Every finding on record at Katherine Healthcare

Based on interview and record review, the facility failed to complete the nutritional initial screener (NIS) for seven of eight residents (Resident 1, 2, 4, 5, 6, 7, and 8) upon admission. This failure had the potential for residents nutritional needs being unmet.Findings:Resident 1 was admitted to the facility on [DATE] with diagnoses which included severe protein-calorie malnutrition, muscle weakness, chronic metabolic acidosis (a long-term buildup of acid in the body fluids, usually caused by reduced kidney function or excessive acid production. It is frequently linked to chronic kidney disease (CKD), resulting in symptoms like fatigue, nausea, and rapid breathing).Resident 2 was admitted to the facility on [DATE] with diagnoses which included morbid obesity (a person carries enough excess weight that could significantly harm their health).Resident 4 was admitted to the facility on [DATE] with diagnoses which included gastric ulcer (an open sore in the stomach lining).Resident 5 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus (a condition that affects the insulin production that could cause sugar to build up in the blood stream).Resident 6 was admitted to the facility on [DATE] with diagnoses including obesity (having an unhealthy excess of body fat).Resident 7 was admitted to the facility on [DATE] with diagnoses including type II diabetes.Resident 8 was admitted to the facility on [DATE] with diagnoses including severe protein-calorie malnutrition, and type II diabetes mellitus.During an interview with the dietary manager (DM) on 5/5/26 at 10:07 a.m., the DM stated he would usually start the NIS upon residents admission, and then the registered dietitian (RD) would complete the NIS and lock it. The DM stated he did not see a nutritional assessment created and documented while he was on vacation from 12/26/25 through 1/26/26. The DM stated he completed a NIS for Resident 1 on 1/27/26.During a review of the facility's admission Report (AR) dated 12/26/25 through 1/25/26, the AR indicated the following:Resident 1 was admitted on [DATE] and had a Nutritional Initial Screener (NIS) was created on 1/27/26.Resident 2 was admitted on [DATE] and the NIS was created on 1/28/26.Resident 4 was admitted on [DATE] and the NIS was created on 2/6/26.Resident 5 was admitted on [DATE] and did not have a NIS created, only a Nutritional Quarterly/Annual Review (NQR) which was created on 4/15/26.Resident 6 was admitted on [DATE] and the NIS was created on 1/27/26.Resident 7 was admitted on [DATE] and the NIS was created on 2/23/26.Review of the email sent by the Administrator dated 5/28/26, indicated Resident 8 was admitted on [DATE] and Resident 8 did not have a NIS.During a telephone interview with the ADM on 5/28/26 at 10:50 a.m., the ADM confirmed Resident 8 was admitted on [DATE] and a NIS was not created.During a telephone interview with the registered dietitian (RD) on 5/28/26 at 3:12 p.m., the RD stated that the NIS should be finished within seven days of a resident's admission. The RD further stated the DM will start the NIS within the first day or two, then the RD will finish within seven days. The RD acknowledged some NIS were not done by the previous registered dietitian.Review of the facility's policy & procedure (P&P) titled Nutritional Assessment, revised October 2017, indicated Policy Statement - As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Policy interpretation and implementation - 1. The dietitian, in conjunction with the nursing staff and health care practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and is indicated by a change in condition that places the resident at risk for impaired nutrition.

Based on observation, interview and record review, the facility failed to protect one of three resident (Resident 1) from misappropriation of property (unauthorized use of someone else's property) when Resident 1's controlled medication (medications that are regulated due to higher risk of misuse) Lorazepam (used to treat severe anxiety) with 19 tablets were missing or unable to be located.This failure resulted in Resident 1 missing two doses of the medication and potential adverse health outcomes and violated patient rights.During an interview with Registered Nurse (RN) A, on 12/2/25 at 1:30 p.m., RN A stated he was counting the narcotics (used to treat moderate to severe pain) in the Station 2 medication cart with the night shift nurse (RN B) on 11/30/25. RN A stated he could not find a bubble pack containing the medication named Lorazepam (a controlled medication used to treat severe anxiety) 0.5 milligrams (mg, unit of measurement) for Resident 1. RN A stated three medication carts and 48 resident rooms were checked but were not able to find the medication. RN A called the pharmacy for a replacement of the medication and received the replacement on 12/2/25. RN A confirmed Resident 1 missed two doses of the medication Lorazepam tablet 0.5 mg give 1 tablet by mouth one time a day on 11/30/25 and 12/1/25 at 9 a.m.During an interview with RN B, on 12/2/25 at 1:52 p.m., RN B stated she worked the night shift on 11/29/25. RN B confirmed all narcotic medications were accounted for at the beginning of her shift on 11/29/25. At the end of RN B's shift on 11/30/25 around 7 a.m., RN B stated that RN A noticed a bubble pack of Lorazepam was missing during the count of the narcotics. RN B stated the narcotic record book for Resident 1's Lorazepam indicated there were 19 tablets remaining. RN B looked for the missing medication with RN A but were unable to locate it. RN B stated she did not know how the medication went missing during her shift.During an interview with RN C, on 12/23/25 at 3:53 p.m., RN C confirmed he was working the evening shift on 11/29/25 prior to RN B's shift. RN C stated all narcotics were accounted for during the count with RN B. RN C confirmed Resident 1's Lorazepam medication was counted during the count at the end of the shift with RN B. RN C and RN B signed the narcotic book indicating no medications in the medication cart was missing.During an interview with the Minimum Data Set Coordinator (MDSC), on 12/2/25 at 12:34 p.m., the MDSC stated she found a torn label of a medication at the bottom drawer of a bedside table in an empty resident room. The MDSC confirmed the label was from the missing medication of Resident 1. The MDSC stated the 19 tablets of Lorazepam were not found.During a concurrent interview and record review with the Director of Nursing (DON), on 12/2/25 at 12:50 p.m., the DON confirmed RN B and RN C signed the narcotic record book on 11/29/25 indicating all narcotics were accounted for. The DON stated Resident 1's Lorazepam medication with 19 tablets was accounted for on 11/29/25. The DON confirmed Resident 1's Lorazepam medication was missing during RN B's night shift on 11/29/25. The DON also confirmed the torn label found was part of the bubble pack of Resident 1's missing medication. The DON confirmed that the 19 tablets of Lorazepam was not found.Review of the facility's policy and procedure (P&P), titled Controlled Substances, dated 4/19, indicated Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together.Review of the facility's P&P, titled Resident Rights, dated 12/16, indicated Federal and state law guarantee certain basic rights to all residents of this facility. These rights include the resident's right to be free from.misappropriation of property.Review of the facility's P&P, titled Investigating Incidents of Theft and/or Misappropriation of Resident Property, dated 14/17, indicated Residents have the right to be free from theft and/or misappropriation of personal property.

Based on observation, interview and record review, the facility failed to meet the needs of one of three residents (Resident 1) when there was no accurate accountability of the controlled medication (medication that can be easily abused and are under strict government control) lorazepam 0.5 milligram (mg, unit of measurement) tablet.This failure resulted in Resident 1 not receiving two doses of the controlled medication.Findings:During an interview with Registered Nurse (RN) A, on 12/2/25 at 1:30 p.m., RN A stated he was counting the narcotics (used to treat moderate to severe pain) in the Station 2 medication cart with the night shift nurse (RN B) on 11/30/25. RN A stated he could not find a bubble pack containing the medication named Lorazepam (a controlled medication used to treat severe anxiety) 0.5 milligrams (mg, unit of measurement) for Resident 1. RN A stated three medication carts and 48 resident rooms were checked but were not able to find the medication. RN A called the pharmacy on 11/30/25 for a replacement of the medication. Per RN A pharmacy stated refill of the medication was too early and will need authorization from the Director of Nursing (DON). RN A stated the replacement medication was received on 12/2/25. RN A confirmed Resident 1 missed two doses of the medication Lorazepam tablet 0.5 mg give 1 tablet on 11/30/25 and 12/1/25 at 9 a.m.Review of Resident 1's physician's order, dated 9/24/25, indicated lorazepam oral tablet 0.5 mg give 1 tablet by mouth (taken orally) one time a day for anxiety (feeling of fear, worry or uneasiness) as evidenced by repetitive questions/verbalizations.Review of Resident 1's Medication Administration Record (MAR, a record of prescribed medications) indicated lorazepam was documented as not administered on 11/30/25 and 12/1/25.During a concurrent interview and record review with the DON, on 12/2/25 at 12:50 p.m., the DON confirmed Resident 1's Lorazepam medication was missing during RN B's night shift on 11/29/25. The DON confirmed that Resident 1 missed the dose of the medication on 11/30/25 and 12/1/25 at 9 a.m.During a concurrent observation and interview with the DON on 12/2/25 at 3:05 p.m., the DON confirmed there were no lorazepam in the five E-kits (Emergency Kits, a kit/box containing medications and supplies for immediate use during a medical emergency).Review of the facility's policy and procedure (P&P), titled Controlled Substances, dated 4/19, indicated The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications.

Based on observation, interview, and record review, the facility failed to ensure that infection control practices were implemented when: 1. Unlabeled personal care items; 2. Uncovered BiPAP (bilevel positive airway pressure, a machine used to help breathe by providing two different levels of air pressure through a mask) face mask; 3. No appropriate receptacle (a container to hold or store things) in room with contact precautions (CP: infection control measures used to prevent the spread of germs between residents) to discard used personal protective equipment (PPE: equipment worn to minimize exposure to infections and illnesses); 4. Cloudy urine in foley catheter (F/C: a thin, flexible tube inserted into the bladder [a body organ that stores urine] to drain urine) drain tube for Resident 8; 5. Appropriate hand hygiene between task while feeding residents was not followed. These above failures could result in the spread of infection and cross-contamination that could affect 43 residents who currently reside in the facility. Findings: 1.During room rounds on 9/2/2025 at 10:58 a.m., noted unlabeled gray color plastic wash basin (small plastic container used to provide personal hygiene for residents) in bathroom [ROOM NUMBER]. During room rounds on 9/2/2025 at 11:15 a.m., observed unlabeled small gray color plastic kidney shape basin with toothbrush and toothpaste inside in bathroom [ROOM NUMBER]. During an interview with certified nursing assistant D (CNA D) on 9/2/2025 at 11:30 a.m., CNA D confirmed above findings. CNA D stated above care items been in use and both bathrooms been shared between multiple residents. CNA D also stated resident's care items should have labeled, without label, these items would potentially use by unassigned residents and risk infection control. During an interview with facility's director of staff development/infection preventionist (DSD/IP) on 9/4/2025 at 2:07 pm., DSD/IP stated care items should be labeled to prevent use by unassigned residents for infection control practices. 2.During room observation rounds on 9/2/2025 at 11:37 a.m., noted uncovered BiPAP face mask, left on tray table when not in use in room [ROOM NUMBER] and no smoking sign posted. During an interview with registered nurse A (RN A) on 9/3/2025 at 1:56 a.m., RN A confirmed uncovered BiPAP face mask in room [ROOM NUMBER] and no smoking sign posted for this room. RN A stated mask should have been in a bag when not in use. During an interview with DSD/IP on 9/4/2025 at 2:07 pm., DSD/IP stated BiPAP face mask should have been in a bag when not in use. During an interview with facility's director of nursing (DON) on 9/5/2025 at 1:53 p.m., DON stated smoking sign should have been posted when using BiPAP machine for room [ROOM NUMBER], and BiPAP mask should be covered when not in use. 3. During room observation on 9/2/2025 at 10:40 a.m., noted CP sign posted outside on wall for room [ROOM NUMBER]. There was no closed lid receptacle available inside the room. During room rounds on 9/3/2025 at 1:25 pm., noted CP sign posted outside on wall for room [ROOM NUMBER]. There was no closed lid receptacle available inside the room. During an observation and interview with RN A on 9/3/2025 at 1:56 pm., RN A observed room [ROOM NUMBER] and 3 and confirmed there were no close lid receptacles available in both rooms. RN A stated should have placed closed lid receptacle to discard used PPE before coming out of these rooms. During an interview with facility's DSD/IP on 9/4/2025 at 2:07 p.m., IP stated rooms with CP to follow should have assigned receptacle to discard used PPE before coming out of the room for infection control. 4.During an observation on 9/5/2025 at 10:50 a.m., noted F/C urine collection drain tube with cloudy urine for Resident 8. Review of Resident 8's face sheet (FS: a document that provides resident's information at a quick glance) indicated Resident 8 was admitted to facility on 7/2/2022. Review of Resident 8's FS indicated Resident 8's diagnosis included obstructive and reflux uropathy (a condition in which the flow of urine blocked and flows backward). Review of Resident 8's order summary report indicated, Foley catheter 16 fr (fr: french, size of the F/C external diameter measurement) /10ml (ml: milliliter, a measure of volume equal to one thousandth of a liter) for., dated 8/9/2022. During an observation and interview with RN A on 9/5/2025 at 10:59 a.m., RN A confirmed F/C drain tube with cloudy urine for Resident 8. RN A stated urine should have been clear and amber color, not cloudy. RN A also stated will follow up with medical doctor. During an interview with DSD/IP on 9/5/2025 at 1:49 pm., DSD/IP stated urine draining from F/C should be clear and amber color, charge nurse will follow up with medical doctor today for cloudy urine for Resident 8. 5. During a lunch meal observation on 9/2/2025, at 12:12 p.m., on the second floor of dining room, there were two tables; Residents 19 and 36 sat down by a table facing each other and Resident 39 sat alone by the other table. At 12:25 p.m., Resident 39 was taken back to her room by a restorative nursing assistant C (RNA C). At 12:36 p.m. RNA C was back to dining room without performing hand hygiene, RNA C mixed food in plate for Resident 19 to scoop easy while eating. During a follow-up interview on 9/2/2025, at 12:45 p.m., with RNA C, RNA C confirmed that she should have performed hand hygiene before handling resident's food. During another lunch observation on 9/3/2025, at 12:36 p.m., on the second floor dining room, CNA F did not perform hand hygiene before to use Resident 18's spoon twice to encourage eating meal. During a follow-up interview on 9/3/2025, at 12:40 p.m., with CNA F, CNA F confirmed he should have performed hand hygiene before touching Resident 18's utensil to scoop food from the plate. Review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated August 2019, Before and after eating or handling food. Review f facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Non-Critical Resident-Care Items, revised June 2011, the P&P indicated, Single resident use items are for single resident use only. [NAME] with the resident's name and/or room number and discard upon transfer or discharge. Review of facility's P&P titled, CPAP (continuous positive airway pressure)/BiPAP Support, revised March 2015, the P&P indicated No SMOKING sign for the resident's room. Review of facility's P&P titled, Personal Protective Equipment- Using Gowns, revised September 2010, the P&P indicated, If the gown is disposable, discard it into the waste receptacle inside the room. Use gowns only once and then discard into an appropriate receptacle. After completing the treatment or procedure, gowns must be discarded in the appropriate container located in the room. If mask was used during the procedure(s) or service, remove it at this time and discard it into waste receptacle inside the room. Review of facility's P&P titled, Oxygen Administration, revised October 2010, the P&P indicated, Discard personal protective equipment in designated receptacles. Review of facility's P&P titled, Catheter Care, Urinary, revised September 2014, the P&P indicated, Check the urine for unusual appearance (i.e., color, blood, etc.). Observe for other signs and symptoms of urinary tract infection or urinary retention (difficulty urinating and emptying). Report findings to the physician or supervisor immediately.

Based on observation, interview and record review, the facility failed to follow its Policy and Procedures regarding oxygen administration for two out of six sampled residents (Resident 43 and Resident 3) when:1. No oxygen (O2: a colorless, odorless and tasteless gas, essential for life) administration order for Resident 43;2. O2 humidifier(a device, often a bottle contains water that adds moisture to dry supplemental O2 use) not adequately replaced for Resident 43;3. No O2 administration order, unlabeled oxygen tubing, and no oxygen in use sign posted for Resident 3;4. No care plan for O2 administration for Resident 3.These failures had the potential to affect sampled residents medical condition, well-being, and safety.Findings: 1. Review of Resident 43's clinical record indicated she was admitted to the facility on [DATE] with a diagnoses of dementia (a disorder of the brain that causes a person to lose their memory), ischemic cardiomyopathy (enlarging of the heart due to lack of oxygen), and acute on chronic systolic congestive heart failure (a worsening of the pump function of the heart on top of existing disease). During an observation on 9/2/25 at 12:46 p , Resident 43 was seen sitting on the side of the bed, wearing a nasal cannula (a type of oxygen delivery device through the nostrils). The O2 delivery rate was set at 2 liters (L, amount of oxygen delivered from an oxygen delivery device per minute). During a second observation on 9/4/25 at 1:56 p.m., Resident 43 was seen sitting on the side of the bed, talking to her son, wearing the nasal cannula. The oxygen device rate was set to 2 L. Review of Resident 43's physician orders on 9/4/25 at 2:00 PM indicated there was no documented evidence of physician order for oxygen administration. During an interview with the director of staff development/infection preventionist (DSD/IP) on 9/4/25 at 2:12 p.m., the DSD/IP stated there needs to be a physician order for oxygen administration to residents. During a concurrent interview and record review with the director of nursing (DON) on 9/4/25 at 2:26 p.m., the DON stated there needs to be an order to administer oxygen and currently there was no order for oxygen for Resident 43. 2.During an observation on 9/2/25 at 12:46 p.m., Resident 43 was seen receiving O2 via nasal cannula. The nasal cannula tubing was connected to a humidifier bottle, which was also labeled 9/2/25. During a second observation on 9/5/25 at 11:27 a.m., the humidifier bottle was seen half full, still labeled 9/2/25. During an interview with the DSD/IP on 9/5/25 at 12:31 p.m., the DSD/IP stated humidifier bottle was change whenever the bottle is empty. Review of facility policy and procedure (P&P) titled, Oxygen Administration, revised October 2010, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's order or facility protocol for oxygen administration. Review of facility P&P, titled, Departmental (Respiratory Therapy)-Prevention of Infection, revised 2011, the P&P indicated, Distilled water used in respiratory therapy must be dated and initialed when opened, and discarded after twenty-four (24) hours. 3. During an observation on 9/2/2025 at 11:44 a.m., noted Resident 3's bed side, unlabeled nasal cannula (NC) wrapped on humidifier, which was attached to room air concentrator (RAC: a medical device that filters room air to make pure O2) while Resident 3 was not in room, and RAC was turned off. NC progs (part of NC tubing goes into nose to deliver O2) was open to air. Oxygen in use sign was not posted for this room. Review of Resident 3's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 3 was admitted to facility on 8/8/2025. Review of Resident 3's FS indicated Resident 3 was admitted with diagnoses included chronic respiratory failure with hypoxia (a persistent inability to breath adequately, resulting in low levels of blood O2 levels), congestive heart failure (a chronic condition in which heart cannot pump blood efficiently, fluid buildup and difficult to breath), and end stage renal disease (loss of kidneys [ pair of body organs, responsible to filter waste and excess fluids from blood to produce urine] function to remove excess fluid from blood). Review of Resident 3's minimum data set (MDS: clinical assessment tool) dated 8/14/2025 indicated Resident 3's brief interview for mental status (BIMS) score of 14 (score of 0-7: severe cognitive impairment, 8-12: moderate cognitive impairment, 13-15: intact cognition), intact cognition. Review of Resident 3's order summary report noted no documented evidence of an order to administration O2 for Resident 3. During an interview with Resident 3 on 9/3/2025 at 1:35 pm., Resident 3 stated using O2 on and off for shortness of breath while in facility. During an observation and interview with registered nurse A (RN A) on 9/3/2025 1:56 pm., RN A confirmed NC tubing not labeled, uncovered and no oxygen in use sign posted for Resident 3's room. RN A also stated Resident 3 uses O2 as needed. RN A also stated nursing staff should have labeled NC when changed on weekly basis and placed NC tubing in a cover when not in use for infection control. RN A further stated this room should have posted sign for oxygen in use. 4. Review of Resident 3's care plans indicated there was no documented evidence of care plan for O2 use. During a concurrent record review for O2 orders, care plan for O2 and interview with director of nursing on 9/5/2025 at 9:43 am., DON confirmed there was no documented evidence of an order and care plan for oxygen administration for Resident 3. DON stated license nursing staff should have received an order to administer oxygen and care planned for use of oxygen for Resident 3. Review of facility's P&P titled, Oxygen Administration, revised October 2010, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility's protocol for oxygen administration. Place an Oxygen in Use sign on the outside of the room entrance door. Review of facility's P&P titled, Departmental (Respiratory Therapy)-Prevention of Infection, revised November 2011, the P&P indicated, Change the oxygen cannulae and tubing every seven (7) days, or as needed. Keep the oxygen cannula and tubing used PRN (pro re nata: as needed) in a plastic bag when not in use.

Based on observation, interview, and record review, the facility failed to ensure 3 out of 14 sampled residents (Resident 35, Resident 53, and Resident 3) were free from unnecessary medications when:1. Resident 35 received calcium acetate (brand name: Phoslo; medication to treat high phosphate [phosphorous] in the blood, in patients with end-stage renal disease [ESRD, a condition when the kidneys no longer function well enough to meet the body's needs]) for a wrong indication and not given with mealtimes as in accordance with the manufacturer's specifications. This resulted in inadequate indication and ineffective use of the medication to treat/prevent high phosphorous level.2. Resident 53 had an as-needed order for milk of magnesia (product containing magnesium, to treat constipation), a medication to avoid in residents that have ESRD. This had the potential for adverse effects (such as high magnesium level in the blood) for the resident 53.Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 9/2/25 at 10:25 a.m., RN A was observed administering 17 medications to Resident 35 including 2 tablets of calcium acetate (Phoslo) 667 milligrams (mg, unit of measurement). During an interview post medication administration, on 9/2/25 at 10:26 a.m., when asked when Resident 35 had his breakfast, RN A stated, I am not sure. A review of the Prescribing Information (PI; detailed information about a medication and its use) for calcium acetate, dated 3/2011, indicated it is a phosphate binder for the reduction of serum phosphorus in patients with ESRD. The PI indicated to take calcium acetate with each meal, as it combines with dietary phosphate to form an insoluble calcium phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration. During an interview with Resident 35 on 9/2/25 at 12:02 p.m., Resident 35 stated he ate breakfast around 7 a.m. (about 3 hours before receiving the calcium acetate). During an interview with Certified Nursing Assistant B (CNA B) on 9/2/25 at 2:54 p.m., she stated Resident 35 had his breakfast around 7:40 a.m., but she has not had a chance to document in the computer system yet. A review of Resident 35's clinical record indicated he was admitted to the facility with diagnoses including ESRD and kidney dialysis (medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so). Resident 35 had a physician's order, dated 2/13/25, for Calcium Acetate (Phosphate Binder), Give 2 tablet[s] by mouth two times a day for Supplement. It was scheduled to be administered daily at 9 a.m. and 7 p.m. A review of the facility's meal schedule indicated breakfast is scheduled daily at 7:10 a.m., and dinner at 5:10 p.m. During an interview with RN A and the Director of Nursing (DON) on 9/3/25 at 10:30 a.m., the DON stated the calcium acetate should be written for ESRD, not supplement; and should be given with meals. RN A confirmed he administered the medication to Resident 35 around 10 a.m. yesterday and not with a meal. RN A and the DON reviewed Resident 35's clinical record and confirmed it was scheduled daily at 9 a.m. and 7 p.m., not at or around mealtimes. They confirmed the medication has the wrong indication and wrong time of administration. On 9/3/25 at 10:50 a.m., a review of the 10-day administration history for Resident 35's calcium acetate, from 8/24/25 to 9/2/25, with the DON and RN A indicated was administered at the following days and times. They confirmed it was not given with meals. - 8/24/25 at 9:41 a.m. and 6:09 p.m. - 8/25/25 at 9:46 a.m. and 8:28 p.m. - 8/26/25 at 8:22 a.m. and 6:45 p.m. - 8/27/25 at 9:33 a.m. and 6:18 p.m. - 8/28/25 at 9:08 a.m. and 7:22 p.m. - 8/29/25 at 9:03 a.m. and 6:22 p.m. - 8/30/25 at 9:41 a.m. and 6:42 p.m. - 8/31/25 at 9:11 a.m. and 8:03 p.m. - 9/1/25 at 10:27 a.m. and 6:05 p.m. - 9/2/25 at 10:20 a.m. and 7:01 p.m. During a telephone interview with the Consultant Pharmacist (CP) on 9/3/25 at 12:16 p.m., he stated calcium acetate works by binding to phosphate in the food, it will not work to its capacity if not with meals. When questioned about the indication, the CP stated, Certainly for chronic kidney disease. Definitely not a supplement. The CP also stated medication administration with meals should be scheduled 7:30 a.m. for breakfast, and 5:30 p.m. for dinner. On 9/3/25, the facility provided Resident 35's laboratory report from the dialysis center. It indicated the following phosphorous levels and dates: Date Level 7/15/25 7.3 (normal level: 2.5 – 4.5) 7//29/25 7.2 8/02/25 8.9 8/26/25 6.8 A review of the facility's policy and procedures (P&P) titled Medication Therapy, revised 4/2007, indicated: 1. Each resident's medication regimen shall include only those medications necessary to treat existing conditions. All decisions related to medications shall include appropriate elements of the care process.Consideration of the clinical relevance of symptoms.conditions Upon or shortly after admission, and periodically thereafter, the staff and partitioner (assisted by the Consultant Pharmacist) will review an individual's current medication regimen, to identify whether: a. There is a clear indication for treating that individual with the medication. A review of the facility's P&P titled Administering Medications, dated 4/2019, indicated, Medication administration times are determined by resident need and benefit. Enhancing optimal therapeutic effect of the medication. 2. Review of Resident 53's clinical record indicated that Resident 53 was admitted to the facility on [DATE] with diagnoses including end stage renal disease (ESRD, failure of the kidneys to filter out toxins from the bloodstream and create urine), acute respiratory failure with hypoxia (difficulty with breathing caused by lack of oxygen), type 2 diabetes mellitus (a disease that causes elevated blood sugar levels), and unspecified dementia (a disorder of the brain that causes people to lose their memory). Review of Resident 53's physician orders indicated an order for aluminium and magnesium hydroxide-simethicone suspension 40 milligrams (mg, measuring amount) in 5 milliliters (mL, measuring liquid), give 10 mL, every 4 hours as needed for indigestion, heartburn, gas, nausea, dated 9/1/25. During an interview with the consulting pharmacist (CP) on 9/4/25 at 2:29 p.m., the CP stated Milk of Magnesium is not recommended for residents who are diagnosed with ESRD, and that on the next review he does for the facility, he would provide recommendation to discontinue. During an interview with the director of staff development/infection preventionist (DSD/IP) on 9/4/25 at 2:52 p.m., the DSD/IP stated there should not be an order for Milk of Magnesium for residents who receive dialysis, and that the order for Resident 53 would be discontinued.

Based on observation, interview and record review, the facility failed to maintain equipment and environment in safe operating and sanitary condition when; 1. Unsteady bed side commode (a portable toilet, chair like structure to accommodate different user heights) with missing floor grip pads and broken chest of drawers in room for Resident 40; 2. Penetrating holes in room [ROOM NUMBER] and bathroom [ROOM NUMBER]; 3. Red to dark brown color metal plumbing pipes and missing on and off button for light switch in bathroom [ROOM NUMBER]. Above failures had the potential to adversely affect the health and safety of residents in facility.Findings:1.During an initial room rounds on 9/2/2025 at 11:25 a.m., Resident 40 stated bedside commode was unsteady, missing floor grip pads for both legs on back, chest of drawers in the room, doors were not opening and closing appropriately, and both bottom drawers falling on floor when opened.Review of Resident 40's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 40 was admitted to facility on 8/20/2025.Review of Resident 40's minimum data set (MDS: clinical assessment tool) dated 8/26/2025 indicated Resident 3's brief interview for mental status (BIMS) score of 13 (score of 0-7: severe cognitive impairment, 8-12: moderate cognitive impairment, 13-15: intact cognition), intact cognition. During a concurrent observation and interview with facility's maintenance supervisor (MS) on 9/5/2025 at 8:41 a.m., MS confirmed Resident 40's bedside commode was unsteady due to missing floor grip pads on back legs and chest of drawers was broken. MS stated the bedside commode and chest of drawers were not safe to use for Resident 40. MS also stated he will replace both today.2. During initial room rounds on 9/2/2025 at 10:55 a.m., observed penetrating hole approximately 6 inches long on one side and 3 inches long on another side of light switch plate on the wall in bathroom [ROOM NUMBER]. During room rounds in room [ROOM NUMBER] on 9/2/2025 at 11:37 a.m., noted small penetrating holes x5 on the wall at the head of bed (HOB), and penetrating hole on the wall behind metal cover for heater near room door. During a concurrent observation and interview with facility's MS on 9/5/2025 at 8:41 a.m., MS confirmed penetrating hole on the wall around light switch plate in bathroom [ROOM NUMBER], penetrating holes x5 at HOB on the wall and one penetrating hole on wall behind metal heater cover in room [ROOM NUMBER]. MS stated these concerns would have been potential for safety for residents. MS also stated all above concerns should have been fixed as soon as possible.3. During room rounds in bathroom [ROOM NUMBER] on 9/2/2025 at 11:50 a.m., observed 3 metal plumbing pipes x3 with red to dark brown in color near the sink in bathroom [ROOM NUMBER] and missing on and off button for light switch on the wall in bathroom [ROOM NUMBER].During concurrent observation and interview with facility's MS on 9/5/2025 at 8:41 a.m., MS confirmed metal plumbing pipes x 3 with red to dark brown in color and missing on and off button for light switch in bathroom [ROOM NUMBER]. MS stated these metal pipes got rusted badly due to water use in the bathroom and on and off button broken for light switch. MS also stated he should not have rusted plumbing pipes in resident's bathroom. MS further stated he would remove rust and paint all these pipes, if unable to remove rust, will replace with new pipes and replace on and off button for light switch. Review of facility's policy and procedure (P&P) titled, Maintenance Service, revised December 2009, the P&P indicated, The maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. Maintaining the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to ensure to implement comprehensive person-centered care plan for two of 14 sampled residents (Resident 4 and 29) when:Bilateral (both) heel boots were not applies while in bed for Resident 4;Floor mat (padded mat to reduce the risk of serious injury from fall) was not placed while Resident 29 was in bed. Above these failures had potentially affect Resident 4 and 29 's quality of care for prevention of pressure ulcer and injury in the facility. Findings: 1. During a review of Resident 4's physician order dated 4/29/25, it indicated, Keep weight off heels: use heel boot on right foot while in bed and check placement every shift (QS). During a review of Resident 4 's care plan for the potential impairment to skin integrity, revised on 8/6/25, care plan indicated, Boots to heels when in bed for preventative measure. During an observation on 09/02/2025, at 10:19 a.m., Resident was in bed and there were bilateral boot left on the bedside table. No pillow under her feet for offloading pressure for both feet.During an interview on 09/02/2025, at 2:40 p.m., with certified nursing assistant D (CNA D), CNA D confirmed she did not apply boots for Resident 4's legs until afternoon. 2. During a review of Resident 29's physician orders dated 2/14/23, it indicated, Floor mat left side of bed to decrease risk for injury.During a review of Resident 29's care plan for a floor mat to left side of bed o decrease risk for injury, dated 4/10/23, it was indicated the goal for Resident 29 was free from injury from device usage. During an observation on 09/02/2025, at 10:45 a.m., Resident 29 was in bed watching a television. Her bed was against the wall to the right side of bed and there was no floor mat on left side of her bed. During an interview on 9/3/25, at 12:45 p.m., with CNA D, CNA D confirmed there was no floor mat on Resident 29's left side of the bed. CNA D stated that Resident 29's floor mat should have been placed to her left side of bed to prevent injury. During an interview on 9/5/25 at around 9 a.m., with director of nursing (DON) and director of staff development (DSD), DON and DSD both confirmed above findings and stated nursing staff should have followed orders and implemented care plans for Resident 4 and 29. Review Of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on observation, interview, and record review, the facility failed to ensure to provide a restorative nurse assistant (RNA, a nursing program to increase and/or to prevent decrease in range of motion [ROM, the extent or limit to which a part of the body can be moved around a joint or a fixed point] exercise) program for one of 14 sample resident (Resident 4 ). Above this failure had the potential to result in further decline of ROM for sample Resident 4. Findings: 1. During a review of Resident 4's clinical record indicated she had diagnoses including Parkinson disease (a brain disorder that causes problems with movement, such as tremors (shaking), stiffness, and slow movement) and muscle weakness (a lack of muscle strength). Review of Resident 4's minimum data set (MDS, an assessment tool) assessment dated [DATE], she was totally dependent on her activities of daily living (ADL, such as eating, grooming, dressing, walking, transferring, and toileting). Resident 4 had impaired ROM on both sides of upper and lower extremities (hands and legs). During a review of Resident 4's order summary record indicated , RNA program: active assisted range of motion (AAROM, ability of a joint to move without external assistance) to passive range of motion (PROM, unable to move a joint without assistance) of bilateral lower extremities (BLE) 10 reps (repeat) x3sets, 3x/week (3 times per week) to maintain mobility of BLE, dated 10/29/2024.During a review of Resident 4's order summary record indicated, RNA program: Right upper extremity resting hand splint (a medical device to support and limit movement of the hand and wrist) and left upper extremity hand roll 5x/ week for 4 to 6 hours to prevent further wrist/digits contracture (joints stiffen and shorten), dated 4/11/2025.During a review of Resident 4's RNA monthly summary (treatment progress and resident's response) dated 7/31/25, it was indicated Resident was provided ROM on BLE to maintain strength and mobility. There is no improvement, both hands and legs are stiff. She screamed when I attempted to put on the handroll and the splintDuring a review of Resident 4's RNA weekly summary from 5/2025 to 8/5/25 (total of 16 weeks) indicated there were no documented evidence of weekly summary for the week of 5/2/25, 5/9/25, 5/16/25 , 7/18/25, 7/25/25 and 8/1/25 (total 6 weeks). During an observation on 9/2/25, at 10:19 a.m., Resident was lying in bed and her bilateral hand noted with contractures. During an interview with RNA C on 9/8/25, at 10:22 a.m., RNA C stated Resident 4's bilateral extremities were stiff than before. RNA C further stated she was on vacation during the weeks of 5/2/25, 5/9/25, 5/16/25 , 7/18/25, 7/25/25 and 8/1/25 and the RNA services should have been covered by the certified nursing assistants (CNAs) while she was gone for vacation. RNA C confirmed there should have been RNA services provided to Resident 4 and there were no written documents in place when RNA services were provided during those weeks of 5/2/25, 5/9/25, 5/16/25 , 7/18/25, 7/25/25 and 8/1/25. Review Of the facility's policy and procedures (P&P) titled, Restorative Nursing Services, revised July 2017, the P&P indicated, Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical [a healthcare profession that focuses on improving and restoring physical function], occupational [a healthcare profession that helps to improve ability to perform daily activities] or speech [focuses on assessing and treating disorders related to speech and swallow difficulties] therapies).

Based on interview and record review, the facility failed to ensure one out of 18 sampled resident (Resident 5) was appropriately treated for a urinary tract infection (UTI, an infection of the bladder [body organ that collects urine] which causes burning while urinating, abdominal pain and blood in the urine) with an appropriate medication as ordered by the physician. This failure had the potential for further progress of UTI and affect Resident 5's overall health condition.Findings:Review of Resident 5's clinical record indicated he was admitted on [DATE] with diagnoses including acute kidney failure (failure of the kidneys [pair of organs that produces urine], due to an outside cause such as other diseases or infection), hepatorenal syndrome (a complication of advanced liver [a large organ in the digestive system] disease that affects the kidneys), spontaneous bacterial peritonitis (an infection in the abdominal area due to bacteria) and Unspecified Cirrhosis (destruction of healthy liver tissue). Review of Resident 5's clinical record further indicated he was sent to an acute care hospital (AH, a healthcare facility that provides short-term intensive medical treatment) emergency department (ED, a specialized hospital unit that provides unscheduled medical care for acute and severe illnesses) on 8/9/25, diagnosed with a UTI and returned back to the facility on the same day, with a medication order for cephalexin (a type of antibiotic medication used to treat UTI) 500 milligram (mg, unit of measurement) every six hours for seven days. It was then ordered in the facility and given to the resident from 8/10/25 until 8/16/25. Review of Resident 5's document from AH's ER (emergency room/ED) Report dated 8/11/2025 indicated, the ED physician documented an addendum: I saw this patient 2 days ago in the emergency department. He (Resident 5) had some abdominal discomfort and UA (urinalysis, a test that examine a urine sample to detect and analyze various substances) was concerning for UTI. He was placed on Keflex [cephalexin]. Unfortunately his UA is growing out an ESBL (extended spectrum beta lactamase, a group of enzymes [help for the chemical reactions in our body] produced by certain bacteria that make them resistant [medication becomes less effective or completely ineffective] to wide range of antibiotic medications) E coli (a type of bacteria that normally harmless) Resistant to cephalosporins. However, there was sensitivity [easily able to be treated with another antibiotic medication] to Macrobid (an antibiotic medication used to treat UTI).I sent the new Macrobid to the pharmacy. Attempted to contact his nursing facility however there has been no answer. The AH physician documented giving an order for macrobid 100 mg every 12 hours for seven days.During a concurrent interview and record review with the director of staff development/infection preventionist (DSD/IP) on 9/5/25 at 9:04 a.m., the DSD/IP reviewed Resident 5's physician orders, and confirmed there was no documented evidence for an order of Macrobid, or administration of Macrobid for Resident 5.During a concurrent interview and record review with the DSD/IP on 9/5/25 at 11:00 AM, the DSD/IP verified she had asked the AH to send the ED documentation for Resident 5 on 8/11/25, two days after the resident returned from the AH ED, and confirmed she received the AH ED documentation on 8/18/25. The DSD/IP also stated she did not follow up on Macrobid physician order from the AH ED physician and Resident 5 did not receive Macrobid as ordered by the physician.Review of facility policy and procedure (P&P) titled, Medication and Treatment Orders, revised 2016, indicated, Drugs and biological orders must be recorded on the Physician's Order Sheet in the resident's chart.Review of facility P&P titled, Antibiotic Stewardship, revised 2016, indicated, When a resident was admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders.

Based on observation, interview, and record review, the facility failed to ensure residents receiving dialysis (medical treatment that filters blood to remove waste and excessive fluids from body to sustain life) treatment received care consistent with professional standards for two of three sampled residents (Resident 3 and 35) when:1. Inadequate communication from dialysis center (a place which provides dialysis treatment) to nursing facility for Resident 3; 2.Order for milk of magnesia (MOM: medication used to treat constipation [problem with passing stool]) for Resident 3 with dialysis status;3.Antibiotic (medication used to treat infection) order was not discontinued as ordered for Resident 3;4.No documented evidence for side effects (S/E, unwanted or unexpected effects that occur when taking medication) monitoring for use of antibiotic medications x2 for Resident 3;5.Dialysis emergency kit (to prepare for emergency where regular dialysis treatments may be unavailable to manage condition) not available and fluid intake (amount of fluids taken) and output (amount of fluids left the body) not monitored for Resident 35.These above deficient practices had the potential for sampled residents to be inadequately assessed and be at risk for complications for medical health and well-being.Findings: 1.Review of Resident 3's dialysis communication record (DCR), dated 8/9/2025 and 8/23/2025 indicated, dialysis center did not complete Resident 3's dialysis visit/treatment information, this section of the form was left blank on both dates. Review of DCR dated 8/14/2025 indicated partially completed with Resident 3's dialysis visit/treatment by dialysis center. Review of Resident 3's face sheet (FS: a document that provides resident's information at a quick glance) indicated Resident 3 was admitted to facility on 8/8/2025. Review of Resident 3's FS also indicated Resident 3 admitted with diagnoses included end stage renal disease (ESRD, a condition where the kidneys [a pair of bean-shaped body organs that filter waste and excess fluid from blood to produce urine] permanently failed, lost the function), dependence on renal dialysis, and cellulitis (bacterial infection of skin and the tissues beneath the skin) of left lower limb (leg). Review of Resident 3's order summary report indicated, Dialysis: Dialysis Center. On Tuesday, Thursday, Saturday. Chair time: 9:00 AM pick up at 8:00 AM. During record review of dialysis communication record for Resident 3 and interview with registered nurse A (RN A) on 9/5/2025 at 10:32 a.m., RN A confirmed above DCA were not completed by dialysis center for scheduled dialysis treatment visits for Resident 3. RN A stated dialysis center should have complete required information to communicate and coordinate care with facility for Resident 3. RN A also stated facility will reach out to dialysis center for incomplete DCR. 2. Review of Resident 3's order summary report indicated Milk of Magnesia Suspension 2400 MG (milligram, unit of mass, equal to one thousandth of a gram)/30 ML (milliliter, unit of volume, equal to one thousandth of a liter) Give 30 ml for constipation if no bowel movement in 2 days, dated 8/8/2025. During an interview over the telephone with facility's consultant pharmacist (CP) on 9/4/2025 at 2:29 p.m., CP stated it would not recommend medication MOM for residents who depended on dialysis due to risk for increase magnesium levels and impaired kidneys were not able to remove excess magnesium from body. PC also stated will discuss with facility for MOM order for residents with dialysis status during his next visit. During an interview with director of nursing (DON) on 9/4/2025 at 2:52 p.m., DON confirmed a physician order for MOM for Resident 3. DON stated MOM contraindicated for residents with impaired kidney function and dialysis status. Resident 3 should not have an ordered MOM due risk of increased magnesium levels if taken. 3.Review of Resident 3's order summary report indicated Cefazolin (antibiotic medication used to treat bacterial infections) medication order was not discontinued on 8/26/2025 as ordered. Review of Resident 3's order summary report indicated, Cefazolin 1gm (gm: gram, a unit of weight, equal to one thousandth of kilogram) IV (intravenous, a needle inserted into a vein to administer fluids and medications into blood stream) will be given at dialysis center during dialysis days, dated 8/13/2025. Review of Resident 3's discharge summary from acute hospital (a healthcare facility that provides short-term intensive medical treatment with sudden and severe illnesses or injuries) dated 8/8/2025 indicated, Continue IV Ancef (brand name for cefazolin) x 6 weeks (stop date August 26,2025). During an interview with facility's director of staff development/infection preventionist (DSD/IP) on 9/4/2025 at 1:49 p.m., DSD/IP confirmed Resident 3's medication Cefazolin order was not discontinued on 8/26/2025 as stop order received from acute hospital. DSD/IP stated should not have continued cefazolin order to receive at dialysis center after 8/26/2025. 4.Review of Resident 3's clinical record indicated there was no documented evidence of facility monitored S/E for use of two different antibiotic medications. Review of Resident3's order summary report indicated, Cefazolin 1 gm IV will be given at dialysis center during dialysis days, dated 8/13/2025, and Cephalexin 500 MG give by mouth two times a day for cellulitis to LLE (left lower extremity), dated 8/8/2025. During an interview with facility's DSD/IP on 9/4/2025 at 1:49 pm., DSD/IP confirmed there was no documented evidence for facility monitored S/E when received two different antibiotic medications for Resident 3. DSD/IP stated nursing staff should have monitored and documented S/E every shift for Resident 3. During a telephone interview with CP on 9/4/2025 at 2:29 pm., CP stated facility should have monitored S/E for antibiotic medications for Resident 3. CP also stated she would recommend monitoring for S/E for Resident 3 due to impaired kidney function and dialysis status to identify drug toxicity (adverse effects that occur when too much of medication in system) and interactions. CP further stated would have missed to identify and recommend above concern to facility. During an interview with facility's DON on 9/4/2025 at 2:52 p.m., DON stated should have S/E monitoring for Cefazolin and Cephalexin medications for Resident 3. DON also stated nursing staff should have monitored and documented for S/E for both antibiotic medications for Resident 3. Review of facility's policy and procedures (P&P) titled, Coordination of Care of Residents on Dialysis, undated, the P&P indicated, The Dialysis Center communicates changes in medication or lab abnormalities in the same form. Review of facility's P&P titled, End-Stage Renal Disease, Care of a Resident with, P&P revised September 2010, the P&P indicated, Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. The type of assessment data that is to be gathered about resident's condition on a daily or per shift basis; How information will be exchanged between the facilities; Review of facility's P&P titled, Antibiotic Stewardship, revised December 2016, the P&P indicated, when a resident is admitted from an emergency department (a specialized unit in acute hospital that provides immediate medical care for urgent or life threatening conditions), acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Review of facility's P&P titled, Antibiotic Stewardship-review and Surveillance of Antibiotic Use and Outcomes, revised December 2016, the P&P indicated, All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The information gathered will include: Outcome; and Adverse events. 5.During review of Resident 35's clinical record indicated Resident 35 was admitted to the facility on [DATE] and had diagnoses including end stag of renal disease and dependence on renal dialysis. He was scheduled for dialysis every Tuesday, Thursday, and Saturday. During an observation on 9/3/2025, at 8:35 a.m., Resident 35 had a permacath (long, flexible tube inserted into a vein most commonly in the neck and into the heart to allow dialysis to occur) covering with clean dry dressing to his right chest. During a review of Resident 35's physician orders, dated 7/8/2025, indicated he had a hemodialysis catheter for dialysis via right chest permacath and was scheduled to go to a dialysis center three times a week. During a review of Resident 35's care plans indicated he had two care plans to address dialysis; the first care plan for dialysis with revision date of 3/18/25 had interventions including monitoring intake (total amount of fluids taken) and output(total amount of fluids out from body) and fluid restrictions (limit of fluids) 1400 milliliters (ml, unit of measurement for amounts) per day (24 hours), and the second care plan of dialysis dated 9/3/25 with intervention for emergency kit at bedside including gauze dressing, wrap bandage and tape. During an interview on 9/03/2025 at 9:17 a.m. and 9/5/2025 at 8:40 a.m., with registered nurse A (RN A), RN A stated he did not receive training to deal with emergency situation of hemodialysis residents, and he was not familiar with where the emergency kit was stored at the beginning of interview on 9/3/2025 and during an interview on 9/5/25 he was able to explain the emergency kit was stored in medication cart (mobile cart used to store, organize and transport medications for residents). RN A further stated if Resident 35 had bleeding at dialysis access site, he would just call 911(a phone number used to contact the emergency services). During a concurrent interview and record on 9/5/25, at 10:11 a.m. and 12:55p.m.,with minimum data set (MDS, clinical assessment tool) coordinator (MDSC), she reviewed Resident 35's care plans for dialysis, stated facility did not monitor Resident 35's intake and output as a intervention for resident with dialysis status. During a review of the facility's P&P titled, End of Stage Renal Disease (ESRD), Care of a Resident With, revised 9/2010, the P&P indicated, Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.How to recognize and manage equipment failure or complications (according to the type of equipment used in the facility);. How the care plan will be developed and implemented. Review of facility's P&P, titled, Coordination of Care of Residents on Dialysis, undated, the P&P indicated, Ensure Dialysis Emergency Kit is available at bedside at all times.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled substances (that can be easily abused and are under strict government control) when controlled medications were signed out of the controlled drug record (CDR, an accountability sheet of controlled medications) but not documented on the medication administration record (MAR) to show they were administered for 2 out of 4 residents (Residents 54 and 55). This resulted in facility not having accurate accountability and the potential for abuse/loss of controlled medications.Findings: During the survey, the CDRs for 4 residents receiving as-needed medications were requested for review.During a concurrent interview and record review with the Director of Nursing (DON) and Registered Nurse (RN) A on 9/3/25 at 10:37 a.m., the DON stated whenever an as needed controlled medication is requested by a resident, the nursing staff needs to assess the resident, remove the medication from the medication cart, sign it out of the book (the CDR), and document the administration on the MAR.a. A review of Resident 54's clinical record indicated she had a physician's order, dated 6/28/25, for hydrocodone/acetaminophen (brand name: Norco, a narcotic for pain) 5/325 milligrams (mg, unit of measurement), 1 tablet by mouth every 4 hours as needed for severe pain.On 9/03/25 at 10:40 a.m., a review of Resident 54's CDR for Norco 5/325 mg and July 2025 MAR with the DON and RN A indicated a nursing staff signed out 1 tablet of Norco 5/325 mg but did not document the administration on the MAR on 7/16/25 at 10:30 p.m. Both staff verified this finding.b. A review of Resident 55's clinical record indicated she had a physician's order, dated 6/24/25, for hydrocodone/acetaminophen 5/325 mg, 1 tablet by mouth every 4 hours as needed for moderate to severe pain.During a concurrent interview and record review with the DON and RN A on 9/03/25 at 10:44 a.m., a review of Resident 55's CDR for Norco 5/325 mg and July 2025 MAR indicated the nursing staff signed out the Norco but did not document the administration on the [DATE] occasions: on 7/1/25 at 11:06 p.m.; 7/5/25 at 2:18 a.m., and on 7/6/25 at 0:13 a.m. RN A reviewed these documents and confirmed they were not documented on the MAR. Both the DON and RN A stated they should have been documented on the MAR to account for the medications.A review of the facility's policy and procedures titled Administering Medications dated 4/2019, indicated: The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered .

Based on observation, interview, and record review, the facility had a medication error rate of 7.89% when three medication errors occurred out of 38 opportunities during the medication administration for three out of six residents (Residents 3, 27, and 35). Resident 35 did not receive calcium acetate (brand name: Phoslo; medication to treat high phosphate in the blood, in patients with end stage kidney disease) as in accordance with the manufacturer's specifications; Resident 27 received an insulin (medication to lower blood sugar) injection not in accordance with the manufacturer's specifications; and Resident 3 did not receive his metoprolol (medication to treat high blood pressure [BP]) as ordered.The failures resulted in the residents not receiving medications as prescribed or per manufacturer's specifications, which had the potential for complications of their medical conditions (such as high phosphate level, high blood sugar, or high BP).Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 9/2/25 at 10:25 a.m., RN A was observed administering 17 medications to Resident 35 including 2 tablets of calcium acetate (Phoslo) 667 milligrams (mg, unit of measurement).During an interview post medication administration, on 9/2/25 at 10:26 a.m., when asked when Resident 35 had his breakfast, RN A stated, I am not sure.During an interview with Resident 35 on 9/2/25 at 12:02 p.m., Resident 35 stated he ate breakfast around 7 a.m. (about 3 hours before receiving the calcium acetate).During an interview with Certified Nursing Assistant B (CNA B) on 9/2/25 at 2:54 p.m., she stated Resident 35 had his breakfast around 7:40 a.m. but she has not had a chance to document in the computer system yet.A review of Resident 35's clinical record indicated he was admitted with diagnoses including end-stage kidney disease (when the kidneys no longer function well enough to meet the body's needs); and a physician's order, dated 2/13/25, for Calcium Acetate (Phosphate Binder), Give 2 tablet by mouth two times a day for Supplement. A review of the Prescribing Information (PI; detailed information about a medication and its use) for calcium acetate, dated 3/2011, indicated to take calcium acetate with each meal. The PI indicated, Calcium acetate (PhosLo(R)), when taken with meals, combines with dietary phosphate to form an insoluble calcium phosphate complex, which is excreted in the feces, resulting in decreased serum phosphorus concentration.During an interview with RN A and the Director of Nursing (DON) on 9/3/25 at 10:30 a.m., the DON stated the calcium acetate should be written for end-stage kidney failure and should be given with meals. RN A confirmed he administered the medication around 10 a.m. yesterday and not with a meal.2. During a medication administration observation with Licensed Vocational Nurse (LVN) E on 9/2/25 at 4:24 p.m., she was observed drawing up into a syringe 3 units of insulin lispro (a short-acting insulin) for Resident 27.On 9/2/25 at 4:25 p.m., at Resident 27's bedside, LVN E injected the insulin into the resident's right lower abdomen. On 9/2/25 at 4:28 p.m., when asked when dinner is served, LVN E stated the resident gets dinner a little after 5 p.m.A review of Resident 27's clinical record indicated an order, dated 8/25/25, for insulin lispro injection solution 100 units/ milliliter, to inject as per sliding scale (set of instructions for administering insulin dosages based on specific blood sugar readings) before meals and at bedtime. The afternoon dose was scheduled daily at 4:30 p.m.During a concurrent interview and record review with LVN E on 9/2/25 at 5:10 p.m., LVN E stated Resident 27 typically gets her insulin dose around 4 p.m. because it is scheduled daily at 4:30 p.m.; and with insulin, she would typically give it about 30 minutes before or after due time. A review of the online Prescribing Information for insulin lispro, revised 9/2023, with LVN E indicated, Administer Insulin Lispro by subcutaneous injection into the abdominal wall.within 15 minutes before a meal or immediately after a meal. LVN E verified that it has been 45 minutes since she administered the insulin to Resident 27, and the resident has not received her dinner yet.On 9/2/25 at 5:17 p.m., the dinner cart was observed being brought in the hallway where Resident 27's room was located. By 5:20 p.m. (almost an hour after the insulin administration), no dinner tray was brought into Resident 27's room yet.During a telephone interview with the Consultant Pharmacist (CP) on 9/3/25 at 12:16 p.m., he stated sliding scale insulin lispro should be given within 15 minutes of a meal.3. During a medication administration observation on 9/3/25 at 8:34 a.m., RN A was observed assessing Resident 3's BP. The BP reading was 179/98 (high; normal BP for adults is typically defines as less than 120/80).On 9/3/25 at 8:45 a.m., RN A was observed administering 7 medications to Resident 3. The medications did not include metoprolol.A review of Resident 3's clinical record indicated a physician's order, dated 8/13/25, for metoprolol succinate extended release (ER) 100 mg, 1 capsule by mouth one time a day for hypertension (high BP). It was scheduled daily at 9 a.m.A review of Resident 3's September 2025 MAR indicated RN A placed a code 9 (meaning Other/See Progress Notes) in the entry for metoprolol administration on 9/3/25 at 9 a.m. A review of the corresponding progress notes, written by RN A at 9/3/25 at 8:41 a.m., indicated, Waiting for pharmacy to deliver. Will follow up. MD will be notified.During an interview with RN A on 9/3/25 at 10:28 a.m., he stated Resident 3' metoprolol ER was not available for administration. He said, I just realized it was out this morning.A review of the facility's policy and procedures titled Administering Medications, dated 4/2019, indicated, Medications are administered in accordance with prescriber orders including any required time frame. Medication administration times are determined by resident need and benefit. Enhancing optimal therapeutic effect of the medication. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview and record review, the facility failed to ensure to conserve nutritional food value and palatability for one of 42 sampled resident (Resident 47), when:1. Resident 47 stated vegetables were soft, mushy and overcooked;2. A test tray for cooked vegetable was soft.This failure had the potential to compromise nutritional quality and palatability of meals for sampled resident 47.Findings: 1.During an initial room rounds on 9/2/2025 at 11:10 a.m., Resident 47 stated food in facility horrible, bland, no taste, veggies served soft, mushy and overcooked. Review of Resident 47's face sheet (FS: a document that gives resident's information at a quick glance) indicated Resident 47 was admitted to facility on 7/14/2024. Review of Resident 47's minimum data set (MDS: clinical assessment tool) assessment dated [DATE] indicated Resident 47's brief interview for mental status (BIMS) score of 13 (score of 0-7: severe cognitive impairment, 8-12: moderate cognitive impairment, 13-15: intact cognition), intact cognition. Review of Resident 47's order summary record indicated NAS (no added salt) diet regular texture, thin liquids consistency, chopped meats, dated 11/18/2024. Review of facility menu for lunch on 9/3/25 indicated the meal included cheesy broccoli rice as the vegetable dish. During a concurrent test tray observation and interview done with the certified dietary manager (CDM) on 9/3/25 at 12:40 PM, the cheesy broccoli rice was noted to be soft, close to mushy. The CDM stated the broccoli was soft, but not mushy. CDM also stated broccoli cooked with rice, made broccoli softer. During an interview with facility's registered dietitian (RD) on 9/4/2025 at 3:39 p.m., RD stated vegetables should have cooked and served not hard and not soft for residents with regular consistency diet order. RD also stated vegetables should have been cooked and served between al [NAME] (cooked until tender but still firm to bite than being soft or mushy) and soft. 2. Review of lunch meal menu for 9/3/25 indicated the meal included cheesy broccoli rice as the vegetable dish. During a concurrent observation and interview with [NAME] H on 9/3/25 at 11:25 a.m., [NAME] H was seen preparing the lunch meal for the day, with broccoli in a pot of boiling water. [NAME] H says he makes the broccoli softer, for residents who have a bite size diet order (a therapeutic diet order that calls for food to be cut into small pieces so that it is easy to chew). During a concurrent test tray observation and interview done with CDM on 9/3/25 at 12:40 p.m., the cheesy broccoli rice was noted to be soft, close to mushy. The CDM stated the broccoli was soft, but not mushy. Review of facility's policy and procedure (P&P) titled, Food and Nutrition Services, revised October 2017, the P&P indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meet his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive.

Based on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) for two of five sampled residents (Resident 3 and 8). These failures could lead to the delivery of unnecessary or inappropriate medical services against sampled resident's goals and wishes. Findings:Review of Resident 3's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 3 was admitted to facility on 8/8/2025. Review of Resident 3's POLST form date prepared 8/8/2025 indicated, section D for advance directive was not completed and available all three options were left blank.Review of Resident 8's face sheet indicated, Resident 8 was admitted to facility on 7/2/2022. Review of Resident 8's POLST form date prepared 8/1/2022 indicated, section C for artificially administered nutrition was not completed and available all three options were left blank.During a concurrent record review of POLST form for Residents 3 and 8 and interview with facility's director of nursing (DON) on 9/4/2025 at 12:12 p.m., DON confirmed POLST form section D for Resident 3 and section C for Resident 8 were not completed and left blank. DON stated nursing staff responsible to review and complete all sections of POLST upon resident's admission to facility. DON also stated nursing staff should have completed all sections of POLST form for both Resident 3 and Resident 8. DON further stated interdisciplinary team (IDT: a group of healthcare professionals from different specialties who collaborate to provide comprehensive care to residents) reviews and completes POLST form as needed during care plan meeting for each resident.Review of facility's P&P titled, Physician Orders For Life-Sustaining Treatment (Or POLST), updated 4/8/2022, the P&P indicated, A qualified healthcare provider, preferably a registered nurse or social worker will review the POLST form for completeness . The POLST will be reviewed by the facility interdisciplinary team:

Based on interview and record review, the facility failed to ensure free from unnecessary psychotropic medication (medications capable of affecting the minds, emotions, and behaviors) for one of four sampled resident (Resident 56) when: There was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before administered psychotropic medication quetiapine (used to treat mental health condition); 2. There was no documented evidence for episodes of appropriate behavior monitored for quetiapine; 3. There was no documented evidence for side effects monitored for quetiapine.These above failures had the potential to place sampled resident at risk to receive unnecessary psychotropic medication. Findings:Review of Resident 56's face sheet (FS: a document that gives a resident's information at a glance) indicated Resident 56 was admitted to facility on 8/1/2025 and discharged from facility on 8/3/2025.Review of Resident 56's diagnoses included mood disorder (type of a mental illness affects emotional state).Review of Resident 56's order summary report indicated Quetiapine Fumarate 25 MG (mg: milligram, a unit of weight, equal to one thousandth of a gram) every 12 hours as needed for Mood Disorder for 14 days, dated 8/1/2025. Review of Resident 56's electronic medication administration record (EMAR, a digital system used in healthcare setting to track and document the administration of medications to residents) for August/2025 indicated Resident 56 received quetiapine one dose on 8/2/2025 at 7:11 p.m.1.Review of Resident 56's electronic clinical documentation indicated there was no documented evidence of non-pharmacological approaches attempted before administered quetiapine on 8/2/2025.2.Review of Resident 56's electronic clinical documentation indicated there was no documented evidence of indicated episodes of appropriate behavior monitored for use of quetiapine.3. Review of Resident 56's electronic clinical documentation indicated there was no documented evidence for side effects monitored for quetiapine use.During a concurrent record review and interview with director of nursing (DON) on 9/8/2025 at 11:08 a.m., DON reviewed physician orders, EMAR, and clinical documentation for Resident 56. DON confirmed there was no documentation for attempted of non-drug approaches before administered antipsychotic medication to Resident 56 on 8/2/2025. DON also confirmed there was no contraindication for above resident to attempt non-drug approaches. DON also confirmed there was no documented evidence of behavior and side effects monitored for use of quetiapine for Resident 56. DON stated license nursing staff should have provided non-drug interventions before administered, monitored, documented for episodes of behavior and side effects for use of quetiapine for Resident 56 to minimize the need for antipsychotic medication for this resident. Review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, undated 4/8/2022, the P&P indicated, Psychoactive can only be prescribed if there is an appropriate indication: diagnosis and behavior. Behavior must be individualized and specific to the patient. If a psychoactive is being prescribed after admission Non-pharmacological interventions must be attempted first and clearly documented. Side effect monitoring should be mentioned/documented .

Based on interview, and record review, the facility failed to accurately code the minimum date set (MDS: an assessment tool) assessment for one of three sample resident (Resident 3) when Resident 3's MDS assessment did not reflect status of the resident. This failure had the potential to affect inappropriate care and interventions. Findings:Review of Resident 3's face sheet (FS: a document that gives a resident's information at a quick glance) indicated Resident 3 was admitted to facility on 8/8/2025.Review of Resident 3's diagnoses included diabetes type 1(a chronic condition in with high level of sugar in the blood).Review of Resident 3's order summary report indicated insulin (a hormone that helps to regulate blood sugar levels) glargine ( a type of long acting insulin used to trat treat diabetes) 100 Unit (unit: specific volume of fluid) /ML (ml: milliliter, a unit of volume, equal to one-thousandth of a liter) inject 5 units subcutaneously (SQ: a method of administering medication by injecting into the layer just below the skin) at bed time for diabetes 1, dated 8/9/2025.Review of 3's order summary report also indicated insulin lispro (a type of short acting insulin used to treat diabetes) 100Unit per milliliter as per sliding scale (dose chart that uses to correct high blood sugar based on sugar levels in blood) SQ at bed time dated 8/9/2025 and before meals dated 8/8/2025.Review of Resident 3's electronic medication administration record (EMAR: digital system for documenting medication administration) for August/2025 and September 2025 indicated Resident 3 received insulin every day.Review of Resident 3's MDS assessment dated [DATE], section N, N0415 for high-risk drug classes: used and indication indicated No for Hypoglycemic (including insulin). During concurrent record review of Resident 3's EMAR for August and September/2025, MDS assessment dated [DATE], section N, and interview with facility's MDS coordinator (MDSC) on 9/5/2025 at 1:18 p.m., MDSC confirmed Resident 3 received insulin every day after admitted to facility. MDSC also confirmed MDS assessment, section N for hypoglycemic medication not coded accurately. MDSC stated hypoglycemic medication should be coded Yes for Resident 3. MDSC also stated she would modify MDS assessment to correct above concern.Review of facility's policy and procedures (P&P) titled, Resident Assessments revised November 2019, the P&P indicated, The Resident Assessment Coordinator is responsible for ensuring that the Interdisciplinary Team (IDT: a group of healthcare professionals from different specialties who collaborate to provide comprehensive care to residents) conducts timely and appropriate resident assessment and reviews .

Based on observation, interview and record review, the following multi-resident rooms were less than 80 square feet per resident. Findings:Room Beds Square Feet/Room Square Feet/Resident 3 2 148.5 74.25 10 2 156.96 78.48 23 2 152.6 76.30 During an observation of room [ROOM NUMBER] on 9/3/2025 at 1:43 p.m., noted there were no care or privacy issues identified with lack of space regarding the size of resident room.During an observation of room [ROOM NUMBER] on 9/3/2025 at 2:36 pm., noted there were no care or privacy issues identified with lack of space regarding the size of resident room.During an interview with certified nursing assistant D (CNA D) on 9/3/2025 at 2:50 p.m., CNA D stated no concerns with care and safety for taking care of both residents in room [ROOM NUMBER] and 23 regarding the size of both rooms.During an interview with registered nurse A (RN A) on 9/3/2025 at 2:45 pm., RN A stated no concerns with providing care to both residents in rooms [ROOM NUMBERS] regarding to the space and size of both rooms.During an observation of room [ROOM NUMBER] on 9/3/2025 at 2:50 pm., noted there were no care or privacy issues identified with lack of space regarding the size of room.During an interview with CNA B on 9/3/2025 at 2:54 pm., CNA B stated there were no concerns with providing care for two residents in room [ROOM NUMBER] regarding the size and space of this room.During an interview with RN G on 9/3/2025 at 2:56 pm., RN G stated no issues with providing care for two residents in room [ROOM NUMBER] related to size of the room.During an interview with facility's maintenance supervisor (MS) on 9/5/2025 at 9:12 a.m., MS confirmed size of above three rooms less than 80 square feet for each resident and each room shared by two residents.The residents were observed in their rooms throughout the survey. The nursing care and services were not impacted by the shortage of space for residents' rooms. The closet and storage spaces were sufficient to accommodate the needs of the residents.Review of facility's policy and procedure titled, Bedrooms, revised May 2017, the P&P indicated, Bedrooms measure at least 80 square feet of space per resident . Review of the facility's room variance reports recommend the waiver

Based on observation, interview, and record review, the facility failed to ensure the proper use of bed or side rails (adjustable rigid bars attached to the side of a bed) for five (Residents 26, 145, 194, 17, and 4) of five sampled residents (residents who used bed or side rails) when: 1. There was no documentation that indicated the facility followed the manufacturers' recommendations and specifications for installation and maintenance of the facility's beds and side rails for five of five sampled residents (Residents 26, 145, 194, 17, and 4); 2. There was no documentation that indicated alternatives were offered and/or attempted prior to the use of bed or side rails for three of five sampled residents (Residents 194, 17, and 4); 3. There was no documentation that indicated an entrapment risk assessment was completed prior to the use of bed or side rails for two of five residents (Residents 17, and 4); 4. There was no updated bed or side rail assessment form completed for one of five residents (Resident 4); and, 5. There was no physician's order that indicated the use of bed or side rails for one of five residents (Resident 4). These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: 1. During a concurrent observation and interview on 4/22/2024 at 9:47 a.m., in Resident 26's room, Resident 26 had the bilateral (both sides) upper bed rails in upright position. Resident 26 stated she used her bed rails to transfer out of bed. During an observation on 4/22/2024 at 10:11 a.m., in Resident 145's room, Resident 145 had the left upper bed rail in upright position. During an observation on 4/22/2024 at 10:16 a.m., in Resident 194's room, Resident 194 was asleep on his bed and the right upper bed rail was observed in upright position. During an observation on 4/22/2024 at 11:51 a.m., in Resident 17's room, Resident 17 was in bed and had the bilateral upper bed rails in upright position. During an observation on 4/22/2024 at 2:54 p.m., in Resident 4's room, Resident 4 had the left upper bed rail in upright position. During a concurrent observation and interview with licensed vocational nurse A (LVN A) on 4/24/2024 at 11:05 a.m., in Resident 26's room, Resident 26 had the bilateral upper bed rails in upright position. LVN A confirmed the observation. During a concurrent observation and interview with LVN A on 4/24/2024 at 11:07 a.m., in Resident 194's room, Resident 194 had the right upper bed rail in upright position. LVN A confirmed the observation. During a concurrent observation and interview with LVN A on 4/24/2024 at 11:10 a.m., in Resident 17's room, Resident 17 had the bilateral upper bed rails in upright position. LVN A confirmed the observation. During an interview with maintenance supervisor (MS) on 4/24/2024 at 3:40 p.m., MS confirmed there should be no bed rails installed in bed for newly admitted residents (Resident 194). MS stated the nurses would call him when they needed him to install the bed rails on resident's bed. MS confirmed he would install the bed rails as instructed by nurses without following the manufacturers' specifications for bed installation. MS stated he did not have any documentation indicated that he followed the manufacturer's recommendations for safe use of bed rails. During an interview with director of nursing (DON) on 4/24/2024 at 4:14 p.m., DON confirmed their beds were old and they did not have the manufacturer's handbook anymore. Review of the facility's policy and procedure titled, Proper Use of Side Rails, date revised 12/2016, indicated, Manufacturer instructions for the operation of side rails will be adhered to. The resident will be checked periodically for safety relative to side rail use. 2. During a concurrent interview and record review with minimum data set coordinator (MDSC, a licensed nurse in charge of resident assessment) on 4/24/2024 at 12:30 p.m., MDSC reviewed Resident 17's Device Assessment Tool for bed rail use dated 3/7/2024. MDS confirmed there was no documentation that indicated alternatives were offered or attempted prior to Resident 17's used of bilateral upper bed rails. During a concurrent interview and record review with DON on 4/24/2024 at 12:43 p.m., DON reviewed Resident 4's, Device Assessment Tool for bed rail use dated 8/19/2023. DON confirmed there was no documentation that indicated alternatives were offered or attempted prior to Resident 4's used of left upper bed rail. During a concurrent interview and record review with DON on 4/24/2024 at 12:49 p.m., DON reviewed Resident 194's Bed Rail Observation/Assessment (INITIAL), dated 4/22/2024. DON confirmed she completed Resident 194's assessment on 4/22/2024 at 11:37 a.m. DON was informed about the surveyor's above observation on 4/22/2024 at 10:16 a.m. when Resident 194 had the right upper bedrail already installed in his bed before the DON did the assessment and before they tried to attempt an alternative. DON confirmed there was no alternatives offered or attempted prior to Resident 194's used of right upper bed rail. During an interview with MS on 4/24/2024 at 3:40 p.m., MS stated Resident 194 was admitted to the facility on [DATE]. MS further stated the nurse called him on 4/21/2024 to install Resident 194's right bed rail. MS confirmed he came to the facility on [DATE] and installed Resident 194's right bed rail as instructed. Review of the facility's policy and procedure titled, Proper Use of Side Rails, date revised 12/2016, indicated, Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails. 3. During a concurrent interview and record review with DON on 4/24/2024 at 12:35 p.m., DON reviewed Resident 17's Device Assessment Tool for bed rail use dated 3/7/2024. DON confirmed Resident 17 had no entrapment risk assessment completed prior to bed rail used. During a concurrent interview and record review with DON on 4/24/2024 at 12:43 p.m., DON reviewed Resident 4's Device Assessment Tool for bed rail use dated 8/19/2023. DON confirmed Resident 4 had no entrapment risk assessment completed prior to bed rail used. Review of the facility's policy and procedure titled, Proper Use of Side Rails, date revised 12/2016, indicated, An assessment will be made to determine the resident's symptoms, risk of entrapment . 4. During an interview with DON on 4/24/2024 at 12:35 p.m., DON confirmed bed rail assessment should be completed upon admission, quarterly, and during significant change in resident's condition. DON stated the assessment should collaborate with minimum data set (MDS, an assessment tool) assessments (admission, quarterly, annual, and significant change in status assessment). During a concurrent interview and record review with DON on 4/24/2024 at 12:43 p.m., DON reviewed Resident 4's Device Assessment Tool for bed rail use dated 8/19/2023. DON confirmed although an initial Device Assessment Tool done on 8/19/2023 for Resident 4's bed rail use, it was not updated quarterly. Review of Resident 4's assessment form title, Device Assessment Tool V1.1 - V2 (version 1.1 - version 2), dated 8/19/2023, indicated licensed nurses should complete each section of the assessment and it should be done initially, quarterly, annually, and during significant change. 5. During a concurrent observation and interview with DON on 4/29/2024 at 9:52 a.m., in Resident 4's room, Resident 4 had the left upper bed rail in upright position. DON confirmed the observation and stated nurses should obtain a physician's order for bed rail use prior to installation of bed rails. Review of Resident 4's Order Summary Report, dated 4/3/2024, indicated Resident 4 did not have a physician's order for the bed rail used. 37409 46553

Based on observation and interview, the facility failed to maintain hygiene in the kitchen and to ensure food was stored in accordance with professional standards for food safety when: 1. Past use-by date food, rotten bananas, and dented cans were found in the freezer and on the shelves in the kitchen; 2. Cook K's (CK K) and dietary aid L's (DA L) hair were out of their hair nets; the maintenance director (MD) did not wash his hands when he entered the kitchen and opened the ice machine; the dietary director (DD) did not sanitize the thermometers before checking the food temperatures; and, 3. The screw in the ice storage bin was rusty with rusty water that dripped down onto the ice, and the ice machine did not have an air gap. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illnesses and cross-contaminated food for residents eating at the facility. Findings: 1. On 4/22/24 at 9:25 a.m., during an observation of the ice cream freezer, walk-in freezer, and the storage shelves in the kitchen, with the Dietary Director (DD), the followings were observed: a. One third of a 5-gallons container of Blue Bunny sherbet had a use by date of 4/5/24 b. Half of a 20-pound container of frozen cookie dough had a use by date of 3/22/24 c. Two 7-pound cans of lemon pudding were dented d. Seven bananas had black spots During a concurrent interview with the DD, he stated he would discard these food items. Review of the facility's policy, Washing and Handling Produce, dated 1/2015, indicated . Produce that looks rotten is discarded . Review of the facility's policy, Dented Cans, dated 2/2011, indicated, Employees inspect cans for dents when putting them away after delivery . Set aside in separate box, bin, or container; labeled Dented Cans . 2. During an observation in the kitchen on 4/22/24 at 9:25 a.m., half bottom of cook K's (CK K) hair was out of his hair net at the backside, and half of the front of dietary aid L's (DA L) hair was out of her hair net. During a concurrent interview, CK K and DA L acknowledged that their hair were out of their hair nets. CK K and DA L stated their hair should be covered with their hair nets. During an observation in the kitchen on 4/22/24 at 12:50 p.m., the maintenance director (MD) came in the kitchen, put on gloves, and started to open the ice machine. During a concurrent interview, the MD acknowledged that he should have washed his hands when he came into the kitchen. During an observation of the tray line on 4/24/24 at 12:05 p.m., the dietary director (DD) removed the caps of three thermometers and checked the temperature of rice, yellow squash, and chicken without sanitizing the thermometers. During a concurrent interview with the DD, he acknowledged he should have sanitized the thermometers before checking the food temperatures. Review of the facility's policy, Personal Hygiene Standards, dated 8/2018, indicated Hair restraining devices (e.g., hair nets), covering all hair, are worn while on duty . Hands are washed after each trip to the restroom, washrooms, after touching the hair, mouth, or nose, when leaving and reentering the kitchen . Review of the facility's policy, Cleaning and Sanitizing a Thermometer, dated 7/2009, indicated When taking temperatures during meal service, the thermometer is re-sanitized before taking the next temperature. 3. During an observation with the maintenance director (MD) on 4/22/24 at 12:50 p.m., a interior screw of the ice storage bin that anchored a white panel above the ice was rusty with a line of rusty water that dripped down to the ice of the storage bin. The ice machine lacked an air gap, since the drainage pipe led from the ice machine into a bigger drainage pipe on the floor. During a concurrent interview, the MD confirmed the ice in the ice storage bin was contaminated, and that the ice machine did not have an air gap. The MD stated he would throw out all of the ice, change out the rusty screw, and that he would lift the ice machine drainage pipe to create an air gap. Review of the 2017 Food and Drug Administration (FDA) Food Code, Section 5-402.11, indicated, Backflow Prevention, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.

Based on observation, interviews, and record review, the facility failed to ensure safe and effective medication use to meet the needs of residents when: a. Facility utilized the open medication administration scheduling, since (MONTH) (YEAR), where the facility allowed a 4-hour window (such as 7 a.m. - 11 a.m. for daily; and 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. for twice daily administration times) for routine medication administration without addressing any exceptions (medications that did not fit this medication scheduling) such as types of medications and time-critical medications (those for which early or late administration greater might cause harm or have significant, negative impact on the intended therapeutic effect) such as insulin (medications to manage blood sugar), pain medications, anticonvulsant ([MEDICAL CONDITION]) medication, anti-[MEDICAL CONDITION] medications, antibiotics, anticoagulants (blood thinners), etc.; b. The assignment of the open medication administration on the monthly medication administration records (MARs) was assigned by non-clinical staff members who had no training or licenses in clinical practice; c. The nursing staff member, who reviewed the monthly MARs for completeness and accuracy, did not review the MARs in relation to the 4-hour window scheduling for medications; d. The Consultant Pharmacist (CP) was not involved in the open medication administration decision, and did not identify the inappropriate medication administration scheduling for 8 of 15 sampled residents (Residents 3, 7, 8, 9, 15, 17, 20, and 25) in the monthly medication regimen review (MRRs); e. The facility did not conduct a quality assurance (QA) process (procedure ensuring quality of service) to assess and monitor whether this open medication administration process was safe and effective for residents since its implementation in (MONTH) (YEAR). The failure resulted in: inappropriate scheduling of Resident 7's anti-[MEDICAL CONDITION] medication ([MEDICATION NAME]) that may have contributed to her experiencing a [MEDICAL CONDITION] on 1/11/20; two medication errors identified during the medication pass observation for Residents 17 and 25; medications with specific requirements (such as given with food, before food, on empty stomach, at the same time each day to maintain steady bloodstream level, etc.) were not given in accordance with the physician's orders [REDACTED].) for residents. On 1/14/2020 at 3:49 p.m., the survey team called Immediate Jeopardy (IJ) concerning Pharmacy Services, in the presence of the Executive Director (ED) and the Director of Nursing Services (DNS). The noncompliance in Pharmacy Services placed residents at risk for adverse outcomes (as stated above) related to inappropriate medication use, and also posed the potential for medication overdose (when given too close together) and/or inappropriate treatment (such as in appropriate pain management, too low/high blood sugar, fluctuation in blood level of medications) when given too far apart due to the wide window of medication administration. The facility provided the acceptable removal plan, and the IJ was removed on 1/15/2020 at 4:43 p.m. The removal plan, dated 1/15/2020, included discontinuance of the open medication administration process immediately; nursing staff and the CP reviewing MEDICATION ORDERS FOR [REDACTED]. Findings: A review of the facility's policy, Open Medication Administration, signed by the Medical Director (MD) on 1/25/18, indicated the following under Procedure: 1. The Center identifies the desire for open medication administration times, to meet the individual needs and preferences of the Resident population. 2. The Center works with the Medical Director to define open medication times. 3. The Center meets with Resident and Families through Resident/Family Counsel to present the open medication administration program prior to implementation. 4. Residents who do not wish to participate in open medication administration times are provided with the option to continue with standard administration times. The policy indicated, for once daily dosing, the open medication time was 7 a.m. - 11 a.m. (4-hour interval); and for twice daily dosing, the open medication administration times were: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. (4-hour interval). This policy did not specify exceptions, such as types of medications and/or time-critical medications, that did not fit the open medication administration; nor did it address who could designate the open medication administration scheduling. A review of the 2011 ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications, the Institute for Safe Medication Practices (ISMP), a nationally recognized organization focusing of safe medication practices, indicated that time-critical scheduled medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal (below standard) therapy or pharmacological (drug-related) effect. In this publication, ISMP specified time-critical medications as: opioids used for chronic pain (fluctuations in the dosing interval may result in unnecessary break-through pain), medications that must be administered apart from other medications (such as [MEDICATION NAME], antacids), certain medications that require administration within a specified time before, after, or with meals; insulin; anti-infective; certain antidiabetic agents; etc. The ISMP publication also indicated, Policies should allow prescribers, pharmacists, or nurses to declare any scheduled medication to be time-critical . by including this designation with medication order and/or Medication Administration Record [REDACTED] 1. A review of the U.S. Food & Drug Administration's (FDA) FY2015 Regulatory Science Research Report: Narrow Therapeutic Index Drugs, it defined narrow therapeutic index (NTI) drugs as drugs where small differences in dose or blood concentration may lead to serious therapeutic failures and/or adverse drug reactions that are life-threatening or result in persistent or significant disability or incapacity. [MEDICATION NAME] (brand name: [MEDICATION NAME]) is one of the NTI drugs. A review of the U.S. National Library of Medicine indicated [MEDICATION NAME] is used to control certain type of [MEDICAL CONDITION], and to treat and prevent [MEDICAL CONDITION]. It indicated to take [MEDICATION NAME] at around the same time(s) every day and (i)f you are receiving . supplements through a tube feeding . You will need to allow some time between receiving your feedings and taking [MEDICATION NAME]. (https://medlineplus.gov/druginfo/meds/a 2.html, accessed 1/22/2020) During a medication pass observation on 1/13/2020 at 1:08 p.m., licensed vocation nurse (LVN) B was observed preparing a 6-milliliters (ml) of [MEDICATION NAME] liquid 125 milligrams per ml (total 150 mg) for Resident 7. At the bedside, LVN B was observed giving [MEDICATION NAME] via Resident 7's [DEVICE] (gastrostomy tube; a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications). After finishing giving the [MEDICATION NAME], LVN B poured 225 mls of [MEDICATION NAME] HN (an enteral feeding) into Resident 7's [DEVICE], followed by flushing of water. Shortly after the medication observation, LVN B stated, I always give it (the enteral feeding) before or after the [MEDICATION NAME]. A concurrent review of the facility's Nursing 2019 Drug Handbook with LVN B at this time indicated, Enteral tube feedings: (MONTH) interfere with absorption of oral drug. Stop enteral feeds for 2 hours before and 2 hours after drug use. Monitor serum drug level more frequently. LVN B said she did not know the enteral feeding would interfere with the [MEDICATION NAME] absorption. A review of Lexi-comp online (www.lexi.com), a nationally recognized drug information resource, indicated the following: Tube feedings: Tube feedings decrease [MEDICATION NAME] absorption . The manufacturer recommends not to administer concomitantly (at the same time) with an enteral feeding preparation. There is a variety of opinions on how to administer [MEDICATION NAME] with enteral feedings. Be consistent throughout therapy. Under Food Interactions, Lexi-comp indicated, If [MEDICATION NAME] is administered with enteral feeding preparations and/or related nutritional supplements, serum concentrations of [MEDICATION NAME] may be decreased. Management: Do not administer [MEDICATION NAME] concomitantly with an enteral feeding preparation. On 1/13/2020, a review of Resident 7's medical record indicated she was a [AGE] year old resident admitted to the facility with [DIAGNOSES REDACTED]. Resident 7 was dependent on staff for all activities of living (such as bathing, toileting, getting dressed) and could not communicate her needs. Review of the medication orders indicated a physician's orders [REDACTED]. Prior to 1/12/2020, she had a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. The (MONTH) 2020 MAR indicated [REDACTED] A review of the (MONTH) 2019 to (MONTH) 2020 MARs indicated the facility scheduled twice daily [MEDICATION NAME]: 7 a.m. to 11 a.m. for the AM dose; and 3 p.m. to 7 p.m. for the PM dose until it was changed to three times daily on 1/12/2020. There was no time stamp of when the medication was given within this 4-hour window; there were only the nurses' initials indicating the medication was given. Thus, prior to 1/12/2020, Resident 7's [MEDICATION NAME] was not consistently given every day, and, due to the 4-hour window scheduling, it may be given with or without the enteral feedings since 3/1/18. During an interview on 1/13/2020, at 2:12 p.m. LVN B stated when the medication was scheduled from 7 a.m. to 11 a.m., the nurse had the flexibility to give it any time during the 4-hour window. She said, It depends on my schedule when I give it. On 1/13/2020, a review of Resident 7's medical record reflected she had an episode of [MEDICAL CONDITION] on 1/11/20, after which the [MEDICATION NAME] level was ordered and obtained. A review of the laboratory report, dated 1/12/2020, indicated the [MEDICATION NAME] level was 3.7 L(low) (normal range: 10 - 20 micrograms (mcg)/ liter(L)). The previous [MEDICATION NAME] level, obtained on 8/21/19, was 19.7 mcg/mL (normal range). Resident 7 did not have any new medication orders that may have interacted with the [MEDICATION NAME], and her other laboratory tests (such as kidney and liver functions) remained consistent since 3/1/18. During an interview with LVN D on 1/14/2020 at 10:53 a.m. she stated the nurses had the flexibility to give scheduled medications within the 4-hour window if it was scheduled from 7 a.m. to 11 a.m. on the MAR. When questioned how she gave the [MEDICATION NAME] to Resident 7, she stated, I give it with the bolus feed (the enteral feeding). When informed of the manufacturer's instructions not to give [MEDICATION NAME] with enteral feedings at the same time, she said, I didn't know. No one told me. The doctor didn't specify. During a telephone interview with the Medical Director (MD) on 1/14/2020 at 12:07 p.m. the MD stated she was aware of the open medication administration practice at the facility. The MD confirmed the facility did not specify exceptions to the open medication scheduling. She added, If you find those, give me a list and next time we order we will specify. The MD further explained that the nurses made the determination when to give the medications, as she only gave orders for how often, such as once or twice daily, to give the medications. The MD agreed [MEDICATION NAME] liquid is a short acting medication, and should be given consistently every day to maintain steady bloodstream level. The MD stated the most recent [MEDICATION NAME] level was low (3.7 mcg/mL) and could be caused by the way the medication was given. During an interview with the DNS on 01/14/2020 at 12:21 p.m., she said the open medication administration was a corporate change policy, meaning it was a corporate-mandated change. She explained, when a resident was admitted to the facility, the nursing staff handwrote the medications and the specific times (such as 9 a.m. for daily dosing, and 9 a.m. and 5 p.m. for twice daily dosing) on the handwritten MAR. Then at the end of the month, the Medical Records staff (namely the Health Information Manager (HIM)) entered the orders into the computer and changed some of the once-daily and twice-daily scheduled medications to open medication administration scheduling. DNS was uncertain how the HIM made the determination which medications to convert to open medication scheduling. She continued, the recap nurse (LVN A) would review the monthly computer-generated MARs for completeness and accuracy. The DNS stated the HIM left her employment in (MONTH) 2019, but ran the (MONTH) 2020 MARs before she left. During an interview with the Business Office Manager (BOM) on 1/14/2020 at 12:59 p.m., the BOM stated she was also doing interim medical records. She stated she entered the MARs in the computer and they were then checked by LVN [NAME] During an interview on 1/14/2020 at 1:50 p.m., LVN A said she reviewed the monthly MARs for completeness and accuracy. LVN A stated the nurses did not have access to the computer; it was the HIM who input the physician's orders [REDACTED]. She stated it was the HIM who converted the specific time administration (such as 9 a.m.) from the handwritten MAR indicated [REDACTED]. She explained, when she reviewed the computer-generated MARs, she did not pay attention to the open medication scheduling, that she only paid attention to the medication orders and the frequency. She stated, when she first started employment at the facility, she questioned the open medication administration practice, but the HIM told her it was the facility's policy that allowed it. During a telephone interview with the CP on 1/14/2020 at 2:07 p.m., the CP stated he started consulting at the facility since 11/2018, at which time the facility already implemented the open medication administration. The CP stated [MEDICATION NAME] liquid is a short acting medication, and putting it on the open medication scheduling gave the leeway for nursing staff to not give it consistently every day. During a concurrent review and interview on 1/15/2020 at 2:03 p.m., the DNS reviewed the personnel files for both the HIM and BOM, and confirmed they had no training or licenses in clinical practice. During an interview on 1/15/2020 at 4:07 p.m., the CP stated he had a chance to review Resident 7's medical record. He said, I agree there was some inconsistency when the medication ([MEDICATION NAME]) was given and whether it was the cause of the [MEDICAL CONDITION]. There also could be an issue with giving with the tube feeding. The CP stated, I was unaware the enteral feeding was given with the [MEDICATION NAME]. 2a. During a medication administration observation on 1/13/2020 at 9:26 a.m., LVN A was observed giving six medications to Resident 25. Included in the medications was a tablet of [MEDICATION NAME] (a diabetes medication) 1,000 milligrams (mg, unit of weight). During the medication pass, Resident 25 stated he had breakfast between 7:30 a.m. to 8 a.m. that morning. During the medication pass, a review of the pharmacy label on Resident 25's [MEDICATION NAME] indicated, Give 1 tablet by mouth twice daily with morning and evening meals. On 1/13/2020, a review of Lexi-comp online indicated, Drug may cause GI (gastrointestinal - related to stomach/intestine) upset; take with food (to decrease GI upset). Take at the same time(s) each day. On 1/13/2020, a review of the physician's orders [REDACTED]. On 1/13/2020, a review of Resident 25's (MONTH) 2020 MAR indicated [REDACTED]. During an interview on 1/13/2020 at 3:56 p.m., LVN A reviewed pharmacy label and acknowledged [MEDICATION NAME] was given at least 1.5 hrs after food, inconsistent with the manufacturer's specifications. 2b. During another medication pass observation on 1/13/2020 at 10:10 a.m., LVN A was observed giving 14 different medications to Resident 17. Included in the medications was a tablet of potassium (to treat low potassium level in the blood) 10 milliEquivalent (mEQ, unit of measure). LVN A said Resident 17 had breakfast around 730ish that morning. The medication administration time was at 10:10 a.m. (more than 2.5 hours later). A review of the physician's orders [REDACTED]. A review of the MAR, dated (MONTH) 2020, indicated the facility assigned the medication administration time for potassium from 7 a.m. to 11 a.m. daily when the order indicated to give with breakfast. A review of Lexi-comp online indicated oral dosage forms of potassium should be taken with meals and a full glass of water or other liquid to minimize the risk of GI irritation. During an interview on 1/13/2020 at 4:03 p.m., LVN A said potassium should be scheduled around 8 a.m. and confirmed it should be given with breakfast as per the physician's orders [REDACTED].>3. On 1/15/2020, a review of the sampled resident's medical records reflected the following medications not given in accordance with the physician's orders [REDACTED]. a. Resident 3 was admitted to the facility with [DIAGNOSES REDACTED]. Her medication orders included a physician order, dated 1/1/19, for [MEDICATION NAME] 850 mg two times daily for type 2 diabetes. A review of her (MONTH) 2020 MAR, indicated [MEDICATION NAME] was scheduled: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. A review of Lexi-comp online indicated, Drug may cause GI upset; take with food (to decrease GI upset). Take at the same time(s) each day. b. Further review of Resident 7's medical record also indicated a physician's orders [REDACTED]. A review of her (MONTH) 2020 MAR, indicated it was scheduled to be given daily from 3 p.m. to 7 p.m. A review of Lexi-comp online indicated to give [MEDICATION NAME]: Administer early in day to avoid nocturia (nighttime urination). Take the last dose of multiple doses no later than 6 PM unless instructed otherwise. c. A review of Resident 8's medical record reflected a physician's orders [REDACTED]. A review of her (MONTH) 2020 MAR, indicated it was scheduled to be given daily from 7 a.m. to 11 a.m. A review of an article, Taking Your Medication Regularly is Essential to Controlling Your [MEDICAL CONDITION], by the [MEDICAL CONDITION] Foundation, dated 8/2018, it indicated, [MEDICAL CONDITION] medicines must be taken each and every day as prescribed. If the right amount is not taken at the right time, the medicine may not be able to prevent [MEDICAL CONDITION], or might cause unwanted side effects. (https://www.[MEDICAL CONDITION].com/learn/treating-[MEDICAL CONDITION]-and-[MEDICAL CONDITION]/[MEDICAL CONDITION]-and-[MEDICAL CONDITION]-medicines/importance-taking-medication; accessed 1/22/2020) d. A review of Resident 9's medical record indicated she was admitted to the facility with [DIAGNOSES REDACTED]. Her medication orders included the following: - Basaglar Kwikpen (insulin [MEDICATION NAME], to control blood sugar) 18 units subcutaneously (under the skin) one time a day for diabetes, dated, 2/27/19. A review of the (MONTH) 2020 MAR, indicated it was scheduled to be given from 7 a.m. - 11 a.m. daily. Lexi-Comp online indicated: Insulin [MEDICATION NAME] should be administered consistently at the same time each day. - [MEDICATION NAME] (to treat type 2 diabetes) 5 mg by mouth two times daily for type 2 diabetes, dated 10/12/19. A review of the (MONTH) 2020 MAR, indicated it was scheduled to be given: 7 a.m. - 11 a.m. and 3 p.m.- 7 p.m. daily. Lexi-Comp online indicated to give [MEDICATION NAME] 30 minutes before a meal to achieve greatest reduction in postprandial [MEDICAL CONDITION] (high blood sugar after eating). - [MEDICATION NAME] 1,000 mg twice daily for type 2 diabetes, dated 4/1/18. Review of the (MONTH) 2020 MAR indicated [REDACTED]. Lexi-Comp online indicated to take with food (to decrease GI upset). Take at the same time(s) each day. - [MEDICATION NAME] 10 mEQ (potassium supplement) once daily for low potassium in the blood, dated 4/1/18. A review of the (MONTH) 2020 MAR, indicated it was scheduled to be given from 7 a.m. - 11 a.m. Lexi-Comp online indicated [MEDICATION NAME] should be taken with meals and a full glass of water or other liquid to minimize the risk of GI irritation. e. Resident 15 was admitted to the facility with [DIAGNOSES REDACTED]. A review of her medication orders indicated a physician's orders [REDACTED]. A review of the (MONTH) 2020 MAR, it was scheduled to be given daily from 3 p.m. to 7 p.m. A review of Lexi-Comp online indicated to administer [MEDICATION NAME] at bedtime. The facility scheduled bedtime medications at 9 p.m. d. Further review of Resident 17's medical record indicated she was admitted to the facility with [DIAGNOSES REDACTED]. A review of her medication orders indicated: - Linzess (to treat constipation) 290 mcg by mouth in the morning, dated 5/1/18. A review of the (MONTH) 2020 MAR, indicated it was scheduled to be given from 6 a.m.- 10 a.m. Lexi-Comp online indicated to give Linzess at least 30 minutes before the first meal of the day on an empty stomach. - [MEDICATION NAME] 12.5 mg one time daily for high blood pressure, dated 4/1/18. A review of the (MONTH) 2020 MAR, indicated it was scheduled daily from 7 a.m. - 11 a.m. Lexi-comp online indicated to give it early in day to avoid nocturia. - [MEDICATION NAME] (an opioid pain medication) 100 mg by mouth two times daily for unspecified pain, dated 4/1/18. A review of the (MONTH) 2020 MAR, indicated it was scheduled: 7 a.m. - 11 a.m. and 3 p.m.- 7 p.m. daily. A review of the ISMP publication (as indicated above) indicated opioids used for chronic pain should be given consistently at the same time every day as fluctuations in the dosing interval may result in unnecessary break-through pain. During an interview on with Resident 17 on 1/16/2020 at 9:18 a.m., Resident 17 stated she had a slipped disc (herniated cervical disc in the neck) and had pain behind her neck radiating to her back. She stated sometimes the pain was so bad she needed a Tylenol on top of the [MEDICATION NAME]. f. A review of Resident 20's medical record indicated she was admitted to the facility with [DIAGNOSES REDACTED]. A review of her medication orders reflected the following: - Losartan (for high blood pressure) 50 mg one daily for [MEDICAL CONDITION] hypertension (high blood pressure in the arteries of the lungs), dated 9/5/19. A review of the (MONTH) 2020 MAR, indicated it was scheduled to be given: 7 a.m. - 11 a.m. daily. A review of Lexi-comp online indicated to administer without regard to meals; however, administer consistently with respect to food intake at about the same time every day. - [MEDICATION NAME] (for high blood pressure and water retention) 2.5 mg one time daily unspecified [MEDICAL CONDITION] (swelling), dated 9/5/19. A review of the (MONTH) 2020 MAR, indicated it was scheduled: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. A review of Lexi-comp online indicated to give [MEDICATION NAME]: Therapy should be taken early in the day to avoid nocturia. - [MEDICATION NAME] (to prevent heartburn) 20 mg in the morning for [MEDICAL CONDITION] reflux (reflux of acid), dated 9/5/19. A review of the (MONTH) 2020 MAR, indicated it was scheduled to be given: 7 a.m. - 11 a.m. daily. A review of Lexi-comp online indicated to administer [MEDICATION NAME] 30 to 60 minutes before a meal; best if taken before breakfast. g. A review of Resident 25's medical record indicated he was admitted to the facility with [DIAGNOSES REDACTED]. A review of his medication orders indicated: - Insulin [MEDICATION NAME] (a short acting insulin, to manage high blood sugar) 5 units subcutaneously one time a day for type 2 diabetes, dated 11/5/19. A review of the (MONTH) 2019 MAR, indicated it was scheduled daily from 11 a.m. to 2 p.m. (3-hour window). A review of Lexi-comp online indicated: Insulin [MEDICATION NAME] should be administered within 15 minutes before or immediately after a meal. - [MEDICATION NAME] 112 mcg by mouth in the morning for [MEDICAL CONDITION] ([MEDICAL CONDITION] doesn't produce enough [MEDICAL CONDITION] hormone), dated 10/1/19. A review of the (MONTH) 2020 MAR,indicated it was scheduled to be given daily from 6 a.m. to 10 a.m. A review of Lexi-Comp online indicated to administer consistently in the morning on an empty stomach, at least 30 to 60 minutes before food. Alternatively, may consistently administer at night 3 to 4 hours after the last meal. h. A review of Resident 27's medical record indicated he was admitted to the facility with [DIAGNOSES REDACTED]. A review of his medication orders indicated a physician's orders [REDACTED]. Review of the (MONTH) 2020 MAR, indicated it was scheduled: 7 a.m. - 11 a.m. and 3 p.m. - 7 p.m. daily. A review of Lexi-Comp online indicated to administer [MEDICATION NAME] with food (to decrease GI upset). Take at the same time(s) each day. j. A review of Resident 80's medical record indicated he had a physician's orders [REDACTED]. A review of the (MONTH) 2020 MAR, indicated it was scheduled daily from 3 p.m. - 7 p.m. A review of Lexi-Comp online indicated [MEDICATION NAME] should be given 30 minutes after the same mealtime each day. 4. During a telephone interview with the MD on 1/14/2020 at 12:07 p.m., the MD stated the QA Committee met every three months to go over data, but had not discussed open medication administration times as part of the QA evaluation and monitoring since implementation in (MONTH) (YEAR). During a telephone interview with the CP on 1/14/2020 at 2:07 p.m., the CP stated there were no medications exempt from the open medication administration, and made recommendations related to open medication scheduling as he caught them during the monthly MRRs. The CP agreed having a 4-hour window gave leeway for the nursing staff to give the medications too far apart (such as 7 a.m. for the AM dose, and 7 p.m. for the PM dose; or 12 hours apart), or too close together (such as 11 a.m. for morning dose, and 3 p.m. for the p.m. dose; or 4 hours part), this could potentially lead to overdose of medications (such as opioids) when given too close together. Also, certain medications, such as anti-[MEDICAL CONDITION] medications, were not given on consistent basis to maintain the steady level in the bloodstream. In regard to QA process, the CP stated, I am not aware of any QA process. I have been in some QA meetings. I did recognize there was a part where the medication time frame was identified. During an interview with the CP on 1/15/2020 at 4:07 p.m., the CP was asked if he had identified in the MRRs regarding the incorrect scheduling for medications that had specific requirements for: Resident 3's [MEDICATION NAME]; Resident 7's [MEDICATION NAME] and [MEDICATION NAME]; Resident 8's levetiracetam; Resident 9's insulin [MEDICATION NAME], and [MEDICATION NAME]; Resident 15's [MEDICATION NAME]; Resident 17's Linzess and [MEDICATION NAME]; Resident 20's [MEDICATION NAME]; and Resident 25's insulin [MEDICATION NAME] and [MEDICATION NAME]. The CP stated he did not recall making these recommendations. He agreed, certain types of medications such as insulin, anti-[MEDICAL CONDITION] ([MEDICATION NAME] and levetiracetam), and pain medications (such as [MEDICATION NAME]) should be given consistently at the same time every day. He stated he relied on the nurses to give the medications correctly. He acknowledged the nurses did not document the time the medications were given, so he could not confirm they were given appropriately. On 1/16/2020, a review of the MRR Binder (a book consisting of the CP's recommendations to the facility) for Year 2019 reflected there were no CP's recommendations related the incorrect scheduling for the residents mentioned above. This was confirmed with the DNS during a concurrent interview and review of the MRR binder on 1/16/2020 at 1:35 p.m. During a review of the facility's policy and procedure, MONITORING OF MEDICATION ADMINISTRATION, dated (MONTH) (YEAR), indicated The consultant pharmacist evaluates medication administration to verify that the resident has received medications in accordance with the prescriber's orders and facility policy . A review of the facility's policy and procedure, CONSULTANT PHARMACIST REPORTS .MEDICATION REGIMEN REVIEW (MRR), dated (MONTH) (YEAR), indicated The consultant pharmacist identifies irregularities through a variety of sources including the resident's clinical record . medication administration administration records (MARs) . Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented in the resident's active record and reported to the Director of Nursing, Medical Director and/prescriber as appropriate.

Based on observation, interview and record review the facility failed to monitor the warm compress applied on Resident 12's abdominal area. This failure resulted in Resident 12 sustaining a second degree burn (an injury to the outer and middle layers of the skin) on his abdomen. Findings: Review of Resident 12's clinical record on 2/26/18, indicated he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His brief interview of mental status (BIMS, cognitive performance) dated 12/13/17, indicated Resident 12 was cognitively intact. Review of Resident 12's Situation, Background, Appearance, and Review (SBAR, an assessment tool used to facilitate prompt and appropriate communication of a problem), indicated on 2/11/18, at 11:30 p.m., Resident 12 complained of pain to his right abdominal area. Licensed vocational nurse E (LVN E) administered pain medication and applied a warm compress on the affected area. Review of the SBAR dated 2/13/18, indicated two blisters (bubble on the skin filled with serum and caused by friction, burning, or other damage) measuring 3.0 centimeters x 2.0 centimeters (cm, a unit of measurement) and 1.0 cm x 2.0 cm on the right lower abdominal area with redness on the surrounding areas. Treatment order included application of silver [MEDICATION NAME] (a topical antibiotic used in partial thickness and full [MEDICAL CONDITION] prevent infection) daily and cover with sterile dressing for 14 days. Review of Interdisciplinary Progress Notes dated 2/13/18, indicated Resident 12 sustained a second degree burn to the right lower side of his abdomen. The clinical record also indicated that when Resident 12 complained of discomfort, the charge nurse heated a sheet in a plastic bag and placed it on Resident 12's abdomen. Resident 12 was half asleep and did not feel discomfort. The bag was not removed until the following morning. Review of Physician's Progress Notes dated 2/12/18, indicated Resident 12 had a second degree burn to the right abdominal area. During an observation on 2/26/18, at 9:34 a.m., Resident 12 was noted to have light brown scabs surrounded by pinkish discoloration in the abdominal area. During an interview with Resident 12, on 2/26/18, at 9:59 a.m., he stated he was having pain on his right abdomen. LVN E told him he would be given a heating pad. He acknowledged he was half asleep and did not feel the heat when LVN E applied the warm compress on his stomach. Resident 12 stated LVN E did not check him until the next morning. He also stated one of the certified nursing assistants (CNA) found something on my abdomen the following morning and when Resident 12 looked at it, he saw blisters on his stomach. During an interview with the director of nursing (DON), on 2/26/18, at 12:31 p.m., she indicated there was no facility policy and procedure for applying a heating pad or warm compress. The DON acknowledged LVN E should not have applied a warm compress on Resident 12. During a telephone interview with LVN E, on 2/27/18, at 7:48 a.m., she stated on 2/12/18, Resident 12 complained of abdominal pain. She administered pain medication and offered a warm compress. LVN E asked CNA F to heat up a towel and put it in a Ziploc bag. LVN E stated she placed the heat pack on Resident 12's abdomen but did not return to check back on the resident. On 2/12/18, at 5:30 a.m., LVN E met Resident 12 in the hallway and he told her he was feeling better. She also confirmed she did not call the attending physician (AP) prior to applying the warm compress. LVN E stated she later found out that the facility did not have a policy and procedure for application of a warm compress. During a telephone interview with CNA F, on 2/27/18, at 10:09 a.m., she acknowledged she worked the night of 2/11/18 with LVN E. She stated when LVN E asked her to make a heat pack, she took a wet wash cloth and put it in the microwave before placing it in a Ziploc bag. CNA F confirmed the facility did not have a heating pad. During an interview with the AP, on 2/28/18, at 9:41 a.m., she indicated Resident 12 developed a second degree burn to the abdominal wall after application of a warm compress.

Based on interview and record review, the facility failed to ensure Resident 1 had adequate interventions and supervision to prevent accidents and injuries. Resident 1 was admitted to the facility on ,[DATE] with [DIAGNOSES REDACTED]. On 8/7/14, a psychologist documented Resident 1 experienced a functional decline and had increased confusion. On 8/21/14 at 6:30 p.m., Resident 1 was found on the floor next to her bed complaining of right shoulder pain and blood was observed on the floor near her head. She was transferred to the hospital emergency room for an evaluation and required sutures to her forehead for a laceration (cut). The facility failed to follow their policy and procedure related to implementing interventions for residents identified as a high risk for falls which resulted in Resident 1 falling out of bed and sustaining a head injury. Findings: Review of the facility's policy, "Fall Evaluation and Management," revised 1/14, showed if a resident's Fall Evaluation Form had a score of 13 or greater, the resident is considered as having a high potential for falls, and staff should implement appropriate care plan interventions for fall management. Review of the facility's High Potential Fall Quick Reference Guide indicated for residents who are confused, have a history of falls within the last three months and have a score of 13 or higher, interventions may be required which include non-skid mats next to the bed, high/low bed, and ? siderails. Clinical record review for Resident 1 was initiated on 9/2/14. Resident 1 was admitted to the facility on ,[DATE], with [DIAGNOSES REDACTED]. Review of Resident 1's minimum data sets (MDS, an assessment tool), dated 6/23/14 and 7/18/14, indicated she had moderately impaired cognition and had a history of [REDACTED]. Review of Resident 1's Nursing Admission Evaluation dated 6/16/14, indicated she had a history of [REDACTED]. Review of a facsimile (FAX) transmission sent to Resident 1's physician on 6/17/14, indicated the resident requested the use of siderails related to her fear of falling out of bed. Review of Resident 1's Fall evaluation dated 6/22/14, indicated a score of 15 (a score of 13 or above-fall intervention review is required). Review of Resident 1's Device Evaluation Form dated 6/27/14, indicated the resident had weakness, syncope (fainting or passing out) and collapse. No device implementation was recommended. Review of Resident 1's Care Directive Form (certified nursing assistant guide) dated 6/29/14, 7/6/14, 7/20/14 and 7/27/14 and initialed by certified nurse assistants (CNA) to show Resident 1's care needs, documented Resident 1 was confused and forgetful. The sections were blank for safety equipment (floor mat, positioning pillows) and devices (low bed, perimeter mattress). A Care Directive Form initialed 8/3/14 indicated Resident 1 was forgetful, had positioning pillows for safety, and a bed and chair alarm. No other interventions were documented. Review of Resident 1's Nurse's Notes indicated on 8/3/14, 8/4/14, and 8/5/14, Resident 1 had occasional episodes of confusion and forgetfulness. On 8/5/14, Resident 1's physician was contacted to obtain an order for [REDACTED]. On 8/16-8/20/14, Resident 1 had continued episodes of confusion and increased anxiety. Review of Resident 1's Psychology Consult evaluation dated 8/7/14, indicated Resident 1 had an episode of confusion, dizziness and shortness of breath. He documented "the question is the cause of her decline in cognitive functioning from the time of admission." Review of Resident 1's care plan, revised 8/5/14, to address her fall risk of 15, indicated an approach plan was to use bed and wheelchair alarms (alarm used to alert the staff when a resident is attempting to get up unassisted). Review containing Resident 1's cognitive pattern care plan was updated and revised on 8/8/14, and indicated Resident 1's mental status changed and she now had short and long term memory impairments. Further review of Resident 1's clinical record showed a FAX dated 8/15/14 directed to a physician from the facility which indicated Resident 1 had increased confusion for three days. Review of Resident 1's Screening Referral to Rehabilitation Services dated 8/21/14, indicated the staff requested a screening secondary due to Resident 1's decline in health. The physical therapist documented "it became apparent that her (Resident 1) functional mobility declined significantly in the past three weeks." On 8/21/14 at 6:25 p.m., a licensed nurse documented Resident 1 was found face down on the floor. The resident's head was bleeding, an alarm was sounding and the bed was not in the lowest position. At 9:30 p.m., Resident 1 was transported to the hospital emergency room . Review of Resident 1's Communication Form dated 8/21/14, showed Resident 1 fell out of bed and had increased confusion. Review of CNA C's Investigator's Interview/Statement of Event dated 8/21/14, indicated CNA C found Resident 1 lying face down on the floor, and bleeding. She documented the bed "was so high" and Resident 1 kept repeating "help me; I am bleeding." Review of licensed vocational nurse (LVN) B's interview statement dated 8/21/14, indicated on 8/21/14 at 4:40 p.m., Resident 1 was restless and tried to get out of bed. LVN B documented she told the resident to relax and not to get out of bed. Review of registered nurse (RN) A's interview statement dated 8/21/14, indicated she observed Resident 1 face down the floor and her head was bleeding. The resident's bed was in a high position (raised above the floor). During an interview on 9/2/14 at 9:50 a.m., RN D stated Resident 1 was alert with periods of confusion. She stated Resident 1's mental status had declined since her admission on 6/14. RN D stated prior to Resident 1's fall on 8/21/14, she had witnessed Resident 1 trying to climb out of bed and a physician's orders [REDACTED]. When RN D was asked the interventions that would be implemented for a resident with a high risk for falls, she stated a pad alarm, low bed and floor mats. She confirmed Resident 1 was a high risk for falls and thought Resident 1 had a low bed and floor mats in place. On 9/2/14 at 10:25 a.m., a telephone interview was conducted with LVN B. She stated Resident 1 was alert with periods of confusion. LVN B stated on 8/21/14, around dinner time, a CNA told her Resident 1 was face down on the floor and bleeding from her head. She stated upon entering Resident 1's room, she found Resident 1 lying on the floor on the left side of her bed. LVN B stated Resident 1 had "a lot of blood" on the right side of her face and "it looked really deep." The pad alarm was sounding and the resident's bed was in a high position. LVN B stated she did not think Resident 1 had floor mats in place. During a telephone interview on 9/2/14 at 10:45 a.m., RN A stated Resident 1 is alert with periods of confusion. She stated on 8/21/14, a CNA told her Resident 1 fell out of the bed. RN A stated upon entering Resident 1's room, she observed Resident 1 lying on the left side of the bed and had a moderate amount of bleeding from her right forehead. She stated the pad alarm was beeping and the resident did not have floor mats. During an interview on 9/2/14 at 10:50 a.m., the interim director of nurses (DON) stated Resident 1 was disoriented. She stated on 8/21/14, she observed Resident 1 lying on the left side of her bed and had a large amount of bleeding coming from the resident's right orbit (eye). She was unable to recall if Resident 1 had floor mats in place. The DON stated Resident 1's fall could have been prevented if more interventions were implemented. Review of Resident 1's emergency room discharge instructions dated 8/21/14, indicated she was treated for [REDACTED]. Review of Resident 1's computerized tomography scan (CT scan: X-ray images) dated 8/21/14 indicated Resident 1 had an altered level of consciousness (change in mental condition) after her fall. The results showed the resident sustained [REDACTED]. Review of Resident 1's emergency room history and physical dated 8/21/14, indicated Resident 1 fell out of bed and sustained a 1.5 centimeter laceration to the right side of her head, requiring sutures. On 8/22/14 at 5:30 a.m., a licensed nurse documented Resident 1 returned from the hospital at midnight following the resident's fall. Upon examination, Resident 1 had sutures to her right forehead, a small skin tear to her right forearm, bruises to her right hand and left shin, both knees had abrasions and were slightly swollen and bruised and the resident had bruising under her right eye. The licensed nurse documented Resident 1 would have a 1:1 sitter (a person to stay with the resident at all times for safety) until full siderails were installed.