrim and change patient to cipro per sensitivity report. Patient otherwise doing well.During an interview on 1/28/2026 at 7:56 PM the Director of Nursing stated, I reviewed the culture and sensitivity and Cipro was resistant. There was a note in the system that stated the antibiotic was changed to cipro due to the sensitivity. Normally the results will come in and the Infection Preventionist will review the antibiotic and the sensitivity. The expectation and normal process is to make sure that the antibiotics prescribed are correct.During an interview on 1/28/2026 at 3:54 PM the Infection Preventionist stated, I don't remember that one [Resident #61's culture and sensitivity]. When I looked in the antibiotic time out it was the same day that the provider had changed it [the antibiotic] to cipro and I thought she had looked at it [the culture and sensitivity]. I understand now that I am to look at the culture to see if the antibiotic the provider changes it to is susceptible or not and notify the provider.During an interview on 1/29/2026 at 11:41 AM APRN #2 stated, The preliminary results showed E. Coli and I started her on Cipro. I have been notified that the antibiotic was resistive and had to be changed.Review of the facility policy and procedure titled Antibiotic Stewardship with a last review date of 9/23/2025 read, Policy Statement. Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Policy Interpretation and Implementation: 11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on observation, interview, and record review, the facility failed to ensure 2 of 5 residents reviewed for weight loss, Residents #12 and #14, received nutritional supplements. Findings include: 1) During an observation on 8/20/2024 at 12:18 PM, Resident #12 was sitting in a recliner, eating independently in her room. The resident's tray contained two cups of soup, apple juice, and coffee. There was no magic cup on the tray. During an observation on 8/21/2024 at 12:10 PM, Resident #12 was sitting in a recliner, eating independently in her room. The resident's tray contained tuna salad, curly fries, pie, and vanilla ice cream. There was no magic cup on the tray. Review of Resident #12's physician order dated 7/29/2024 read, Magic Cup (Formulary) two times a day for weight loss lunch and dinner. Review of Resident #12's weight record showed the weight of 136 lbs (pounds) on 7/21/2024, and 122.6 lbs on 8/18/2024, which is a -9.85% loss. Review of Resident #12's progress note dated 8/19/2024 read, Has orders for compression stockings to be worn daily d/t [due to] edema. Resident has order to be up daily for meals. Hx [history] of weight loss. Has intervention of magic cup offered at lunch and dinner (600 calories). accepts some of time. History of refusing oral supplements (Ensure, Boost). continue to follow. Review of Resident #12's Dietary/Nutrition Profile dated 7/19/2024 showed the resident was at risk for unintentional weight loss due to fair appetite and refusal of supplements under Section K. Nutritional Risk. During an interview on 8/21/2024 at 12:36 PM, the Registered Dietician stated, [Resident #12's name] has been a challenge for me. The first time I went to see her, she did not want to talk about her preferences and refused any supplements. She has been an ongoing challenge. [Resident #12's name] takes the magic cups some of the times. Her BMI [Body Mass Index] is 22.4 at this time. Anything above 21, I like. Ice cream does not have the same nutritional value as the magic cup. The ice cream has 200 to 250 calories and magic cup has more than 300 calories. Not having the magic cup can affect the weight but she will sometimes have half of it or sometimes will not. Resident #12 will rarely eat over 75%. It has been a challenge. Ensure would make her sick, so we decided to do the magic cups so if she eats at least 50% of her food plus the magic cup, she would have the minimum calories she needed. 2) During an observation on 8/20/2024 at 12:21 PM, Resident #14 was sitting up in the bed, eating independently. The resident's lunch tray had soup, coffee, sandwich, and beets. There was no magic cup on the tray. During an observation on 8/21/2024 at 12:11 PM, Resident #14 was sitting up in the bed, eating independently. The resident's lunch tray had curly fries, sandwich, and strawberry ice cream. There was no magic cup on the tray. Review of Resident #14's physician order dated 8/19/2024 read, Magic Cup (Formulary) two times a day for give [Sic.] at lunch and dinner. Review of Resident #14's weight record showed the weight of 127 lbs on 8/1/2024, and 117.4 lbs on 8/18/2024, which is a -7.56% loss. Review of Resident #14's Dietary/Nutrition Profile dated 8/5/2024 showed the resident was at risk for unintentional weight loss due to eating fair, over [AGE] years of age under Section K. Nutritional Risk, with discharge goal of weight remaining more than 120 under Section L. Comments. During an interview on 8/21/2024 at 12:43 PM, the Registered Dietician stated, [Resident #14's name] came in on Ensure twice a day and her weight had decreased, so we boosted it to 3 times a day. On August 18, 2024, I saw she came down almost another pound and the nurses noted she hated the taste of ensure, so we recently changed her to the magic cup, which was ordered on the 19th [8/19/2024]. This was a recent change. During an interview on 8/21/2024 at 12:21 PM, the Certified Dietary Manager (CDM) stated, Ice cream and magic cups do not have the same nutritional value. We have magic cups at hand in the facility. The server makes sure they are on the tray when they are sent out to the resident. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing stated, Nursing staff should be checking the trays and if they are missing a magic cup, they are able to get it from the dinning area. Review of the facility policy and procedure titled Nutrition Risk-Weight Loss Management with the last review date of 1/23/2024 read, Policy: Goal: To implement a nutritional risk-weight loss management program that will emphasize implementation of services that minimize episodes of preventable weight loss and promote nutrition.

Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as per physician order for 1 of 2 residents reviewed for respiratory services, Resident #33. Findings include: During an observation on 8/19/2024 at 9:58 AM, Resident #33 was lying in bed, receiving oxygen at 2 liters per minute via nasal cannula. During an observation on 8/20/2024 at 8:14 AM, Resident #33 was lying in bed, receiving oxygen at 2 liters per minute via nasal cannula. Review of Resident #33's physician orders revealed no order for oxygen administration. Review of Resident #33's Weights and Vitals Summary for oxygen saturation showed 94% (oxygen via nasal cannula) on 8/19/2024 at 10:12 AM and 99% (oxygen via nasal cannula) on 8/20/2024 at 8:52 AM. Review of Resident #33's care plan with an initiated date of 8/2/2024 read, Focus: The resident has altered respiratory status due to COPD [Chronic Obstructive Pulmonary Disease], acute respiratory failure with hypoxia and O2 [oxygen] use. During an interview on 8/21/2024 at 1:15 PM, the Director of Nursing (DON) stated, [Resident #33's name] did not have a current order in the facility for oxygen administration. We must have a doctor's order for all medications and interventions in order to know what rate the oxygen should be running at. Review of the facility policy and procedure titled Oxygen Administration with the last review date of 1/23/2024 read, Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Review of the facility policy and procedure titled Administering Medications with the last review date of 1/23/2024 read, Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate personal protective equipment while providing high contact care for the residents on enhanced barrier precautions for 2 of 6 residents observed, Residents #50 and #310, failed to ensure staff performed hand hygiene during medication administration for 1 of 6 residents observed, Resident #164, and failed to ensure staff followed infection control standard of practice while providing wound care for 1 of 2 residents reviewed for pressure wounds, Resident #7, to prevent the possible spread of infection and communicable diseases. Findings include: 1) During an observation on 8/21/2024 at 5:38 AM, Staff F, Licensed Practical Nurse (LPN), entered Resident #50's room and donned gloves. Staff F did not don a gown. Resident #50's room door had an enhanced barrier precautions signage. Staff F administered IV (intravenous) medication and exited the room. While Staff F was standing outside of the room, Resident #50's IV pump started beeping and Staff F entered the resident's room and adjusted the IV pump. Staff F was wearing gloves and no gown. During an interview on 8/21/2024 at 5:54 AM, Staff F, LPN, stated, Wearing a gown is not something we regularly do only when the resident is on isolation. Enhanced barrier is more for infection. 2) During an observation on 8/21/2024 at 8:12 AM, Staff D, LPN, entered Resident #310's room. Resident #310's room door had an enhanced barrier precaution signage posted. Staff D entered Resident #310's room after pouring medication and donned gloves without donning a gown. Staff D administered the medication via Resident #310's gastric tube. During an interview on 8/21/2024 at 9:42 AM, Staff D, LPN, stated, I should have put on a gown since he [Resident #310] has a gastric tube and is under enhanced barrier precautions. 3) During an observation on 8/21/2024 at 8:57 AM, Staff E, LPN, was pouring medication for Resident #164. One Flomax capsule fell on top of the medication cart. Staff E proceeded to grab the capsule with her hands without wearing gloves and placed the capsule back into the medication cup. Staff E entered Resident #164's room and administered the medication. During an interview on 8/21/2024 at 9:05 AM, Staff E, LPN, stated, I should have discarded the medication once it fell on to the medication cart and poured a new medication onto the medication cup. During an interview on 8/21/2024 at 1:45 PM, the Infection Preventionist stated, Staff should wear gloves and gown when providing direct care to residents who are under enhanced barrier precautions and if they are at risk for a splash, they should wear a face shield. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing (DON) stated, Staff should follow full personal protective equipment when resident is under enhanced barrier precautions. The staff should wear gloves and gown when coming into direct contact with resident. Staff should discard medication and pour a new one if they fall. Medication should not be touched without gloves. Review of the facility policy and procedure titled Enhanced Barrier Precautions with the last review date of 1/23/2024 read, Policy Statement: Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi0frug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation . 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high-contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring use of gown and gloves for EBPs include . g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) Review of the facility policy and procedure titled Administering Medications with the last review date of 1/23/2024 read, Policy Interpretation and Implementation . 25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. 49846 4) During an observation on 8/20/2024 at 1:18 PM, Staff A, Registered Nurse (RN) Supervisor, and Staff B, Registered Nurse, were providing wound care to Resident #7. Staff B did not put down a protective barrier to protect the bed linen and other body sites before wound care. Staff B removed the dressing to the resident's right foot and then removed her gloves. Staff B did not perform hand hygiene before applying another set of gloves to clean the wound on the resident's right foot. Without performing hand hygiene, Staff B applied another set of gloves to dry the wound area. Staff B did not perform hand hygiene before applying dressing to the right foot. Staff B removed her gloves after completing the dressing change to the right foot and applied another set of gloves without performing hand hygiene and removed the dressing to the resident's left foot. Staff B applied a new set of gloves without performing hand hygiene to clean the left foot wound area. Staff B removed her gloves and applied another set of gloves for drying the left foot wound area without performing hand hygiene. Staff B removed her gloves and applied another set of gloves for applying dressing to the resident's right foot wound without performing hand hygiene. During an interview on 8/20/2024 at 2:45 PM, Staff A, RN Supervisor, stated, [Staff B's name] should have washed her hands between each procedure and placed a barrier between the resident and the bed. During an interview on 8/20/2024 at 2:45 PM, Staff B, RN, stated, I did the wound care just like I always do it. I should have washed my hands and should have laid a barrier down between the wound care and the bed before starting the procedure. During an interview on 8/22/2024 at 10:00 AM, the Director of Nursing stated, After removing the old dressing and removing gloves, they should wash hands before applying new gloves again. Review of the facility policy and procedure titled Dressings, Dry/Clean with the last review date of 1/23/2024 showed it read, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressing . Steps in the Procedure . 8. Wash and dry your hands thoroughly. 9. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 10. Label tape or dressing with date, time, and initials, place on clean field. 11. Using a clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). 12. Wash and dry your hands thoroughly. 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area usually from the center outward. 16. Use dry gauge to pat the wound dry.

Based on observation, interview, and record review, the facility failed to ensure staff sanitized the equipment while taking food temperatures in accordance with professional standards. Findings include: During an observation on 8/20/2024 at 7:40 AM, Staff C, Cook, picked up a towel that was sitting on the prep table and used the towel to wipe the temperature probe between taking temperatures of pureed foods including oatmeal, eggs, and waffles. Staff C did not use alcohol wipes after testing the first pureed food. During an interview on 8/20/2024 at 8:32 AM, Staff C, Cook, confirmed he used the towel to clean off the temp probe. During an interview on 8/20/2024 at 8:25 AM, the Certified Dietary Manager (CDM) stated they need to use alcohol wipes to clean the temperature probe and if they have to clean off the probe with another source, they would use a clean paper towel. During an interview on 8/21/2024 on 11:35 AM, the Registered Dietician stated that she expected the dietary staff to use alcohol wipes in between foods when using the temp probe. Review of the facility policy and procedure titled Food Temperatures with the last review date of 1/23/24 showed it read, Policy: Foods should be served at proper temperature to insure food safety and palatability. Procedure: 1. Wash, rinse and sanitize a dial face, metal probe-type thermometer with alcohol wipe. A practical range of 0-220 F [Fahrenheit] is recommended. Re-sanitize the thermometer after each use.

Based on record review and interview, the facility failed to ensure the residents' health record showed the residents either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 2 of 5 residents reviewed for immunization, Residents #3 and #7. Findings include: Review of Resident #3's admission record showed the resident was admitted on [DATE] with diagnoses including dementia, atrial fibrillation, insomnia and chronic pain syndrome. Review of Resident #3's vaccination records showed a flu vaccine consent signed on 11/6/2023. Further review of the records showed the resident received the last flu vaccine on 10/25/2022, with no documentation of a flu vaccine administered after 11/6/2023. Review of Resident #7's admission record showed the resident was admitted on [DATE] with diagnoses including heart failure, atrial fibrillation, dementia and chronic kidney disease. Review of Resident #7's vaccination records showed a flu vaccine consent signed on 11/6/2023. Further review of the records showed the resident received the last flu vaccine on 10/25/2022, with no documentation of a flu vaccine administered after 11/6/2023. During an interview on 8/21/2024 at 10:02 AM, the Infection Preventionist confirmed Residents #3 and #7 had consented to having a flu vaccine administered and there was no documentation of the vaccine being administered after 11/6/2023. She stated, We got the consent on the unit, and it was the previous Infection Preventionist who was responsible for the administration. I cannot find documentation of administration for either resident. During an interview on 8/21/2024 at 2:45 PM, the Director of Nursing stated, It is my expectation that when a resident signs a consent for a vaccine, the staff obtain an order if there is not a standing order, administer it and document it in the record. Review of the facility policy and procedure titled Influenza, Prevention and Control of Seasonal with the last review date of 1/23/2024 showed it read, Policy Statement: This facility follows current guidelines and recommendations for the prevention and control of seasonal influenza. Policy Interpretation and Implementation . Vaccination: 1. The Infection Preventionist organizes and oversees an annual influenza vaccine campaign. 2. All residents and staff are offered the vaccine prior to the onset of the influenza season.

Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles in 1 of 4 units. Findings include: 1) During an observation on 8/19/22024 at 9:52 AM, Resident #14 was lying in bed. On top of the resident's bedside table, there was a bottle of Magnesium Glycinate (Photographic evidence obtained). During an observation on 8/19/2024 at 11:02 AM with Staff G, Licensed Practical Nurse (LPN) Unit Manager, Resident #14 was lying in bed and there was a bottle of Magnesium Glycinate on top of the resident's bedside table. During an interview on 8/19/2204 at 11:02 AM, Resident #14 stated, I brought this Magnesium from home and the nurse will give it to me because the facility does not carry this type. 2) During an observation on 8/19/2024 at 9:43 AM, Resident #36 was not in his room. There was a bottle of Hydrogen Peroxide on top of the resident's drawer (Photographic evidence obtained). During an observation on 8/19/2024 at 11:00 AM with Staff G, LPN Unit Manager, there was a bottle of Hydrogen Peroxide on top of Resident #36's drawer. During an interview on 8/19/2024 at 11:05 AM, Staff G, LPN Unit Manager, stated, Those medications should not be there. Residents should not have medication at bedside. [Resident #36's name] does not even have orders for Hydrogen Peroxide. During an interview on 8/22/2024 at 7:55 AM, the Director of Nursing (DON) stated, Resident medication should be locked in a lock box inside the resident's drawer. Review of the facility policy and procedure titled Medication Labeling and Storage with the last review date of 1/23/2024 read, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.

Based on record review and interview the facility failed to ensure residents received information related to the right to formulate an advance directive upon admission for 8 (Resident #26, #58, #123, #173, #174, #222, #224, and #325) of 18 residents sampled for advance directives review. Findings include: Record review of Resident #26's admission record documented Resident #26 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, chronic obstructive pulmonary disease, end stage renal disease and hyperlipidemia. Record review of Resident #26's Advance Directives Policy and Record on 4/12/2023 documented Resident #26 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #58's admission record documented Resident #58 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, chronic obstructive pulmonary disease, chronic kidney disease and anemia. Record review of Resident #58's Advance Directives Policy and Record on 4/12/2023 documented Resident #58 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #123's admission record documented Resident #123 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, essential hypertension, personal history of pulmonary embolism, and gout. Record review of Resident #123's Advance Directives Policy and Record on 4/12/2023 documented Resident #123 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #173's admission record documented Resident #173 was admitted to the facility on [DATE] with diagnoses that included hypokalemia, peripheral vascular disease and essential hypertension. Record review of Resident #173's Advance Directives Policy and Record on 4/12/2023 documented Resident #173 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #174's admission record documented Resident #174 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications and pruritus. Record review of Resident #174's Advance Directives Policy and Record on 4/12/2023 documented Resident #174 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #222's admission record documented Resident #222 was admitted to the facility on [DATE] with diagnoses that included essential hypertension, Walden [NAME] macroglobulinemia, and hypo-osmolality and hyponatremia. Record review of Resident #222's Advance Directives Policy and Record on 4/12/2023 documented Resident #222 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #224's admission record documented Resident #224 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of bone and articular cartilage, intrahepatic bile duct carcinoma, and essential hypertension. Record review of Resident #224's Advance Directives Policy and Record on 4/12/2023 documented Resident #224 had not been provided information related to the right to formulate an advance directive until 4/11/2023. Record review of Resident #325's record documented Resident #325 was admitted to the facility on [DATE] with diagnoses that included hypertensive crisis, dysphagia, heart failure, chronic kidney disease and atherosclerotic heart disease. Record review of Resident #325's Advance Directives Policy and Record on 4/12/2023 documented Resident #325 had not been provided information related to the right to formulate an advance directive until 4/11/2023. During an interview on 4/12/2023 at 11:02 AM, the Administrator confirmed the facility had not consistently provided residents with information related to the right to formulate advance directives upon admission. Record review of the facility policy titled Advance Directives, last reviewed 2/28/2023, read 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

Based on observation, interview, and record review, the facility failed to ensure food was safely stored, covered, labeled, or discarded in the areas of the kitchen coolers and freezers, and failed to ensure equipment was cleaned and sanitized before use (Photographic evidence obtained). Findings include: During an observation at the time of initial walk-through tour of the kitchen on [DATE] at 9:16 AM with the Certified Dietary Manager (CDM), there were a large container with what appeared to be approximately 20 pieces of fresh raw chicken with red bloody fluids surrounding the bottom of the container in the walk-in cooler, a container of food that had a product with Fresh Sliced Mushrooms label by the [NAME], with no received or expiration date, and a partial box of frozen raw beef patties located on the bottom shelf with the lid open and the product exposed in the reach-in freezer. During an interview on [DATE] at 9:45 AM, the CDM verified that the fresh raw chicken was stored in a container with blood pooling on the bottom of the container and should have been on an ice bed, that the fresh sliced mushrooms did not have a received, opened, or a use by date, and that the raw frozen beef patties should have been stored in a closed container that did not expose the product to freezer burn. The CDM stated that the products should be labeled according to the policy, and all products should be closed or covered when stored. Review of the facility policy and procedure titled Food Storage revised on [DATE] and last reviewed on [DATE], reads, Procedure . Raw Meat . 4. Hamburger and fresh chicken should be cooked within one to two days of purchase. Fresh Chicken should be stored on ice to maintain an optimal temperature of 28 to 32 degrees F [Fahrenheit] . Food Storage Frozen Meat/Poultry and Foods . 3. Storage: Store items promptly to 0 degrees F or less or at a temperature maintains the food frozen. Foods should be stored in their original containers if designed for freezing. Foods to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items. During an observation at the time of follow-up tour of the kitchen on [DATE] at 7:28 AM with the CDM, the can opener had a buildup of food residue and rust. The sanitation test strips being used had an expiration date of [DATE]. During an interview on [DATE] at 7:28 AM, the CDM confirmed the can opener had food residue and that the test strips currently being used were expired. Review of the facility policy and procedure titled Can Opener, revised on [DATE] and last reviewed on [DATE], reads, Sanitation of Equipment. Frequency: After each meal; more frequently if needed. 1. Remove shank to pot and pan sink, or to the dish machine area. 2. Scrub shank, paying attention to blade and moving parts. Use sanitizing solution and brush, or run through dish machine. 4. Air dry on clean surface. Review of the facility policy and procedure titled Recording of Dish Machine Temperatures revised on [DATE] and last reviewed on [DATE] reads, 6. The concentration of the sanitary solution during the rinse cycle is ,d+[DATE] ppm with Chlorine sanitizer. This is used on low temperature dish machines. Assure that test strips are within the Use-By-date and not outdated.

Based on observation and interview the facility failed to ensure that all drugs and biologicals used in the facility were properly labeled and stored in accordance with professional standards in 2 of 4 medications carts and two resident's rooms, Resident # 222 and Resident #326. Photographic evidence obtained. Findings include: 1). During an observation on 4/10/2023 at 2:52 PM of the west wing medication cart #2 with Staff B, Licensed Practical Nurse (LPN), two opened insulin pens, Toujeo Solostar and Insulin Glargine, were not dated with date opened. During an interview on 4/10/2023 at 2:55 PM, Staff B, LPN, confirmed the insulin pens in the west wing medication cart #2 were not dated with an open date or expiration date when removed from the refrigerator. Staff B stated, When insulin pens are removed from the refrigerator, we are supposed to date them with the open date and the expiration date. During the observation on 4/10/2023 at 3:18 PM of the west wing medication cart #2 with the east wing Nurse Manager, one Novolog insulin pen was lying in the cart, opened with no resident's name on the pen and one Lispro insulin pen with no opened date labeled on the pen. During an interview on 4/10/2023 at 3:18 PM the east wing Nurse Manager confirmed the Novolog insulin was opened with no resident's name on the pen and one Lispro insulin pen with no opened date labeled on the pen. During an interview on 4/10/2023 at 3:22 PM, the East Wing Nurse Manager confirmed the insulin pens were not dated when opened and no expiration dates were entered on Insulin pens. She stated, When the insulin pens are removed from the refrigerator the open date and the expiration date must be written on the insulin pen. These insulin pens expire within 28 days, but some insulin pens vary on the expiration days after opening. 2). An observation on 4/10/2023 at 8:30 AM of Residents #222's room revealed a syringe of Normal Saline and a syringe of Heparin lying on a bookshelf unsecured. An observation on 4/11/2023 at 7:51 AM of Residents #222's room revealed a syringe of Heparin lying on bookshelf unsecured. During an interview on 4/11/2023 at 8:05 AM, Staff C, LPN, confirmed the Heparin syringe was lying on the bookshelf in Resident #222's room. Staff C confirmed that Heparin syringe was at the bedside and stated, this is to be locked up on the med cart, it should not be in here. During an interview on 4/10/2023 at 3:58 PM, the Director of Nursing (DON) stated that her expectation was that no medications were to be left at the bedside and that all insulin pens when removed from the refrigerator were dated with the date and an expiration date when the insulin pen was removed. 44571 3). An observation on 04/10/2023 at 10:05 AM, Resident #326 was observed at bedside taking medications from a medication cup. Two pills remained in the med cup. During an interview on 4/10/23 at 10:05 AM Resident #326 stated, I'm not even sure what the meds are but one taste like iron or something. During an interview on 4/11/23 at 10:52 AM Staff A, Registered Nurse (RN) stated that the nurse on the medication cart should prepare the medications for a resident, take it to the resident, administer the medications and then chart that the medications were given. Medications should not be left at bedside. When asked why Resident #326 had medication at bedside, Staff A stated, Oh no, I guess I forgot to go back when I went to get him something to drink. During an interview on 4/11/23 at 11:15 AM the DON stated that the nurse on the medication cart should follow the protocol when passing medications. The DON confirmed that Staff A, RN was the nurse on the medication cart for Resident #326.

Based on observation, interview, and record review the facility failed to ensure care and services were provided for a PICC (Peripherally Inserted Central Catheter) access device in accordance with professional standards of practice for 1 (Resident #222) of 7 residents reviewed. Photographic evidence obtained. Findings include: During an observation on 4/10/2023 at 11:36 AM Resident #222 was sitting in a bed side chair, PICC observed on left upper arm. A transparent dressing was over top of gauze securing the PICC. The dressing was dated 3/30/2023. During an interview on 4/10/2023 at 11:36 AM Resident #222 stated that he came into the facility with the catheter and the dressing has not been changed since he was admitted . During an observation on 4/10/2023 at 1:18 PM Resident #222 a PICC was on left upper arm with a transparent dressing was over top of gauze securing the PICC. The dressing was dated 3/30/2023. During an interview on 4/10/2023 at 2:52 PM Staff B, Licensed Practical Nurse (LPN), confirmed that the dressing was dated 3/30/2023 and should have been changed within 7 days. Review of the admission record for Resident #222 documented the resident was admitted on [DATE] with diagnosis that included but not limited to osteomyelitis of ankle and foot. Review of physician orders for Resident #222, dated 4/3/2023, read: Change PICC dressing and end caps every day shift every 7 days for infectional [sic] control and as needed for soiled or not intact. During an interview on 4/11/2023 at 8:17 AM the Director of Nursing (DON) stated Dressing changes for PICC's are to be changed on admission if gauze is under the Tegaderm (clear dressing). If no gauze is under the Tegaderm and we can see the site and there is no issue, then the dressing on the PICC is changed in 7 days. Review of the policy titled Central Venous Catheter Dressing Changes, last reviewed 2/28/2023, read The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings. General Guidelines. 4. After original insertion of CVAD ( Central Venous Catheter Dressing), the dressing will consist of gauze and TSM (Transparent semi-permeable membrane). This must be changed within 24 hours. 5. Change transparent semi-permeable membrane dressing at least every 5-7 days and PRN (as needed when wet, soiled, or not intact). 6. If gauze is used, it must be changed every 2 days.

Based on observation, interview, and record review the facility failed to ensure respiratory care services were provided for 2 of 2 sampled residents out of 10 residents receiving respiratory services (Resident #22 and #223). Photographic evidence obtained. Findings include: During an observation on 4/10/2023 at 10:19 AM, Resident #223 was sitting in a bedside recliner. The oxygen tubing was hanging on the regulator on the wall and the tubing was not dated. During an interview on 4/10/2023 at 10:19 AM, Resident #223 stated I only use oxygen when I have sinus issues and the oxygen will clear it up, the oxygen rate is 2 and I never change it. The tubing has not been changed since I've been here. During an observation on 4/10/2023 at 1:49 PM Resident #223's oxygen tubing was not dated. During an observation on 4/11/2023 at 8:37 AM Resident #223 was sitting in his bedside recliner with his nasal cannula lying over the bedside table. There was no water observed in the bottle for the humidifier. Review of the admission record for Resident #223 documented an admitted [DATE] with diagnosis that included but not limited to atherosclerosis heart disease, pleural effusion, hypoxia, and encounter for surgical aftercare following surgery on the circulatory system. Review of physician orders for Resident #233 dated 3/23/2023 read O2: Oxygen at 2 liters per nasal cannula as needed for shortness of breath, low oxygen saturation. Review of physician orders for Resident #233 dated 3/29/2023 read O2 (oxygen): Change oxygen tubing and date with securement bag . Every night shift every Wed (Wednesday). During an observation on 4/10/2023 at 9:47 AM Resident #22 was sitting in a recliner beside her bed. Resident #22's oxygen tubing was not dated and the plastic bag hanging on the regulator was dated 3/22. During an interview on 4/10/2023 at 9:47 AM Resident #22 stated I use oxygen at night. During an observation on 4/10/2023 at 1:34 PM Resident #22 was lying in bed. Resident #22's oxygen tubing was not dated. During an interview on 4/11/2023 at 8:27 AM the Director of Nursing confirmed that Resident #22's oxygen tubing was not dated prior to her having the night shift go in and date the tubing the previous night. All tubing is supposed to be dated and changed on Wednesday nights, it was not changed and dated as ordered. Review of the physician orders for Resident #22 dated 3/15/2023 read O2: Oxygen tubing (must be dated) every night shift every Wed [Wednesday] for infection control. Review of the facility policy title Oxygen Administration, last reviewed 2/28/2023, read Purpose. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Steps in the Procedure. 12. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.

Based on record review and interview the facility failed to ensure a drug regimen review recommendation from the pharmacist was acted upon for 1 resident (Resident #6) of 5 residents reviewed. Findings include: Review of the admission record for Resident #6 documented the resident was admitted to the facility on [DATE] with diagnosis that included but not limited to heart failure, muscle weakness, and abnormalities of gait and mobility. Review of physician orders for Resident #6 dated 11/1/2022 read: Voltaren Gel 1 % (Diclofenac Sodium) Apply to Bilat shoulders topically every 8 hours as needed (PRN) for shoulder pain. Review of physician orders for Resident #6 dated 12/31/2022 read: Diclofenac Sodium Gel 1% Apply to Both shoulders topically every 12 hours as needed for shoulder pain. Review of pharmacist consultation report dated 12/08/2022 read Recommendation: Please update the direction for topical diclofenac 1% gel to 'Apply 2 grams to bilateral shoulders every 8 hours as needed.' Physician Response: Diclofenac 1% gel Apply 1 gm to both shoulders every 12 hours prn for pain. Physician dated document 12/29/2023. Review of pharmacist consultation report dated 1/20/2023 read Recommendation: Please update the directions for topical diclofenac 1% gel to Apply 2 grams to bilateral shoulders every 8 hours as needed. (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written. Physician dated document 2/8/2023. Review of pharmacist consultation report dated 3/13/2023 read Recommendation: Please update the directions for topical diclofenac 1% gel to 'Apply 2 grams to bilateral shoulders every 8 hours as needed.' (Clarify dosing - have duplicate orders). Physician Response: I accept the recommendations, please implement as written. Physician dated document 3/23/23. Review of Resident #6's clinical records failed to document the facility acted upon the pharmacist recommendations. During an interview on 4/12/2023 at 1:44 PM, the Director of Nursing stated that the physician had agreed with the pharmacists' recommendation but the recommendations had not been acted upon. Review of policy titled Interim Medication Regimen Review (MMR), last reviewed 2/28/2023, showed the policy read: The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician / Prescriber to either accept and act upon the recommendations contained within the MRR ( Medication Regimen Review) or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety. Findings: During an initial tour of the kitchen on 11/1/2021 at 9:06 AM with the Certified Dietary Manager (CDM), a walk-through of the walk-in cooler showed a large clear container with leftover hotdogs with no label or date, a container of food labeled as brussel sprouts by the [NAME] with a fuzzy substance on the product, a container of food labeled as lemons by the [NAME] with a fuzzy substance on the product, and an approximate 1/4 open container of food labeled as pesto with no opened date. A walk-through of the reach-in cooler showed an open container of food labeled as liquid eggs, which was on the second open shelf placed directly over bottles of assorted condiments. A walk-through of the reach-in freezer showed a partial box of frozen beef steaks located on the top shelf with the lid open and the product exposed, a partial bag of frozen ravioli located on the second shelf with the bag open and the product exposed and no label or opened date, a partial bag of frozen pasta located on the third shelf with the bag open and the product exposed and no label or opened date, and a partial bag of tortilla or wraps located on the second shelf with the bag open and the product exposed and no label or date. During a second tour of the kitchen on 11/2/2021 at 9:33 AM with the CDM, a walk-through of the reach-in cooler showed a small plate on the second shelf containing two raw shell eggs that were not wrapped or with any sides to prevent the eggs from rolling off the plate and were placed directly over multiple food items. A walk-through of the dry storage room showed an opened container of peanut butter on the top shelf, with peanut butter residue build-up on two sides of the container with no opened date, and an opened package of hamburger buns on the bread rack containing three buns remaining in the bag and fully exposed. A walk-through of the reach-in freezer showed a partial box of beef steak remaining open with the product exposed. During an interview on 11/1/2021 at 10:28 AM, the CDM verified that he observed the products with the fuzzy substance, the products without a label or date and identified the products as leftover hotdogs and pesto in the walk-in cooler, in the reach-in freezer as frozen beef steak, ravioli, pasta and wraps, and that he observed the cartons of liquid eggs on the second open shelf of the reach-in cooler. The CDM stated that the products should be labeled according to the policy, all products should be closed or covered when stored and, that raw eggs should never be over other food products. During an interview on 11/2/2021 at 11:28 AM, the CDM stated, I discussed the dating, labeling, and closing of products with my staff and I am very disappointed to find the same or even more items the second time around. Review of the policy and procedure titled, Refrigerated Leftover Storage revised on 12/8/2018 and reviewed on 2/24/2021 reads, Policy: Leftover foods should not be saved and re-used for human consumption if there is any doubt of wholesome quality. A leftover is a product that has been on the meal service line at one time. For items that have been cooked or opened but have not been on meal service line, refer to the Dry, Refrigerated and Freezer Storage Charts (POLs 154a, 154b, 154c). These timeframes are not only used to control sanitation but the quality of the food also. Refer to corporate policy for stricter guidelines. Procedure: 1. Cover with non-absorbent lid or material. 2. Date container with use by date (lids may be misplaced). 3. Label unless easily identifiable without removing cover - such as sliced peaches in glass jar.

Based on observation, record review, and interview, the facility failed to ensure the residents who were incontinent of bladder received appropriate treatment and services for indwelling urinary catheters for 2 of 4 residents, Residents #95 and #96, in a total sample of 20 residents. Findings: 1. During an observation of Resident #95 on 11/1/2021 at 9:15 AM with Staff B, Registered Nurse (RN), Unit Manager, the resident's catheter bag was laying on the floor, folded in half, with no privacy bag. There was about 40 milliliters of dark yellow liquid in the bag. The bag was off the hook on the bottom frame of the bed. The tubing and the connector were on the floor. Review of the medical record dated 10/29/2021 for Resident #95 revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 11/1/2021 at approximately 9:20 AM, Resident #95 stated, I don't know who put it on the ground. I want it in the right place, so I can get well and return home. During an interview on 11/1/2021 at 9:20 AM, Staff B, RN, Unit Manager, verified the catheter bag was not attached to the bed frame. She verified it was laying on the floor, folded in half, with about 40 milliliters of urine in it. 2. During an observation of Resident #96 on 11/1/2021 at 9:30 AM with Staff A, Certified Nursing Assistant (CNA), the resident's catheter bag was facing the doorway with the curtains pulled toward the head of the bed. The catheter bag and urine were visible from the doorway. The tubing had a yellow-colored liquid, which was backed up in the tubing. The tubing draped off the bed, dropped lower than the drainage bag, preventing the urine draining into the connector located at the top of the bag (Photographic evidence obtained). During an interview on 11/1/2021 at approximately 9:35 AM, Staff A, CNA, stated she was assigned to Resident #96, and she had no further information regarding catheter care and techniques. During an interview on 11/1/2021 at 9:50 AM, Resident #96 stated, I prefer having a privacy bag. I do not want the bag in view for others if the door is open. I want the door open today. Review of the policy and procedure titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing revised in September 2017 reads, . Steps in the Procedure: . 6. Maintain unobstructed urine flow. a. Keep the catheter and tubing free of kinks. b. Secure catheter after insertion to prevent movement, c. Keep drainage bag below the level of the bladder at all times. Do not place the drainage bag on the floor. Review of the policy and procedure titled, Quality of Life - Dignity revised in August 2009 reads, . Policy Interpretation and Implementation: . 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: 1. Helping the resident to keep urinary catheter bags covered.

Based on interviews, record review, and policy and procedure review the facility failed to have an active infection prevention program in place. Findings: During an interview on 02/18/2019 at 11:00 AM the Director of Nursing (DON) stated, the facility did not conduct tracking and trending as required for (MONTH) and (MONTH) 2020. The tracking and trending was last completed in (MONTH) of 2019. The tracking and trending had not been reported at the Quality Assurance monthly meeting as required. A clinical review of the infection surveillance program for the facility did not show documentation tracking and trending was conducted for residents that had been identified as having an infection which required the use of antibiotics. There was no documentation to show the facility was identifying trends, investigating outbreaks of infection, and implementing infection prevention interventions. A review of the Infection prevention and surveillance policy and procedure last revised 02/2018 read the nurse leader/designee shall enter infections into the infection trend tracker. Shall provide updates in the infection control tracking and tracker including changes and resolutions. Shall analyze trends identified, investigate outbreaks of infection and implement infection prevention interventions. Shall report infection trends at the monthly quality assurance performance improvement meeting.

Based on record review, interview, and facility policy and procedure review, the facility failed to ensure 1 of 4 sampled residents (Resident #1) was free from neglect by administering incorrect, non-physician ordered medications to Resident #1 resulting in the resident having to be transferred to the hospital. The Director of Nursing, the Administrator designee, was informed of the existence of Immediate Jeopardy on 10/25/2019 at 5:35 PM. The Immediate Jeopardy began on 10/15/2019, was on-going at the time of the exit on 10/25/2019. This has the potential to affect 71 of 71 current residents. Cross reference to F760. The findings included: Review of Resident #1's facility medical record revealed the resident was admitted on [DATE] at 5:40 PM with [DIAGNOSES REDACTED]. Review of the nursing progress notes dated 10/15/2019 at 11:57 PM by Staff A, LPN (Licensed Practical Nurse) read: As I was entering the shared room of 112/113, I accidently gave the medications to 112 that was supposed to be given to 113. I immediately realized the medication error and notified (the physician's name) and gathered baseline vital signs of blood pressure 120/84, pulse 82, respirations 19, and temperature of 98.4. At 11:00 PM - (The physician's name) verbally gave orders on the phone to monitor vital signs every 20 minutes for 3 hours. At 11:48 PM Will continue to monitor vital signs. Review of the record revealed no additional vital signs documented until the documentation on the hospital Transfer Form. Review of the nursing progress notes dated 10/16/2019 at 4:45 PM by the ADON (Assistant Director of Nursing) read: Resident transferred to (the hospital name) via EMS (Emergency Medical Services) at 12:50 PM for [MEDICAL CONDITION] and hypertension per MD (Medical Doctor). Review of the Transfer Form dated 10/16/2019 at 12:30 PM read: Blood pressure 102/39, pulse 35, respirations 18, temperature 95.9, O2 (oxygen) 95% give beta blocker by med error. Review of the Personnel Record for Staff A, LPN revealed a hire date of 09/23/2019, Orientation date of 09/24/2019. Med Error in-service dated 10/15/2019. Review of the hospital Clinical Discharge Instructions dated 10/18/2019 revealed Medical Information - Diagnosis: [REDACTED]. During an interview on 10/25/2019 at 9:00 AM, the DON (Director of Nursing) stated, That morning of the incident the nurses had received an in-service with the pharmacy representative about medication errors. (Staff A's name) attended that in-service. When asked her expectations regarding medication administration the DON stated, My expectation is for these mistakes not to happen. It was an isolated nurse, and she was removed from the schedule. She did resign as of Tuesday 10/22/2019 prior to being terminated by us. She was very excited to go off orientation, (Mentor's name) was there as a mentor to help for the night. A request was made for the investigation documentation and the corrective action put into place following the medication error. The DON stated, On 10/15/2019 at 10:35 PM the Director of Clinical Services received a phone call from (the Mentor's name), LPN reporting that (Staff A's name) LPN had committed a medication error on the new admission, (Resident #1's name and room number). I was upset that (Staff A's name) was not the one who called her that evening, it was the mentor (the Mentor's name). I started an investigation the next day on 10/16/2019. It was due to the combination of a new admit, new nurse, and the nurse's distraction of pain. I called (Staff A's name) and she said that she was in a rush to complete the medication pass due to the pain in her hip. When she administered the medication to (Resident #1's name), she had not confirmed with the resident her name or date of birth. The in-service (Staff A's name) attended was an ongoing education process that was part of the plan of a correction to a near miss event. When asked the plan of correction related to the medication error, the DON stated, We have begun to audit all new admits and compare the medications from the hospital to those entered in the MAR (Medication Administration Record). When asked the system that was put in place to prevent the administration of medications to the wrong resident, the DON stated, Myself and the Unit Managers have begun to conduct medication observations with the nurses. We have done six audits. I had a deadline of (MONTH) 31 to complete all nursing staff medication observations. I got side tracked with the investigation and in-service so this was not completed as planned. During an interview on 10/25/2019 at 9:45 AM, Resident #1 stated, The day the medication error occurred was very confusing. It was the day of my admission and the nurse looked very confused or nervous. I cannot determine which. I got sent right back to the hospital the next day. I did stay there for one day, then got sent back. I ask what pills I am getting. I can't say that on that night the nurse asked my name and date of birth or not. During an interview on 10/25/2019 at approximately 11:00 AM, the Administrator stated, I was in disbelief of the medication error. In my conversations with (Staff A's name), she was eager and felt ready to be on her own. I was informed by the DON that (Staff A's name) had attended the in-service that very morning. During an interview on 10/25/2019 at 3:55 PM, Staff C, LPN (Licensed Practical Nurse) stated, We have recently had an in-service on medication error prevention, but I didn't get it yet, someone told me about it. During an interview on 10/25/2019 at 4:30 PM, Staff F, RN (Registered Nurse) stated, I have done or have not done the online training. I cannot remember with all the online modules done. I heard that a med error was done. It is very difficult to complete all your duties especially med pass without interruptions. During an interview on 10/25/2019 at 4:40 PM, with Staff E, LPN stated, I have not completed my online training yet or attended the in-service. During an interview via telephone on 10/25/2019 at 5:13 PM, the Medical Director stated, My expectations are for this to not happen again. I am aware of the near miss that happened in July. If we have to go to a two-person medication administration, then that is what we will do. My expectation is that the facility has competent staffing. Review of a hand written, signed paper provided by the facility read: 10/16/2019 at 11:28 AM (Staff A's name) In 112 not 113. Had hip pain and was rushing. Tried calling (Physician's name). Called (Physician's name) actually (Mentor's name) did. (Resident #1's name with date of birth). Questioned about doing medpass (Medication Pass), said she did. Asked if she checked her name. Didn't check wrist band or didn't ask name. Hip hurting med error - fully admit her being @ (at) fault. Confirmed that she told me yesterday that she was ready to come off orientation. Med ERROR> Neglect. Reported to Board of Nursing. BP (blood pressure) 102/39. Pulse 41. Reportable short and sweet. Allegation of Neglect. Review of the investigation provided by the facility read: (Staff A's name), LPN - Critical Medication Error Timeline of Events (5 day Report). 10/15/19 @ 10:35 pm - Director of Clinical Services received a phone call from (Mentor's name), LPN reporting that (Staff A's name), LPN, had committed a medication error on the new admission, (Resident #1's initials), in (Resident #1's room number). It was reported that the patient received all of her roommate's evening medications. The nurse was directed to call the medical provider and alert him to the situation and to start checking vital signs regularly. @ 11:28 am - Director of Clinical Services and Administrator spoke with (Staff A's name) via the phone to speak about the mediation error. She stated she realized she gave the medications to the wrong patient shortly after leaving the room. She was asked if she checked the patient's name band or asked the patient her name. She stated she did not verify the patient's name verbally or by looking at the wrist band. When asked why she didn't verify the patient, she stated that her hip hurt so she was distracted and just wanted to get the med pass completed. She was asked if she notified the patient or family. She said she had attempted to but was unable to leave a message with the daughter. @12:10 pm - Director of Clinical Services requested for the patient's Blood Pressure and Pulse to be rechecked. They were 102/39 and 41. A call was put out to the patient's physician to follow up with the medication error and the drop in blood pressure/pulse. The provider was concerned about the low pulse and requested to have the patient sent to the E.R. (emergency room ) for evaluation. @ 12:30 pm - Director of Clinical Services and Administrator spoke to the patient and her daughter about the medication error. Neither of them had known that the error had occurred. The daughter stated she had no missed calls or messages. Patient is fully alert and oriented. @ 12:50 pm When EMS (Emergency Medical Services) arrived pulse had dropped to 35. Patient sent to (the hospital's name) E.R. for evaluation and was admitted as an inpatient stay. 10/18/19 @ 4:11 pm returned from (the hospital's name). Investigation showed that the following medications were administered to the wrong patient: [MEDICATION NAME] 50 mg (milligrams), (used to treat high blood pressure), Montelukast Sodium 10 mg (used to prevent and manage asthmas symptoms), and [MEDICATION NAME] (used to treat anxiety disorders and [MEDICAL CONDITION] disorders). (Staff A's name), LPN was suspended from her position on 10/16/19; termination pending. Review of the employee list revealed a total of 32 registered and licensed practical nurses were employed by the facility. Review of (MONTH) 2019 Med Pass Audits revealed for the period of 10/18/2019 through 10/23/2019, three nurses on the 7 AM - 3 PM shift and three nurses on the 3 PM - 11 PM shift, for a total of six nurses, had been observed while conducting medication pass administration. Review of the policy and procedure titled, Abuse, Neglect & Exploitation Policy dated 12/2018 read: Policy Overview: Our Company is committed to maintaining a safe environment for each resident, visitor and associate. Instances or allegations of abuse, neglect or exploitation should be treated seriously and must be reported to the Executive Director or the supervisor on duty for investigation and appropriate follow-up. Policy Detail - 1. Definitions: a. Neglect is defined in Florida as the failure to or omission on the part of the caregiver to provide the care, supervision and services necessary to maintain the physical and mental health of the vulnerable adult, including, but not limited to food, clothing, medicine, shelter, supervision and medical services, that a prudent person would consider essential for the well-being of a vulnerable adult. The term neglect also means the failure of a caregiver to make reasonable effort to protect a vulnerable adult from abuse, neglect or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death.

Based on record review, interview, and facility policy and procedure review, the facility failed to ensure 1 of 4 sampled residents (Resident #1) was free from significant medication errors by administering incorrect, non-physician ordered medications to Resident #1 resulting in the resident having to be transferred to the hospital. The Director of Nursing, the Administrator designee, was informed of the existence of Immediate Jeopardy on 10/25/2019 at 5:35 PM. The Immediate Jeopardy began on 10/15/2019, was on-going at the time of the exit on 10/25/2019. This has the potential to affect 71 of 71 current residents. Cross reference to F600. Review of Resident #1's facility medical record revealed the resident was admitted on [DATE] at 5:40 PM with [DIAGNOSES REDACTED]. Review of the nursing progress notes dated 10/15/2019 at 11:57 PM by Staff A, LPN (Licensed Practical Nurse) read: As I was entering the shared room of 112/113, I accidently gave the medications to 112 that was supposed to be given to 113. I immediately realized the medication error and notified (the physician's name) and gathered baseline vital signs of blood pressure 120/84, pulse 82, respirations 19, and temperature of 98.4. At 11:00 PM - (The physician's name) verbally gave orders on the phone to monitor vital signs every 20 minutes for 3 hours. At 11:48 PM Will continue to monitor vital signs. Review of the record revealed there was no additional vital signs documented in the record until the documentation on the hospital Transfer Form. Review of the nursing progress notes dated 10/16/2019 at 4:45 PM by the ADON (Assistant Director of Nursing) read: Resident transferred to (the hospital name) via EMS (Emergency Medical Services) at 12:50 PM for [MEDICAL CONDITION] and hypertension per MD (Medical Doctor). Review of the Transfer Form dated 10/16/2019 at 12:30 PM read: Blood pressure 102/39, pulse 35, respirations 18, temperature 95.9, O2 (oxygen) 95% give beta blocker by med error. Review of the Personnel Record for Staff A, LPN revealed a hire date of 09/23/2019, Orientation date of 09/24/2019. Med Error in-service dated 10/15/2019. Review of the hospital Clinical Discharge Instructions dated 10/18/2019 revealed Medical Information - Diagnosis: [REDACTED]. During an interview on 10/25/2019 at 9:00 AM, the DON (Director of Nursing) stated, That morning of the incident the nurses had received an in-service with the pharmacy representative about medication errors. (Staff A's name) attended that in-service. When asked her expectations regarding medication administration the DON stated, My expectation is for these mistakes not to happen. It was an isolated nurse, and she was removed from the schedule. She did resign as of Tuesday 10/22/2019 prior to being terminated by us. She was very excited to go off orientation, (Mentor's name) was there as a mentor to help for the night. A request was made for the investigation documentation and the corrective action put into place following the medication error. The DON stated, On 10/15/2019 at 10:35 PM the Director of Clinical Services received a phone call from (the Mentor's name), LPN reporting that (Staff A's name) LPN had committed a medication error on the new admission, (Resident #1's name and room number). I was upset that (Staff A's name) was not the one who called her that evening, it was the mentor (the Mentor's name). I started an investigation the next day on 10/16/2019. It was due to the combination of a new admit, new nurse, and the nurse's distraction of pain. I called (Staff A's name) and she said that she was in a rush to complete the medication pass due to the pain in her hip. When she administered the medication to (Resident #1's name), she had not confirmed with the resident her name or date of birth. The in-service (Staff A's name) attended was an ongoing education process that was part of the plan of a correction to a near miss event. When asked the plan of correction related to the medication error, the DON stated, We have begun to audit all new admits and compare the medications from the hospital to those entered in the MAR (Medication Administration Record). When asked the system that was put in place to prevent the administration of medications to the wrong resident, the DON stated, Myself and the Unit Managers have begun to conduct medication observations with the nurses. We have done six audits. I had a deadline of (MONTH) 31 to complete all nursing staff medication observations. I got side tracked with the investigation and in-service so this was not completed as planned. During an interview on 10/25/2019 at 9:45 AM, Resident #1 stated, The day the medication error occurred was very confusing. It was the day of my admission and the nurse looked very confused or nervous. I cannot determine which. I got sent right back to the hospital the next day. I did stay there for one day, then got sent back. I ask what pills I am getting. I can't say that on that night the nurse asked my name and date of birth or not. During an interview on 10/25/2019 at approximately 11:00 AM, the Administrator stated, I was in disbelief of the medication error. In my conversations with (Staff A's name), she was eager and felt ready to be on her own. I was informed by the DON that (Staff A's name) had attended the in-service that very morning. During an interview on 10/25/2019 at 3:55 PM, Staff C, LPN (Licensed Practical Nurse) stated, We have recently had an in-service on medication error prevention, but I didn't get it yet, someone told me about it. During an interview on 10/25/2019 at 4:30 PM, Staff F, RN (Registered Nurse) stated, I have done or have not done the online training. I cannot remember with all the online modules done. I heard that a med error was done. It is very difficult to complete all your duties especially med pass without interruptions. During an interview on 10/25/2019 at 4:40 PM, with Staff E, LPN stated, I have not completed my online training yet or attended the in-service. During an interview via telephone on 10/25/2019 at 5:13 PM, the Medical Director stated, My expectations are for this to not happen again. I am aware of the near miss that happened in July. If we have to go to a two-person medication administration, then that is what we will do. My expectation is that the facility has competent staffing. Review of a hand written, signed paper provided by the facility read: 10/16/2019 at 11:28 AM (Staff A's name) In 112 not 113. Had hip pain and was rushing. Tried calling (Physician's name). Called (Physician's name) actually (Mentor's name) did. (Resident #1's name with date of birth). Questioned about doing medpass (Medication Pass), said she did. Asked if she checked her name. Didn't check wrist band or didn't ask name. Hip hurting med error - fully admit her being @ (at) fault. Confirmed that she told me yesterday that she was ready to come off orientation. Med ERROR> Neglect. Reported to Board of Nursing. BP (blood pressure) 102/39. Pulse 41. Reportable short and sweet. Allegation of Neglect. Review of the investigation provided by the facility read: (Staff A's name), LPN - Critical Medication Error Timeline of Events (5 day Report). 10/15/19 @ 10:35 pm - Director of Clinical Services received a phone call from (Mentor's name), LPN reporting that (Staff A's name), LPN, had committed a medication error on the new admission, (Resident #1's initials), in (Resident #1's room number). It was reported that the patient received all of her roommate's evening medications. The nurse was directed to call the medical provider and alert him to the situation and to start checking vital signs regularly. @ 11:28 am - Director of Clinical Services and Administrator spoke with (Staff A's name) via the phone to speak about the mediation error. She stated she realized she gave the medications to the wrong patient shortly after leaving the room. She was asked if she checked the patient's name band or asked the patient her name. She stated she did not verify the patient's name verbally or by looking at the wrist band. When asked why she didn't verify the patient, she stated that her hip hurt so she was distracted and just wanted to get the med pass completed. She was asked if she notified the patient or family. She said she had attempted to but was unable to leave a message with the daughter. @12:10 pm - Director of Clinical Services requested for the patient's Blood Pressure and Pulse to be rechecked. They were 102/39 and 41. A call was put out to the patient's physician to follow up with the medication error and the drop in blood pressure/pulse. The provider was concerned about the low pulse and requested to have the patient sent to the E.R. (emergency room ) for evaluation. @ 12:30 pm - Director of Clinical Services and Administrator spoke to the patient and her daughter about the medication error. Neither of them had known that the error had occurred. The daughter stated she had no missed calls or messages. Patient is fully alert and oriented. @ 12:50 pm When EMS (Emergency Medical Services) arrived pulse had dropped to 35. Patient sent to (the hospital's name) E.R. for evaluation and was admitted as an inpatient stay. 10/18/19 @ 4:11 pm returned from (the hospital's name). Investigation showed that the following medications were administered to the wrong patient: [MEDICATION NAME] 50 mg (milligrams), (used to treat high blood pressure), Montelukast Sodium 10 mg (used to prevent and manage asthmas symptoms), and [MEDICATION NAME] (used to treat anxiety disorders and [MEDICAL CONDITION] disorders). (Staff A's name), LPN was suspended from her position on 10/16/19; termination pending. Review of the employee list revealed a total of 32 registered and licensed practical nurses were employed by the facility. Review of (MONTH) 2019 Med Pass Audits revealed for the period of 10/18/2019 through 10/23/2019, three nurses on the 7 AM - 3 PM shift and three nurses on the 3 PM - 11 PM shift, for a total of six nurses, had been observed while conducting medication pass administration. Review of the policy and procedure titled, General Dose Preparation and Medication Administration dated 01/01/2013 read: 4. Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1. Facility staff should: 4.1.1 - Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 5.1. Identify the resident per Facility policy. Review of the policy and procedure titled, Medication Errors dated 10/2016 read: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with Health Care Provider orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Policy Detail: 1. Examples of medication errors include: (b) Unauthorized drug - a drug is administered without a physician's orders [REDACTED]. Significant is defined as: (b) Requiring hospitalization , or extending a hospitalization . 9. The following information should be documented Preliminary Draft Notes of a Reported Incident and in the resident's clinical record: (e) Resident's condition for 72 hours or as directed.