Every finding on record at Gran Gran's Place

Based on record review and interview, the facility failed to have a trained and designated infection preventionist to oversee the infection control program. The administrator identified 32 residents resided in the facility. Findings:An undated facility INFECTION CONTROL PROGRAM policy, read in part, The goals of the Infection Control Program are to .Insure [sic] compliance with state and federal regulations relating to infection control.An undated, untitled, employee listed did not document a designated infection preventionist.On 04/22/26 at 11:21 a.m., the administrator stated the DON was responsible for infection control surveillance and antibiotic stewardship in the facility. They stated the DON did not complete training required for the infection preventionist role. The administrator stated they did not have a trained and designated infection preventionist since the previous DON left in December 2025.On 04/22/26 at 11:23 a.m., the administrator stated they have not made any attempts to acquire a trained infection preventionist.On 04/22/26 at 11:40 a.m., the DON stated they did not have a formal training for the infection preventionist role.

Based on observation, record review, and interview, the facility failed to ensure a care plan was developed for:a. interventions for anticoagulant use for 2 (#1 and #2) of 5 sampled residents reviewed for unnecessary medication; and b. catheter care for 1 (#6) of 2 sampled residents reviewed for catheter care. The administrator identified 32 residents resided in the facility and MDS coordinator #1 identified 15 residents received anticoagulant medication. The DON identified two residents had indwelling catheters. Findings: 1. On 04/19/26 at 12:56 p.m., Resident #6 was observed to have an indwelling catheter. An undated facility Care Plan Policy, read in part, A care plan policy establishes the standard and expectations for creating and maintaining a care plan that reflects the individual needs, preferences, and goals of a resident.Care plan should be comprehensive.Care plans should be regularly reviewed, especially when a client's health or social circumstances change, to ensure ongoing relevance and effectiveness. A quarterly assessment for Resident #6, dated 02/05/26, showed the resident's cognition was intact with a BIMS of 15. A physician's order for Resident #6, dated 03/12/26, showed to place an indwelling 18 French/cubic centimeter to gravity catheter. A care plan for Resident #6, revised 03/12/26, showed indwelling catheter re-inserted with intake and output every shift. The care plan did not contain interventions for catheter care. On 04/19/26 at 12:57 p.m., Resident #6 stated the indwelling catheter was placed because they could not empty their bladder. On 04/21/26 at 1:33 p.m., LPN #1 stated catheter care was to clean the indwelling catheter tubing and do peri-care each shift and change the indwelling catheter once a month. On 04/21/26 at 1:40 p.m., RN #1 stated catheter care included the use of enhanced barrier precautions, cleaning of the catheter tubing during peri-care, and routine catheter change. On 04/22/26 at 10:36 a.m., MDS coordinator #1 stated Resident #6's care plan did not have catheter care interventions because there was no physician's order for catheter care. 2. A care plan for Resident #2, dated 09/12/25, did not include anticoagulant interventions. A physician's order for Resident #2, dated 08/18/25, showed Eliquis (anticoagulant blood thinner medication) 2.5 mg one tablet by mouth every 12 hours for anticoagulant. A quarterly assessment for Resident #2, dated 02/26/26 showed they received an anticoagulant (blood thinner) medication. On 04/21/26 at 2:20 p.m., LPN #1 stated for anticoagulant usage they would look to see if a resident was bruising out of nowhere, a cut that would not stop bleeding, and look at laboratory. They stated Resident #2 was on Eliquis and that the anticoagulant monitoring would be under lab reports. On 04/21/26 at 2:28 p.m., MDS coordinator #1 stated the anticoagulant side effect monitoring should have been on the care plan and they were aware that it was not. 3. A physician's order for Resident #1, dated 09/16/24, for Xarelto (anticoagulant medication) 15 mg one tablet by mouth one time a day related to atrial fibrillation. A quarterly assessment for Resident #1, dated 03/20/26, showed the resident had diagnoses which included coronary artery disease, atrial fibrillation, and heart failure. The assessment showed the resident was on an anticoagulant. A care plan for Resident #1, dated 04/01/26, did not include interventions for the use of an anticoagulant. On 04/23/26 at 11:46 a.m., MDS coordinator #1 stated Resident #1's care plan did not have interventions for the use of an anticoagulant.

Based on record review and interview, the facility failed to ensure a resident had skin assessments performed to prevent pressure ulcers for 2 (#4 and #26) of 2 sampled residents reviewed for wounds. The administrator identified 32 residents resided in the facility. Findings: An undated policy titled Skin Integrity Check, read in part, Complete Skin integrity check (head to toe) weekly on all residents.Record the results of the assessment on the treatment documentation form. 1. A care plan for Resident #4, dated 09/12/25, showed they were a pressure ulcer risk related to urinary incontinence. The care plan showed to monitor skin during all activities of daily living. The care plan did not show to perform skin assessments. A quarterly assessment for Resident #4, dated 02/09/26, showed a reentry date of 05/09/24. The assessment showed they were dependent on mobility, had a stage four pressure ulcer that was not present on admission, and was at risk for pressure ulcers. Monthly physician's orders for Resident #4, dated 04/2026, did not show to perform skin assessments. 2. admission orders for Resident #26, dated 04/06/26, did not show to perform skin assessments. An interim care plan for Resident #26, dated 04/08/26, showed skin treatment orders, but did not show any skin assessment or monitoring. An admission assessment for Resident #26, dated 04/16/26, showed the resident admitted to the facility on [DATE]. The assessment showed the resident had an unstageable wound present on admission and were at risk for pressure ulcers. The assessment showed Resident #26 was dependent for mobility. There was no documentation of full body skin assessments located in Resident #26's medical record. On 04/22/26 at 1:13 p.m., the DON stated the skin assessments were done every time they did the wound treatment. The DON stated residents received a skin assessment upon admission or readmission and when wound care was done. The DON stated the residents that did not have wounds would not have a skin assessment by the nurse if not an admit, instead the CNA notified the nurse if anything of concern was found. They stated they did not have a skin assessment sheet that had been implemented. The DON stated there was documentation of skin assessments in the nurses note with each dressing change. On 04/22/26 at 1:15 p.m., the DON stated performing skin assessments was not in the scope of practice for the CNA. On 04/22/26 at 1:27 p.m., LPN #2 stated they had been doing the skin assessments with wound care but did not document them anywhere. They stated that other than with wound care, a skin assessment was not completed. On 04/22/26 at 1:27 p.m., CNA #1 stated they performed skin assessments when they laid a resident down or changed them, and if they noticed a concern they notified the nurse.

Based on observation, record review, and interview, the facility failed to obtain a physician's order for catheter care for 1 (#6) of 2 sampled residents reviewed for catheter care. The DON identified two residents who had indwelling catheters resided in the facility. Findings:On 04/19/26 at 12:56 p.m., Resident #6 was observed to have an indwelling catheter.On 04/21/26 at 1:13 p.m., LPN #1 was observed to perform catheter care for Resident #6. Resident #6 had a weak gait and held on to the television stand for support during ambulation from the bed to the recliner upon completion of care.A quarterly assessment for Resident #6, dated 02/05/26, showed the resident needed supervision or touching assistance with toileting hygiene from staff. The assessment showed the resident's cognition was intact with a BIMS of 15.A physician's order for Resident #6, dated 03/12/26, to place an indwelling catheter 18 French/cubic centimeter to gravity.There was no physician's order for catheter care.A care plan Resident #6, revised 03/12/26, showed indwelling catheter re-inserted with intake and output every shift.On 04/21/26 at 8:10 a.m., LPN #1 stated the day shift did not have orders for catheter care for Resident #6.On 04/21/26 at 1:22 p.m., Resident #6 was asked how often staff clean their catheter like LPN #1 just did. They stated they do not unless they were changing their indwelling catheter. Resident #6 stated they cleaned themselves.On 04/21/26 at 1:33 p.m., LPN #1 stated catheter care was to clean the indwelling catheter tubing and do peri-care each shift and change the catheter once a month.On 04/21/26 at 1:34 p.m., LPN #1 stated nurses were responsible for catheter care, but certified nurse aides could perform peri-care.On 04/21/26 at 1:35 p.m., LPN #1 stated Resident #6 did not have an order for catheter care. They stated there should be an order.On 04/21/26 at 1:40 p.m., RN #1 stated catheter care included the use of enhanced barrier precautions, cleaning of the catheter tubing during peri-care, and routine catheter change.On 04/21/26 at 1:51 p.m., RN #1 stated there should be a physician's order for catheter care to ensure documentation of completed care.On 04/22/26 at 9:37 a.m., the DON stated there was no documentation catheter care was completed for the resident since insertion.

Based on record review and interview, the facility failed to ensure anticoagulant medication was not administered without adequate monitoring for 2 (#1 and #2) of 5 sampled residents reviewed for unnecessary medication.MDS Coordinator #1 identified 15 residents received anticoagulant (blood thinner) medication resided in the facility. Findings: 1. A physician's order for Resident #1, dated 09/16/24, for Xarelto (anticoagulant medication) 15 mg one tablet by mouth one time a day related to atrial fibrillation. There was no order for monitoring side effects of the anticoagulant medication. An annual assessment Resident #1, dated 03/20/26, showed the resident had diagnoses which included coronary artery disease, atrial fibrillation, and heart failure. The assessment showed the resident received an anticoagulant medication. A care plan Resident #1, dated 04/01/26, did not include interventions for the use of an anticoagulant. Medication and treatment administration records for Resident #1 from 04/01/26 through 04/22/26 did not show anticoagulant monitoring for Xarelto. The record showed the medication was administered as ordered. On 04/23/26 at 11:43 a.m., LPN #2 stated they had monitored side effects for anticoagulant use but did not document monitoring was completed. 2. A physician order for Resident #2, dated 08/18/25, showed Eliquis (anticoagulant medication) 2.5 mg every 12 hours. A quarterly assessment for Resident #2, dated 02/26/26, showed the resident received an anticoagulant medication. A care plan for Resident #2, dated 03/13/26, did not show anticoagulant therapy or monitoring. Medication and treatment administration records for Resident #2 were reviewed 02/2026 through 04/2026. The records showed the medication was administered 02/2026 through 04/2026. There was no documentation to show any anticoagulant monitoring for Eliquis. On 04/21/26 at 2:30 p.m., LPN #1 stated anticoagulant monitoring was to see if there was bruising out of nowhere or a cut that would not heal and lab. They stated the anticoagulant monitoring was located under the lab section and they had not heard of monitoring anticoagulant medication. On 04/21/26 at 2:25 p.m., LPN #1 stated they only documented either in the nurse's notes or in an incident report if the bleeding took a while to stop or labs were ordered. They stated there was not any other documentation on paper for anticoagulant monitoring. On 04/21/26 at 2:29 p.m., the DON stated anticoagulant therapy monitoring was on the medication and treatment administration record and were checked off twice a day for nose bleeds, dark stools, blood in the urine, bruising and gums bleeding. On 04/21/26 at 2:32 p.m., RN #1 stated they only did documentation of monitoring for nose bleeds, dark stools, blood in the urine, bruising and gums bleeding when a resident received two or more blood thinners. They stated they used their nursing judgment for monitoring when not on two or more medications. They stated the instruction was given by their consulting pharmacist. On 04/22/26 at 8:49 a.m., RN #1 stated they went by the pharmacy recommendations for the medication. They stated signs and symptoms of bleeding included black tarry stools, nose bleeds, and that it would get reported to the nursing staff, and those residents were on routine labs. On 04/22/26 at 8:55 a.m., RN #1 stated staff was educated on what to monitor for but, that it was not documented anywhere. On 04/22/26 at 9:50 a.m., pharmacist #1 stated they would probably expect to see documentation of monitoring for signs and symptoms of bleeding for the use of anticoagulant medication.

Based on observation, record review, and interview, the facility failed to ensure gloves were used appropriately during wound care for 2 (#4 and #11) of 4 sampled residents reviewed for wounds.The DON identified five residents with wounds resided in the facility. Findings:1. On 04/21/26 at 10:39 a.m., LPN #1 was observed to don a gown and gloves to perform wound care for Resident #4.On 04/21/26 at 10:42 a.m., LPN #1 removed Resident #4's old coccyx wound dressing, cleansed the wound, and applied a new dressing to the resident's wound.LPN #1 did not change their gloves after removing the old dressing, cleaning the wound, and applying the new wound dressing for Resident #4. An undated facility Infection Control policy, read in part, Caregivers must wash their hands before contact with supply of clean dressing or dressing supplies, prior to the dressing or treatment.Once the hands of the caregiver are soiled with wound secretions, they should not come in contact with the remaining clean dressings and other supplies until the gloves are removed and hands washed.A quarterly assessment for Resident #4, dated 02/09/26, showed the resident had one unhealed pressure ulcer.A physician's order Resident #4, dated 04/16/26, showed to cleanse coccyx wound with an antiseptic solution, pat dry, apply calcium alginate (a wound dressing), cover with silicone dressing every day and as needed.2. On 04/21/26 at 11:34 a.m., LPN #1 was observed to don on a gown and gloves. They cleaned Resident #11's left pinky toe and applied new dressing.On 04/21/26 at 11:37 a.m., LPN #1 with the same gloves, cleaned Resident #11's left heel, patted dry, applied betadine (an antiseptic solution) to the wound, and left open to air.On 04/21/26 at 11:38 a.m., LPN #1 with the same gloves, cleaned Resident #11's right leg and applied clean dressing.LPN #1 did not change their gloves between cleaning Resident #11's wound and applying the new dressing. LPN #1 did not change their gloves after treating each wound. A quarterly assessment for Resident #11, dated 02/09/26, showed the resident had diagnoses which included peripheral vascular disease and coronary artery disease. The assessment showed the resident had an unhealed pressure ulcer.A physician's order for Resident #11, dated 04/09/26, showed to cleanse skin tear to lateral right lower extremity with normal saline, patted dry, apply triple antibiotic ointment, collagen, dry dressing, and secure with tape every day.A physician's order Resident #11, dated 04/16/26, showed:a. for the left pinky toe, continue with steri-strips, cover with xeroform (a medicated wound dressing), gauze, island dressing every day, andb. to cleanse left heel wound with normal saline, pat dry, apply betadine and leave open to air.On 04/21/26 at 1:36 p.m., LPN #1 stated the process for glove use during wound care was to change the gloves between each wound. They stated they probably forgot to change their gloves.On 04/21/26 at 1:37 p.m., LPN #1 stated they did not change their gloves between cleaning the wounds and applying new dressing unless their gloves became bloody.On 04/21/26 at 2:05 p.m., the DON stated the process for glove use during wound care was to change gloves after removing old dressing, use alcohol-based hand rub or wash hands, wear new gloves, finish wound care, and change gloves prior to applying new dressing. On 04/21/26 at 2:08 p.m., the DON stated gloves should be changed between multiple wounds on the same resident.

Based on observation, record review, and interview, the facility failed to ensure: a. 2:00 p.m. snacks were provided to one (#13) and, b. meal replacements were provided when residents consumed less that 50% of a meal for three (#19, 13, and 24) of three residents reviewed for nutrition. The Long Term Care Application documented 35 residents resided in the facility Findings: An undated, Dietary Services Policy, read in part Food Substitutes If resident refuse food, substitutes of similar nutrition shall be offered. Food substitutes shall be consistent with the usual and ordinary food items provided to residents. 1. Resident #19 had diagnoses which included pressure ulcer and protein calorie malnutrion. A Care plan, dated 03/06/24, documented to provide supplements if Resident #19 eats less than 50% of meals. A Dietary Flow record, dated June 2024, read in part, .Breakfast Replacement if 50% or less consumed .Lunch Replacement if 50% or less consumed .Dinner Replacement if 50% or less consumed . A Dietary Flow record, dated June 2024, did not contain documentation meal replacement had been provided four of 30 opportunities for breakfast, three of 30 opportunities for lunch, and four of 30 opportunities. On 07/08/24 at 1:57 p.m., the DON stated residents would be given a health shake if they did not eat much. The DON was asked where that would be documented. They stated on dietary sheets. The DON was shown Resident #19's dietary flow record for June 2024 that showed the missed opportunities for meal replacements. 41872 2. Resident #13 had diagnoses which included Alzheimer's and dementia. A care plan, dated 05/16/24, documented to provide Resident #13 a healthshake if they eat less than 50% and that the resident had to be fed and and to provide a snack two times a day at 10:00 a.m. and 2:00 p.m. A Dietary Flow record, dated June 2024, read in part, .Breakfast Replacement if 50% or less consumed .Lunch Replacement if 50% or less consumed .Dinner Replacement if 50% or less consumed . A Dietary Flow record, dated June 2024, failed to document meal placements had been provided for 13 of 30 breakfast opportunities, 11 of 30 lunch opportunities, and six of 30 opportunities for dinner. On 07/08/24 at 2:00 p.m., a staff member was observed passing snacks on Resident #13's hall. Resident #13 was observed asleep in their room. Staff was not observed to enter and offer a snack to the resident. On 07/08/24 at 2:09 CMA #1 was asked who had received 2 p.m. snacks. They stated they ask the residents who can respond. They were asked if they had offered a snack to Resident #13. CMA #1 stated no, that Resident #13 was asleep in bed. They were asked who documented meal percentages and health shakes offered and consumed. CMA #1 stated dietary. On 07/09/24 at 2:57 p.m., the DON was asked what staff would do if a was resident asleep and unable to feed themselves when snacks where passed. They stated if the resident is asleep and unable to feed themselves, whoever is passing snacks needs to feed it to them. 3. Resident #24 had diagnoses which included hypertension, dementia, and gastroesophageal reflux disease. A quarterly assessment, dated 05/07/24, documented the resident received a mechanically altered diet. A Dietary Flow record, dated June 2024, failed to document meal replacements had been provided for 22 of 30 breakfast opportunities, nineteen of thirty lunch opportunities, and thirteen of thirty opportunities for dinner. A Dietary Flow record, dated July 2024, failed to document meal replacements had been provided for one of eight breakfast opportunities, four of eight lunch opportunities, and four of seven opportunities for dinner. On 07/07/24 at 9:32 a.m., Resident #24 was observed in the dining room, a plate with raised edges and two cups with lids and a straw were observed in front of the resident. On 07/09/24 at 11:02 a.m., the MDS coordinator was asked if the physician had been notified about the resident refusing their meals. They stated there was nothing documented. On 07/09/24 at 2:43 p.m., the DON was asked who reviewed the dietary flow records to ensure the resident was eating. They stated the dietary supervisor. The DON was asked if the physician had been notified the resident had a decline in their meal intake. They stated any nurse could notify the physician. The DON stated they were not aware Resident #24 had not been eating. On 07/09/24 at 7:39 a.m., dietary aide #1 was asked what the process was for monitoring meal percentages. They stated they were supposed to go around and document what percentage the resident had eaten. They were asked what if the resident refuses their meal or eats less than 50 % or less. They stated they are to offer a shake or magic cup. They were asked where that would be documented. Dietary aide #1 stated in the meal percentages. The dietary manager was asked if they were aware Resident #24 had been refusing their meals in June and July. They stated they had been watching that. They were asked if they had notified the DON. They stated No.

Based on record review and interview, the facility failed to ensure annual competency reviews were completed for two (#1 and #2) of two staff reviewed for annual competency reviews. The Long Term Care Application documented 35 residents resided in the facility. Findings: CNA #1 and CNA #2's personnel files were reviewed for annual competency reviews. On 07/1024 at 1:14 p.m., the DON was asked if annual competency checks were completed. They stated no they are not done annually and there was no documentation checks had been completed for CNA #1 and CNA #2. 41872

Based on record review and interview, the facility failed to ensure the person designated to serve as the dietary manager had completed their certification for dietary management. The Long Term Care Application documented 35 residents resided in the facility. Findings: The dietary manager had been in that position since July 2021. On 07/10/24 at 8:19 a.m., the dietary manager was asked if they had their certificate for dietary management. They stated, No. On 07/10/24 at 8:29 a.m., the Administrator was asked how long the dietary manager had been in their position. They stated they were unsure. The Administrator was asked why the dietary manager had not received their certification. They stated the dietary manager had not gone to training.

Based on observation, record review, and interview, the facility failed to ensure dietary staff did not touch food with their bare hands during meal service. The Long Term Care Application documented 35 residents resided in the facility. Findings: An undated, Dietary Services policy, read in part Foods are prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements so as to avoid manual contact of prepared foods. On 07/07/24 at 8:13 a.m., the dietary manager was observed to remove a piece of bread from the package with their bare hands, place it in the toaster, remove it with their bare hand, brush butter on it, slice it then put it on a plate to serve to a resident. On 07/07/24 at 8:22 a.m., the dietary aide #1 was observed to split a biscuit using their bare hands, and place the biscuit on a plate. They were observed to cut up a piece of round sausage and was observed to touch the sausage with their fingers while cutting it up. They scraped the sausage from the plate onto the plate with the biscuit and then served to the resident. On 07/07/24 at 8:25 a.m., the dietary manager was asked what the policy was regarding touching food with bare hands and gloves. They stated it depended on what it was, if it was a meat product or eggs anything that could be a possible contamination, gloves should be worn.

Based on record review and interview, the facility failed to ensure residents were provided education and potential side effects of the influenza vaccine annually for three (#5, 6, and #13) of five residents reviewed for vaccinations. The Long Term Care Application documented 35 residents resided in the facility. Findings: 1. Resident #5's informed consent for influenza vaccination had been signed on 01/16/2019. The vaccine had been administered on 10/18/23. 2. Resident #6's informed consent for influenza vaccination had been signed on 06/21/22. 3. Resident #13's informed consent for influenza vaccination had been signed on 05/29/18. On 07/10/24 at 2:29 p.m., the DON was asked if residents/resident representatives were provided with education and possible side effects annually. They stated, starting this year, there will be.

Based on record review and interview, the facility failed to notify the physician of a resident who had a significant decline in their meal intake with weight loss for one (#24) of three reviewed for nutrition. The Long Term Care Application documented 35 residents resided in the facility. Findings: Resident #24 had diagnoses which included hypertension, dementia, and gastroesophageal reflux disease. A quarterly assessment, dated 05/07/24, documented Resident #24 received a mechanically altered diet. A Dietary Flow Record, dated June 2024, documented Resident #24 had refused or consumed less than 50% for 22 of 30 breakfast meals, 19 of 30 lunch meals, and 13 of 30 dinner's. A Dietary Flow Record, dated July 2024, documented Resident #24 had refused or consumed less than 50% for one of eight breakfast meals, four of eight lunch meals, and four of seven dinner meals. On 07/07/24 at 9:32 a.m., Resident #24 was observed in the dining room, a plate with raised edges and two cups with lids and a straw were observed in front of the resident. A weight entry form, documented Resident #24's weight was 120 pounds on 05/07/24 and was 112 pound on 07/08/24 for a 6.67 % weight loss. On 07/09/24 at 11:02 a.m., the MDS coordinator was asked if the physician had been notified about the resident refusing their meals. They stated there was nothing documented. On 07/09/24 at 2:43 p.m., the DON was asked who reviewed the dietary flow records to ensure the resident was eating. They stated the dietary supervisor. The DON was asked if the physician had been notified the resident had a decline in their meal intake. The stated any nurse could notify the physician. The DON stated they were not aware Resident #24 had not been eating.

Based on record review and interview, the facility failed to complete a significant change assessment for one (#34) of 14 residents reviewed for assessments. The Long Term Care Application documented 35 residents resided in the facility. Findings: An undated Resident Assessment Policy, read in part .Significant change assessments will be completed as soon as needed to provide appropriate care to the resident, but in no case, later than 14 days after determining a significant change in the resident's physical or mental condition has occurred . Resident #34 had diagnoses which included, Alzheimer's early onset and dementia. A quarterly assessment, dated 01/25/24, documented Resident #34 needed supervision or touching assistance with eating, and substantial or maximal assistance with toileting. A quarterly assessment, dated 04/23/24, documented Resident #34 needed partial to moderate assistance with eating, and was dependent on staff for toileting. On 07/09/24 at 2:29 p.m., the MDS coordinator was asked what constituted a significant change. They stated if there was a change in two or more areas that would be permanent. They were asked to review the January and April assessments; and asked if the Resident #34 had a significant change. They stated a significant change assessment should have been completed.

Based on record review and interview, the facility failed to ensure a physician response was documented for a dose reduction for one (#16) of five residents reviewed for unnecessary medications. The Long Term Care Application documented 35 residents resided in the facility. Findings: An Antidepressants policy, dated 08/01/09, read in part, .If continuation of the medication is deemed necessary, the physician indicated this in the resident's medical record .If the physician determined that the medication may be discontinued, the plan for tapering the dose and the target date for discontinuation are indicated in the resident's medical record .Contraindication to dose reductions must be described in the resident's medical record by the responsible physician . Resident #16 had diagnoses which included depression and Alzheimer's. A physician order, dated 01/02/23, documented Resident #16 was to be administered Sertraline 100 mg along with 25 mg to equal 125 mg dose one time a day. A Consultant Pharmacist's Medication Regimen Review, dated 02/05/24, read in part, This resident currently receives sertraline 125 mg daily. If in your medical opinion a dose reduction is warranted for this medication please provide a new order below -OR- Please provide a written rationale below describing why a dose reduction for this medication is clinically contraindicated. The form did not contain a response from the physician. On 07/09/24 at 12:18 p.m., the DON was asked if a GDR had been attempted for Sertraline. They stated they were not sure and would look. On 07/09/24 at 12:45 p.m., the DON stated they were unable to locate any documentation where the physician had responded to the GDR request, dated 02/05/24, for a decrease in Sertraline.

Based on record review and interview, the facility failed to ensure lab results were received in a timely manner for one (#34) of five residents reviewed for unnecessary medications. The Long Term Care Application documented 35 residents resided in the facility. Findings: Resident #34 had diagnoses which included Alzheimer's, early onset and dementia. A Physician Order, dated 12/01/23 documented to complete a CMP and CBC every six months in April and October. The clinical health record did not contain CMP lab results for April 2024. On 07/09/24 at 3:08 p.m., the MDS coordinator stated they had ordered the lab and it had been drawn on 04/02/24 but the CBC had clotted so the lab returned on 4/10/24 and collected the CBC. The MDS coordinator provided a copy of CMP results that had been received 07/09/24 They stated they had to call the lab and get the results for the CMP dated 04/02/24 it was not in the facility.

Based on observation, record review, and interview, the facility failed to ensure a controlled medication was documented timely and a discrepancy in the narcotic count was reported for one (#4) of three sampled residents whose narcotic counts were reviewed. The MDS Coordinator identified the resident census was 39 and there were 19 total residents receiving controlled medications. Findings: An Administration of Schedule 2 Medications policy, revised 08/07/2012, read in parts, . All Schedule 2 medications removed from storage for the purpose of administering doses to the resident will be entered onto the individual resident's Controlled Drug Receipt/Record/Disposition Form .Any discrepancies in the individual resident's Controlled Drug Receipt/Record/Disposition Form must be immediately reported to the Director of Nursing . Resident #4 had diagnoses which included leukemia and chronic pain. A physician's order, dated 10/05/23, documented Resident #4 was to be administered Hydrocod/APAP (Norco) 5/325mg tab one tablet by mouth every four hours as needed for pain. A Daily Pain Record documented, on 11/07/23 at 8:10 a.m., Resident #4 had a pain rating of six out of ten and complained of bilateral lower extremity pain. The November MAR documented Norco one tab was administered to Resident #4 by LPN #1 on 11/07/23 at 8:10 a.m. On 11/09/23 at 10:24 a.m., this surveyor conducted a count of Resident #4's Hydrocod/APAP (Norco) 5/325mg tablets with LPN #1 and observed a notation on the Controlled Drug Receipt/Record/Disposition Form, initialed by LPN #2 and LPN #3, which changed the amount of the Norco pills remaining from 14 to 13 tablets and stated the count had been corrected. Thirteen Norco tablets were observed. There was no explanation for the correction on the Controlled Drug Receipt/Record/Disposition Form nor in Resident #4's clinical record. LPN #1 reported they were not aware of the discrepancy and CMA #1 had performed the count of narcotics with the off going nurse that morning. On 11/09/23 at 3:08 p.m., LPN #2 was asked if the DON had been notified when they discovered the discrepancy in the Norco count for Resident #4 and documented on the Controlled Drug Receipt/Record/Disposition Form that count had been corrected during change of 3 p.m.-11 p.m. shift on 11/08/23. LPN #2 stated no. On 11/09/23 at 3:13 p.m., the DON was asked the facility policy for reporting discrepancies in the narcotic count. They stated any discrepancies were to be reported to her by phone call or text immediately. The DON was asked if the discrepancy in the Norco count for Resident #4, documented on the Controlled Drug Receipt/Record/Disposition Form at change of the 3 p.m. to 11 p.m. shift on 11/08/23 had been reported to her. She stated, No, I found out when you did, and I am investigating the reason right now. On 10/29/23 at 3:40 p.m., the DON reported they had reviewed the MAR and the Controlled Drug Receipt/Record/Disposition Form for Resident #4 and determined LPN #1 had not signed the medication out on the narcotic count sheet for the dose given 11/07/23 at 8:10 a.m. There was no documentation on the Controlled Drug Receipt/Record/Disposition Form for Resident #4 that Norco one tab had been removed and given at 8:10 a.m. on 11/07/23. On 10/29/23 at 3:50 p.m., the DON was asked how often narcotics should be counted. They stated every shift change. The DON acknowledged there had been five shift change opportunities, since 8:10 a.m. on 11/07/23, where the discrepancy in the Norco count should have been reported and corrected. The DON was asked if facility policy had been followed. She stated no.

Based on record review and interview, the facility failed to ensure the prescribing physician documented the rationale and duration for prescribing prn psychotropic medications for more than 14 days for two (#9 and #24) of five residents sampled for unnecessary medications. The DON identified five residents received prn psychotropic medications and 33 residents resided in the facility. Findings: A SEDATIVE/HYPNOTICS policy, revised 08/07/12, read in parts, . Residents receive sleep-inducing medication's only when medically necessary .hypnotic medication ordered on a PRN basis, or administered only .The continue need for hypnotic medication is reassessed periodically by the prescribing physician .If continuation of the medication is deemed necessary, the physician indicates this in the residents medical record .Contraindication to dose reductions must be described in the residents medical record by the responsible physician .The consultant pharmacist notifies the responsible physician, if any prescribed hypnotic, does not comply with these guidelines . 1. Resident #9 had diagnoses which included quadriplegia, scoliosis, anxiety disorder, and depressive episodes. A annual assessment, dated 05/25/23, documented Resident #9's cognition was intact. Resident #9's Pharmacy Communications, dated 02/27/23, 05/30/23 and, 06/12/23, read in parts, .This resident has been ordered a PRN psychotropic medication, which per CMS regulations .Psychotropic drugs should be limited to 14 days or less unless the prescriber documents the following information .if the attending physician or prescribing practitioner, believe that it is appropriate for PRN orders to be extended beyond 14 days, he or she should: document the rationale in the residence medical record, and indicate the duration for the PRN order . The pharmacy communications did not document the duration for the prn order for Temazepam 15 mg or the rationale and was unsigned by the physician. A Physician's Order, dated 02/27/2023, read in part, .Temazepam 15 mg .1 CAPSULE BY MOUTH ONE TIME A DAY BEDTIME AS NEEDED . Medication Administration records, documented Resident #9 received Temazepam 15 mg for 73 consecutive days from 04/01/23 through 06/22/23. On 06/22/23 at 10:47 a.m., The DON was shown the pharmacy communication, dated 06/12/23, and asked to show where the physician responded and documented the rationale for prn temazepam 15 mg and the duration. They stated, I cannot show you. I did not understand that procedure properly. The DON stated that they thought the resident seeing a physician every 30 days was sufficient to meet compliance. 2. Resident #24 had diagnoses of anxiety, depression, anemia, glaucoma, angina, and hypertension. A Physician's Orders, dated 03/27/2023, read in part, .Alprazolam Tab 0.25mg .1 Tablet by Mouth Every eight hours as needed . Medication Administration records, documented Resident #24 had received Alprazolam 0.25 mg prn eight days in the month of April 2023 and eight days in the month of May 2023. A Pharmacy Communication PRN Psychotropic Notice, dated 06/05/23, read in parts, .This Resident has been ordered a PRN psychotropic medication which per CMS regulations .should be limited to 14 days or less unless prescriber documents the following .Indication for use .document the rationale .duration for the PRN order . Resident #24's pharmacy communication dated, 06/05/23, did not document the duration for the PRN Order for Alprazolam tab 0.25mg or the rationale and was unsigned by the physician. On 06/23/23 at 9:34 a.m.,The DON was shown the pharmacy communication and was asked to show where the physician responded with a rationale to continue the medication. The DON stated, No, the physician did not document the rationale or time frame. They stated they thought psych services seeing the resident monthly covered the procedure. The DON was asked if the resident receive the prn medication for more than 14 days without a physician documenting the rationale and time frame. The DON stated, Yes.

Based on observation,record review and interview, the facility failed to ensure medication pass error rate was less than five percent for one (#27) of four sampled residents reviewed during the medication pass. There were 10 errors and 33 opportunities which resulted in a 30.3 % error rate. The DON identified 33 residents received medication from the facility Findings: Resident #27 had diagnoses which included malignant neoplasm of breast, anxiety, dementia, and high blood pressure. A Crushing of Medications policy, revised 08/07/12, read in parts, .The crushing of medications requires a Physician order .If crushing of the medication is authorized by physician the Pharmacy should be notified and documentation must be made in the resident's medical record . The Admission Orders and Plan of Care, dated 11/09/22, did not contain an order to crush or open medications. Physician's Orders, dated June 2023, did not contain an order to crush or open medications. On 06/22/23 at 7:26 a.m., CMA #1 was observed to prepare and crush the following medications to administer to Resident #27; a. Amlodipine 5 mg one tablet, b. Letrozole 2.5 mg one tablet, c. Levothyroxine 100 mcg one tablet, d. Magnesium Oxide 400 mg one tablet, e. Memantine 10 mg one tablet, f. Metformin 500 mg one tablet, g. Multivitamin one tablet, h. Oxybutynin 5 mg one tablet, i. Senna 8.5 mg one tablet, and j. Florastar 250 mg two capsules was opened. CMA #1 then mixed the medications with a spoonful of jelly and administered the medications to Resident #27. On 06/22/23 at 7:58 a.m., LPN #1 was asked if Resident #27 had physician orders to crush medications. They looked at the physician orders and stated, it was supposed to be on the start up (admission orders and plan of care). LPN #1 looked at the admission orders and plan of care and stated that's why it's not on the physician orders. LPN #1 stated there was no documentation on the admission orders and plan of care, so it did not get put on the physician orders. On 06/22/23 at 8:13 a.m., CMA #1 was asked what medications did they crush during the medication pass for Res #27. They stated all of them and they had opened the probiotic (Florastar) capsules. They were asked if there was an order to crush the medications. They looked at the physician order and admission orders and stated, I cannot find it. I don't see one.

Based on record review and interview, the facility failed to ensure Quality Assurance meetings were held quarterly. The DON identified 33 residents resided in the facility. Findings: A QA sign in sheet, dated 03/01/23, documented attendees of the March QA meeting. On 06/22/23 at 3:00 p.m., the DON was asked for QA meeting documentation. They stated the only sign in sheet was from 03/01/23. They were asked if they had any documentation for the other quarters since last year. They stated they had meetings in June 2022, September 2022, and January 2023, but did not have any sign in sheets or documentation about what had been discussed.

Based on record review and interview, the facility failed to ensure a water management system was in place to track and prevent waterborne diseases. The DON identified 33 residents resided in the facility. Findings: On 06/22/23 at 3:25 p.m., the Administrator was asked if the facility had a system in place to track and identify Legionella. They stated they were not aware they had to do that and did not have anything in place. The Administrator stated they had no policy related to Legionella.

An Immediate Jeopardy (IJ) situation was identified on 11/02/11 at 5:00 p.m., related to the facility's failure to maintain partially cooked hamburger meat at a safe temperature to prevent the potential for food borne illness. On 11/02/11 at 5:15 p.m., the Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ. At 5:15 p.m., the administrator was notified of the IJ situation. At 6:50 p.m., a Plan of Removal (POR) was reviewed. At 7:00 p.m., the OSDH and surveyors accepted the POR. The POR documented : "1.) The facility addresses the deficient practices: a.) Hamburger meat which was prepared was immediately thrown away by the Food Service Supervisor. b.) Facility repurchased additional 15 pounds of hamburger meat and hamburger meat was placed in walk in refrigerator to be cooked in the morning for lunch. c.) Dietary staff that were on premises were immediately trained by the administrator, that no meats were to be prepared the day before. d.) Dietitian will be here on 11/03/11 at 1:00 p.m., to inservice all dietary staff on food preparation which are subject to time and temperature control for safety (especially meats). e.) Dietitian will also provide on November 3, 2011 at 1:00 p.m. information related to Chapter 256 (sic) Food Service Establishment Regulations with emphasis on storage of left overs and time limitations and food safety guidelines. 2.) The measures taken to ensure the deficient practice will not occur: a.) Dietary staff will ensure all staff who are involved with food preparation do not cook any potentially hazardous foods that are subject to time and temperature control prior to time of use. b.) Also each dietary staff and Quality Assurance Coordinator will receive a copy of the Chapter 257 Food Service Establishment Regulations on November 3, 2011. 3.) The measures taken to ensure the deficient practice will not occur: a.) The facility administrator, and the Quality Assurance Coordinator will provide random oversight of food preparation and requirements for temperature control, as well as the contract dietitian during monthly visits. 4.) The facility will monitor its performance, the effectiveness of its interventions by: a.) The facility administrator and the Quality Assurance Coordinator will provide random oversight of food preparation and requirements for temperature control, as well as the contract dietitian, during monthly visits. 5.) Completion date: a.) All in-service will be completed by November 3, 2011 by 3:00 p.m." On 11/03/11 at 2:00 p.m., the registered dietitian completed the inservice for all of the dietary staff. At that time all of the dietary staff were interviewed separately. Each one of them voiced a knowledge of the required method of cooling foods and meats. At 4:00 p.m., the registered dietitian stated she had made a copy of the approved methods of cooling meats and placed it on the kitchen door. She also stated she was going to create a manual about safe food handling for the kitchen staff to refer to. On 11/03/11 at 4:35 p.m., the administrator was informed the IJ had been removed. The deficient practice remained at a widespread level of no actual harm with the potential for more than minimal harm. Based on observation, record review and interview, it was determined the facility failed to follow the approved method for cooling and storing meatloaf. Six hours after the meatloaves were prepared they both had an internal temperature above 70 degrees. This had the potential to affect 48 of 48 residents who consumed food prepared in the kitchen. The facility census was 48 residents. Findings: On 11/02/11 at 11:55 a.m., a tour of the kitchen was conducted with the dietary manager. At 12:05 p.m., the walk-in refrigerator was inspected. It contained two meatloaves which were covered with plastic wrap and stored in a shallow pan. They were labeled, "11/02/11 for Thurs." At 3:30 p.m., the dietary manager was interviewed. She was asked if she prepared foods in advance of the serving day. She said, "Just one day. I have a meatloaf in the refrigerator now that is to be served tomorrow for lunch." She was asked if the meatloaf had been thoroughly cooked. She said, "I cooked it this morning for two hours at 400 degrees until it was firm, covered it, placed it in an ice bath until it wasn't hot, and then placed it in the refrigerator. I'll carve it and cook it for one more hour before I serve it." She was asked how much the hamburger meat weighed. She said, "Fifteen pounds." She was asked if she had followed the approved method for cooling down the meatloaf. She stated that she had. She was asked if she obtained the temperature of the meatloaf when it was removed from the oven or when it was removed from the ice bath and placed in the refrigerator. She said, "No." At 4:58 p.m., the temperature of the meatloaves was obtained. One meatloaf had a temperature of 74.2 degrees Fahrenheit and the other one had a temperature of 72.4 degrees Fahrenheit. She was asked what time she had cooked the meatloaf. She said, "I cooked it from 9:00 a.m. until 11:00 a.m. I put it in an ice bath from 11:00 a.m. until 12:00 p.m., then I placed it in the refrigerator." She was asked if she had attended a safe food handlers course. She stated she had taken the course on line. The IJ situation existed because the meatloaf was cooked from 9:00 a.m. until 11:00 a.m. at 400 degrees (no documentation the meat had reached the kill zone for bacteria was provided), covered, placed in an ice bath for one hour, then placed in the refrigerator at 12:00 p.m. At no time during the process was the temperature of the meatloaf obtained. Six hours after it was removed from the oven it measured a temperature above 70 degrees. According to the federal State Operations Manual, Appendix PP, the two-step method of cooling meat requires the cooked foods temperature to be reduced from 135 degrees to 70 degrees within two hours and from 70 degrees to 41 degrees or colder within an additional four hours. Total cooling time should never exceed six hours.