Every finding on record at Laconia Rehabilitation Center

Based on interview and record review, the facility failed to ensure that the activities program was directed by a qualified professional for a facility census of 106 residents.Findings include:Interview on 7/1/26 at approximately 10:15 a.m. with Staff D (Administrator) revealed Staff T (Activities Director) started in mid-May 2026 but had been on leave since the beginning of June 2026. Staff D revealed that Staff T did not have the qualifications required to direct the facility's activities program. Staff T's previous position at the facility was the front desk receptionist. The facility was registering Staff T for an activities training program this fall. Staff D stated that they were covering for Staff T. Staff D revealed they also did not have the qualifications required to direct the facilities activities program. Staff D revealed they developed the monthly activities calendars and resident care plans for activities. Review on 7/2/26 of Staff D's resume revealed that they had education in Psychology, Business, Public Administration, and Health Care. Staff D's experience did not include experience in a social or recreational program/therapeutic activities program.

Based on interview and record review, the facility failed to ensure that irregularities identified by the pharmacist during the monthly Drug Regimen Review (DRR) were reviewed by the provider and that the provider documented their rationale for the action taken for the pharmacy recommendation for 4 of 5 residents reviewed for unnecessary medications in a final sample of 23 residents (Resident Identifiers are #1, #6, #8 and #30). Findings include: Resident #8 Review on 7/1/26 of Resident #8's DRRs revealed a note written by pharmacy, dated 11/21/25, that stated, .see report for comments/recommendations. Review on 7/1/26 of Resident #8s medical record revealed no DRR recommendation for 11/21/25. Interview on 7/01/26 at approximately 1:15 p.m. with Staff N (Director of Nursing) revealed the above DRR recommendation was not available, and Staff N did not know what the recommendation was or if it was reviewed by the medical provider. Resident #1 Review on 7/1/26 of Resident #1's DRRs revealed a note, dated 4/23/26, that stated .see report for comments/recommendations. Review on 7/1/26 of Resident #1's medical record revealed there was no documentation of the DRR recommendation for 4/23/26. Interview on 7/1/26 at approximately 2:00 p.m. with Staff N revealed the above DRR recommendation was not available, and Staff N did not know what the recommendation was or if it was reviewed by the medical provider. Resident # 6 Review on 7/1/26 of Resident #6's DRRs revealed notes, dated 3/24/26, 4/24/26, and 5/23/26, that stated, .see report for comments/recommendations. Review on 7/1/26 of Resident #6's medical record revealed there was no documentation of the DRR recommendation for 3/24/26, 4/24/26 and 5/23/26. Interview on 7/1/26 at approximately 2:00 p.m. with Staff N (Director of Nursing) revealed the above DRR recommendations were not available, and Staff N did not know what the recommendation was or if it was reviewed by the medical provider. Resident #30 Review on 7/1/26 of Resident #30's Pharmacy MRR dated 5/22/26 revealed the following recommendation to the provider, This resident is currently receiving metoprolol tartrate 12.5 mg [milligrams] once daily for HTN [hypertension] treatment. This mediation is usually dosed BID [twice daily], please review and clarify if this order should be Tartrate form BID or Succinate form once daily. discharged med [medication] from Hospital was Metoprolol Succinate ER 12.5 once daily - please update order to correct medication. Further review revealed that the provider wrote Reviewed and signed and dated the form on 6/3/26. The provider did not indicate if they accepted or declined the MRR recommendation, and the provider did not indicate a rationale for any action taken. Review on 7/1/26 of Resident #30's physician's order revealed an active order for Metoprolol tartrate 12.5 mg once daily, with a start date of 6/25/26. Review on 7/1/26 of Resident #30's medical record revealed no provider's rationale regarding why the Metoprolol order was not changed. Interview on 7/1/26 at 2:23 p.m. with Staff N confirmed the above findings. Review on 7/1/26 of the facility's policy titled Medication Monitoring Medication Regimen Review and Reporting dated January 2024 revealed, . 6. Resident-specific MRR recommendations and findings are documented and acted upon by the nursing care center and/or physician . 8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. a. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical record

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were labeled according to professional standards on 5 of 5 medication carts observed. Findings include: TCU (Transitional Care Unit) Observation on 6/29/26 at approximately 8:20 a.m. of the TCU Back Medication Cart revealed the following expired medications: Resident #50's Fiasp insulin pen, labeled with an open date of 5/23/26 and open/expiration date of 6/19/26. Resident #9's Fluticasone Propionate/Salmeterol inhaler, labeled with an open date of 3/24/26. Interview on 6/29/26 at approximately 8:20 a.m. with Staff A (Registered Nurse (RN)) confirmed the above findings. Review on 6/29/26 of the manufacturer's instruction for Fiasp, Revision Date 6/23 revealed, . In use 3 ml (milliliter) single patient pen, in use (opened) good for 28 days. Review on 6/29/26 of the manufacturer's instructions for Fluticasone Propionate/Salmeterol inhaler, Revision Date 9/22, revealed, Discard fluticasone propionate and salmeterol inhalation powder 1 month after opening the foil pouch . Observation on 6/29/26 at approximately 8:30 a.m. of the TCU Front Medication Cart revealed a 70/30 insulin pen opened, with no resident identifier. Interview on 6/29/26 at approximately 8:30 a.m. with Staff E (RN) confirmed the above findings. Opechee Unit Observation on 6/29/26 at approximately 8:35 a.m. of the Opechee Medication Cart #1 revealed Resident #23's opened Fluticasone Propionate/Salmeterol inhaler with no date opening/open-expiration date. Interview on 6/29/26 at approximately 8:35 a.m. with Staff F (RN) confirmed the above findings. Lakeport Unit Observation on 6/29/26 at approximately 8:50 a.m. of the Lakeport Medication Cart revealed the following medication not labeled with a date of opening or an open-expiration date: Resident #12's Latanoprost eye drops, Resident #86's Ozempic pen, Resident #94's Spiriva inhaler and Resident #6's Fluticasone Propionate/Salmeterol inhaler. Interview on 6/29/26 at approximately 8:50 a.m. with Staff G (Licensed Practical Nurse) confirmed the above findings. Review on 6/29/26 of the manufacturer's instructions for Latanoprost eye drops, undated, revealed, . Once a bottle is opened for use, it may be stored at room temperature . for 6 weeks. Review on 6/29/26 of the manufacturer's instructions for Ozempic, Dated 2017, revealed, . The Ozempic pen you are using should be thrown away after 56 days, even if it still has Ozempic left in it. Review on 6/29/26 of the manufacturer's instructions for Spiriva Respimat inhaler, Dated 2025, revealed, . After, assembly, The Spiriva Respimat inhaler should be discarded at the latest 3 months after first . Winnisquam Unit Observation on 6/29/26 at approximately 9:00 a.m. of the Winnisquam Front Medication Cart revealed the following medication not labeled with a date of opening or an open-expiration date: Resident #65's two Lantus insulin pens, Resident #56's Humalog insulin pen, and Resident #102's Lantus insulin pen. Interview on 6/29/26 at approximately 9:00 a.m. with Staff H (RN) confirmed the above findings. Review on 6/29/26 of the manufacturer's instructions for Lantus Solostar insulin pen, undated, revealed, You can store your Lantus Solostar for 4 weeks after it has been activated. After this time, you must throw it away, even if there is some medicine left in it . Review on 6/29/26 of the manufacturer's instructions for Humalog insulin, Revision Date 3/2013, revealed, . Humalog Kwikpen In-Use (Opened) Room Temperature, . good for 28 days .

Based on observation, record review, and interview, the facility failed to keep residents free from physical restraints for 1 of 1 resident reviewed for physical restraints in a final sample of 23 residents (Resident identifier is #38).Findings include:Observation on 6/29/26 at approximately 9:45 a.m. and at approximately 12:00 p.m. revealed Resident #38 sitting in their scoot Broda chair in the common area with the back of their chair up against the wall and both wheel brakes locked. Interview on 6/29/26 at approximately 12:00 p.m. with Staff G (Licensed Practical Nurse) confirmed that Resident #38's wheels were locked. Staff G stated that Resident #38's wheels are locked so they can keep an eye on him/her because they will go all over the place if their wheels are not locked.Observation on 6/30/26 at approximately 8:15 a.m. revealed Resident #38 sitting in their scoot Broda chair in the common area with both their wheels locked and an empty tray table in front of him/her. Resident #38 was moving their pelvis back and forth and was pushing backwards in chair causing the front wheels to come off the ground several times.Review on 6/30/26 of Resident #38's physician's orders, assessments, and care plan revealed no restraint orders, restraint assessment or restraint care plan in place for locking the wheels on Resident #38's Broda chair, limiting their movement. Interview on 7/1/26 at approximately 8:30 a.m. with Staff M (Unit Manager) confirmed that there were no restraint orders, restraint assessment or restraint care plan in place for locking the wheels on Resident #38's Broda chair, limiting their movement.

Based on interview and record review, the facility failed to follow physician orders for 1 resident in a final sample of 23 residents. (Resident identifier is #9.) Findings include:[NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Page 672 .seven rights of medication administration include right medication, right dose, right patient, right route, right time, right documentation and right indication . Review on 6/30/26 of Resident #9's June 2026 MAR (Medication Administration Record) revealed the following physician's order:Midodrine HCL (hydrochloride) Oral Tablet 2.5 mg (milligram), Give 1 tablet by mouth three times a day for Hypotension, hold for SBP (systolic blood pressure) over 120 ., Start Date 6/19/26. Further review revealed the resident received Midodrine when the SBP was above the ordered parameter:6/20/26 9:00 a.m., SBP 154/66, 6/20/26 1:00 p.m. SBP 152/75, 6/20/26 9:00 p.m. SBP 130/77, 6/21/26 1:00 p.m SBP 136/83, 6/21/26 9:00 p.m. SBP 136/83,6/22/26 9:00 p.m. SBP 123/68,6/26/26 9:00 p.m. SBP 140/71, and6/28/26 1 :00 p.m. SBP 124/62. Interview on 6/30/26 at approximately 2:00 p.m. with Staff N (Director of Nursing) confirmed the above findings.

Based on observation, interview, and record review, the facility failed to provide supervision and assistance at meals for 1 of 5 resident reviewed for ADL's (Activities of Daily Living) in a final sample of 23 residents. (Resident identifier is #94).Findings include:Observation on 6/30/26 at approximately 8:15 a.m. of Resident #94 revealed him/her to be sitting in their wheelchair in common room with meal tray in front of them. Resident #94 was attempting to eat their breakfast. Resident #94 was noted to have a moderate amount of ground sausage and cut up pancakes in their lap and on the floor around their chair. Resident #94 was using their fingers trying to pick up their ground breakfast sausage and would drop it before getting it to their mouth. There were no staff visible in the common area to assist or supervise Resident #94.Observation on 6/30/26 at approximately 8:40 a.m. of Resident #94 revealed him/her to be sitting in the common area being assisted with their breakfast by their Durable Power of Attorney for Healthcare (DPOA-HC).Interview on 6/30/26 at approximately 9:00 a.m. with Resident #94's DPOA-HC revealed that they have requested staff assist Resident #94 with meals as he/she struggled and food ends up on the floor and on their lap. Resident #94's DPOA-HC stated that they have not seen staff assisting him/her with the meal when they visit and they are in the facility a few times a week at meal time.Review on 6/30/26 of Resident #94's care plan revealed the following care plan focus areas and interventions: Resident exhibits or is at risk for impaired swallowing related to Parkinson's disease, initiated on 6/12/26, with the following interventions: Provide supervision to partial mod [moderate] assistance during meals, initiated 6/23/26, encourage small sips/bites and cue as needed, initiated 6/12/26, encourage resident to chew and swallow each bite, initiated 6/12/26, encourage resident to perform chin tuck, initiated 6/12/26, Monitor for signs/symptoms of aspiration i.e. coughing, watery eyes, choking, moist sounding voice, initiated 6/12/26, if coughing occurs, no food/fluids until cough resolves, initiated 6/12.26.; At risk for decreased ability to perform ADL(s)(Activities of Daily Living), initiated 12/9/25, with an intervention to provide with set up to partial/moderate assist of one for eating, initiated 12/9/25; and Restorative swallowing: Patient demonstrates difficulty with swallowing (related to) Parkinson's , initiated 6/9/26, with the following interventions: Help assist with eating during meals, as well as provide verbal cues to maintain safety, initiated 6/9/26, Use verbal cues to guide patient through the meal, initiated 6/9/26, Allow for adequate time and support, initiated 6/9/26, Encourage patient to alternate liquids and solids, initiated 6/9/26.

Based on observation, interview, and record review, the facility failed to ensure that activities were provided to support residents based on the resident's choices and care plan for 1 out of 2 residents reviewed for activities in a final sample of 23 residents (Resident Identifier is #9). Findings include: Observation on 6/29/26 at approximately 9:30 a.m revealed Resident #9 was in his/her room light was off, television not on, and music not playing while he/she was awake sitting in a chair. Resident #9 was observed multiple times wandering in the hallways of the unit, going through the trash and attempting to go into other resident rooms. Observation on 6/29/26 from approximately 11:30 a.m. through 12:20 p.m. on the TCU Unit outside of the nursing station revealed Resident #9 in his/her wheelchair rummaging through a trash located by the sink. Resident #9 then stood up out his/her wheelchair and began touching the nursing station, portable vital signs machine (including the blood pressure coughs), and the top and drawers of the treatment cart. Review on 7/1/26 of the Recreation Participation Record revealed that Resident #9 did not have any activities documented for 6/29/26. Further review of June 2026 revealed the following: Preferences Group Engagements: Not Applicable was checked on 6/2, 6/3, 6/4, 6/5, 6/6, 6/7, 6/8, 6/10, 6/11, 6/12, 6/16, 6/17, 6/18, 6/19, 6/21, 6/22, 6/23, 6/27. and 6/28. Resident Not Available was checked on 6/9, 6/13, 6/15, 6/20,6/23, 6/24, 6/25, 6/26, and 6/30. Interview on 7/1/26 at approximately 10:30 a.m. with Staff O (Activities Assistant) revealed that they select Not Applicable when a resident did not attend an activity on the Preferences for Group Engagements. Further interview revealed that Staff O had not offered any activities to Resident #9 and does not know what Resident #9's preferences were for activity involvement. Interview on 7/1/26 at approximately 9:00 a.m. with Staff R (Recreation Assistant) revealed that he/she was not aware if Resident #1 had been invited to any group activities over the last month. Further interview revealed that Resident #9 is not able to self initiate attending an activity due to his/her cognitive status. Review on 7/1/26 of the facility's Activity Calendar for June 2026 revealed that there was a Coffee Social daily at 10:00 a.m. On 6/29/26, there was Music with a performer at 2:00 p.m. Review on 7/1/26 of Resident #9's MDS (Minimum Data Set) dated March 13, 2026, revealed, Section F (Preferences for Customary Routine and Activities, . F0500. Interview for Activity Preferences revealed:A. how important is it to you to have books, newspapers, and magazines to read? coded 1. Very importantB. how important is it to you to listen to music you like? coded 1. Very importantC. how important is it to you to be around animals such as pets? coded 2. Somewhat importantD. how important is it to you to keep up with the news? Coded 2. Somewhat importantE. how important is it to you to do things with groups of people. Coded 2. Somewhat importantF. how important is it to you to do your favorite activities? Coded 2. Somewhat importantG. how important is it to you to go outside to get fresh air when the weather is good? Coded 1. Very importantH how important is it to you to participate in religious services or practices. Coded 1. Very important Review on 7/1/26 of Resident #9's care plans, Revision Date 6/9/26 revealed the following: Focus, While in the facility, [name omitted] states that is important that he/she has the opportunity to engage in daily routines that are meaningful relative to their preferences. Interventions: Encourage and facilitate [name omitted] activity he/she doesn't go to activities, . It is important for me to have reading materials, Newspaper, I enjoy listening to music country, I keep up with the news by discussions with another person reading the newspaper, watching TV (television), I like to participate in socializing and being outside with groups of people, I like to do crosswords/puzzles/games, listen to music, look out the window, lay down/rest, read, think, watch TV/movies, and or other by myself in my bedroom, I enjoy watching/listening TV, . I am of the blank faith and would like to participate in religious services/practices such as blank. (specify type) ., and I would benefit from accommodation for cognitive limitations by using decreased ., single step activity, small groups, time limited, verbal prompts, .

Based on interview and record review, the facility failed to ensure that the residents' environment remained as free as possible from accident hazards for 1 of 2 residents reviewed for falls in a final sample of 23 residents (Resident identifier is #94).Findings include:Interview on 6/30/26 at approximately 9:00 a.m. with Resident #94's Durable Power of Attorney for Health Care revealed that they were concerned with the number of falls that Resident #94 has had.Review on 6/29/26 of Resident #94's Progress notes for June 2026 revealed the following falls were documented:6/23/26 seen falling out of wheelchair while trying to reach and touch the ground;6/26/26 seen lying on the ground, head against bedside table, unable to give description;6/27/26 found on floor with bedside table on them, unable to give description. Review on 6/29/26 of Resident #94's care plan revealed no new interventions were put into place after the above falls. Interview on 6/30/26 at approximately 2:15 p.m. with Staff B (Interim Director of Nursing) confirmed that no root cause analysis was done for the above falls and no interventions put into place in an effort to prevent further falls or injury.

Based on observation, interview, and record review, the facility failed failed to follow infection control standards for cleaning and disinfecting 2 out of 5 glucometers observed. Findings include: Glucometers Observation on 6/29/26 at approximately 8:20 a.m. of the TCU Back Medication Cart revealed two glucometers in black cloth cases. Further observation revealed that both glucometers had dried red/brown substance adhered to the glucometers. One of the glucometers also had tape on it. Interview on 6/29/26 at approximately 8:20 a.m. with Staff A (Registered Nurse) revealed that the two glucometers were ready for use in the case. Staff A confirmed the above findings. Review on 6/30/26 of the facility procedure titled, Fingerstick Glucose Monitoring, Revision Date 7/15/25, revealed, . 23. Clean and disinfect the blood glucose meter after use with EPA (Environmental Protection Agency) approved disinfectant, following manufacturer's instructions . Review on 6/306/26 of the manufacturer's instructions for [company name omitted], undated, revealed, . Cleaning and Disinfecting your [company name omitted] Meter . Cleaning and disinfecting the meter . is very important in the prevention of infectious disease. wipe all external areas of the meter including both front and back surfaces until visibly clean .

Resident #6 Review on 5/30/25 of Resident #6's care plan meeting notes revealed that Resident #6 had care plan meetings on 11/29/24 and 1/10/25. There was no evidence of a quarterly care plan meeting documented after 1/10/25. Resident #22 Interview on 5/28/25 with Resident #22 at approximately 11:30 a.m. revealed that Resident #22 reported that he/she had was not invited or participated in a care plan meeting for about 6 months. Review on 5/30/25 of Resident #22's care plan meeting notes revealed that Resident #22 had a care plan meeting on 11/27/24. Interview on 5/30/25 at approximately 10:50 a.m. with Staff D (Regional Nurse) confirmed that there is no evidence of quarterly care plan meetings being completed after 11/27/24. Resident #23 Review on 5/30/25 of Resident 23's care plan meeting notes revealed that Resident #23 had a care plan meeting on 9/7/24 and 5/1/25. Further review revealed that there was no evidence of a quarterly care plan meeting documented in December of 2024 or March of 2024. Resident #29 Review on 5/30/25 of Resident #29's medical record revealed that Resident #29 was admitted to the facility on 9/22. Further review revealed that the last documented care plan meeting was on 3/15/24. Resident #57 Review on 5/30/25 of Resident #57's medical record revealed revealed that Resident #57 was admitted in date December of 2024. There was no evidence of care plan meetings being held. Resident #73 Review on 5/30/25 of Resident #73's medical record revealed that Resident #73 was admitted to the facility on [DATE]. Further review of Resident #73's medical record revealed that the last documented care plan meeting was 12/16/24. Resident #80 Review on 5/30/25 of Resident #80's care plan meeting notes revealed that Resident #80 had a care plan meeting on 11/8/24 and 5/8/25. Further review revealed that there is no evidence of a quarterly care plan meeting documented after 11/24 and before 5/25. Resident #86 Review on 5/30/25 of Resident #86's medical record revealed that Resident #86 was admitted to the facility on [DATE]. Further review of Resident #86's medical record revealed no documentation of a care plan meeting. Resident #94 Review on 5/30/25 of Resident #94's medical record revealed Resident #94 was admitted to the facility in January 2024. There was a care plan meeting note dated 4/23/25. Further review revealed that there was no documentation of a care plan meeting for Resident #94 between January 2024 and 4/23/25. Interview on 5/30/25 at approximately 1:00 p.m. with Staff H (Unit Manager) confirmed the above findings and that there was no documentation of a care plan meeting for Resident #94 prior to 4/23/25. Resident #105 Review on 5/30/25 of Resident #105's was admitted on [DATE] and has not had a care plan meeting. Interview on 5/30/25 at approximately 1:30 p.m. with Staff A (Administrator) confirmed that there was no evidence documented of care plan meetings being held after a comprehensive assessment for Resident #6, #22, #23, #29, #57, #73, #80, #85, #86, #94, and #105. Review on 5/30/25 of the facility's Policy OPS416: Person- Centered Care Plan revealed the following . The care plan will be reviewed and revised by the interdisciplinary team after each assessment 10. Care plan meetings will be documented by use of the Care Plan Meeting note. Based on record review and interview, it was determined that the facility failed to hold routine interdisciplinary care plan meetings and revised care plans for 11 of 24 residents reviewed for care planning in a final sample of 24 residents. (Resident identifiers are #6, #22, #23, #29, #57, #73, #80, #85, #86, #94, and #105.) Findings include: Resident #85 Interview on 5/30/25 at approximately 11:30 a.m. with Staff G (Registered Nurse) revealed Resident #85 eats everything given to him/her, will eat clothing and they are unable to give him/her anything or Resident #85 will put it in his/her mouth. In the past they tried foam blocks and Resident #85 tore at them and tried to eat those. Interview further revealed Resident #85 had past surgery to remove a bottle cap he/she had eaten prior to admission. He/she gets one on one throughout the day by all staff and has a private room due to his pica (Pica is a mental health condition where a person compulsively swallows non-food items.) Review on 5/30/25 of Resident #85's care plans revealed no interventions to address Resident #85's pica. Review on 5/30/25 of Resident #85's care plan meetings revealed evidence of only one care plan meeting held on 12/23/24, since admission.

Based on interview and record review, it was determined that the facility failed to report an injury of unknown source timely to the State Survey Agency (SSA) for 1 of 2 residents reviewed for accidents in a final sample of 24 residents (Resident identifier is #7). Findings include: Review on 5/30/25 of Resident #7's medical records revealed a nurses note, dated 5/25/25, that stated Resident #7 had been sent to the emergency room for evaluation due to complaints of right wrist pain. Further review of Resident #7's medical record revealed a nurses note, dated 5/26/25, .brace for right wrist fx (fracture) .can be worn as long as needed for comfort and support. No other acute findings . Interview on 5/30/25 at approximately 9:00 a.m. with Staff A (Administrator) revealed that they were told about Resident #7's injury on 5/26/25. Staff A revealed that the source of the injury is unknown. Staff A confirmed that it was not reported to the SSA. Review on 5/3/25 of facility policy titled Abuse Prohibition, dated 1/24/22, revealed: 6.4 Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected . 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment or neglect, the Administrator or designee will perform the following. 7.3 Report allegations the the appropriate stated and local authority(s) involving .exploitation or mistreatment (including injuries of unknown source) .

Based on record review, interview, and policy review, it was determined that the facility failed to establish and maintain a system of records of receipt and disposition of controlled drugs in sufficient detail to enable an accurate reconciliation for 3 out of 7 residents reviewed for controlled drugs (Resident Identifiers are #2, #6, and #7). Findings Include: Resident #7 Review on 10/1/24 of the controlled drug record for the Opechee Cart #1 for Resident #7's Diazepam 10 milligram (mg) tablets revealed that there were 22 tablets remaining on 9/30/24 at 8:20 a.m. Observation on 10/1/24 at approximately 9:20 a.m. with Staff A (Registered Nurse (RN)) of Resident #7's Diazepam 10 mg medication card revealed that there were 21 tablets remaining in the medication card. Interview on 10/1/24 at approximately 9:21 a.m. with Staff A confirmed the above findings. Resident #6 Review on 10/1/24 of the controlled drug record for Winnisquam D Cart for Resident #6's Clonazepam 0.5 mg tablets revealed that there were 58 tablets remaining on 10/30/24 at 10 p.m. Observation on 10/1/24 at approximately 9:30 a.m. with Staff C (Licensed Practice Nurse (LPN)) of Resident #6's Clonazepam 0.5 mg medication card revealed that there were 57 tablets remaining in the medication card. Interview on 10/1/24 approximately 9:31 a.m. with Staff C confirmed the above findings. Staff C stated that he/she gave Resident #6 his/her Clonazepan 0.5 mg around 8:00 a.m. and he/she didn't document the information on the controlled drug record sheet when he/she administered the medication. Resident #2 Review on 10/1/24 of Resident #2's controlled drug record for Oxycodone 5 mg revealed that there were 50 tablets remaining on 9/25/24. An entry revealed on on 9/26/24, one tablet was administered with 59 tablets left, not 49. The administration entries continued to decrease with each dose from the count of 59 and not 49 and there were 10 entries with the incorrect count and staff did not identify that the count was incorrect. Interview on 10/1/24 at 12:40 p.m. with Staff B (Director of Nursing) confirmed the above finding. Review on 10/01/24 of the facility policy titled, Controlled Drugs: Management of, revision date of 7/17/24, revealed: .Ongoing inventory: A complete count of all scheduled II-IV controlled substances is required at change of shift .The count must be performed by two licensed nurses and/or authorized nursing personnel .Destruction: Two licensed professionals are required to destroy and document destruction of controlled substances . 47129

Based on observation, policy review, and interview, it was determined that the facility failed to maintain locked storage of medications and biologicals in 1 of 3 medication carts. Findings include: Observation on 10/1/24 at 12:30 p.m. of Staff A (Registered Nurse) revealed they were at the Opechee Unit medication cart and walked into the medication room, leaving the medication cart unlocked in the hallway and out of sight until 12:33 p.m. with no other staff in the area of the medication cart. One resident was in the hallway in the area of the medication cart. Interview on 10/1/24 at 12:35 p.m. with Staff A confirmed the above findings. Review on 10/2/24 of the facility's policy, Storage and Expiration Dating of Medication, Biologicals, revised 8/7/23, revealed: .3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that activities were provided to support residents based on the resident's choices and care plan for 1 out of 1 residents reviewed for activities in a final sample of 23 residents (Resident Identifier is #106). Findings include: Resident #106 Observation on 5/29/24 at 9:48 a.m. in Resident #106's room revealed that Resident #106 was awake in her wheelchair with the television off. Resident #106 was staring into the hallway. Interview on 5/29/24 at 11:49 a.m. with Resident #106's family member revealed that he/she was concerned of the lack of music or television when he/she comes to visit Resident #106. Resident #106's family stated that Resident #106 may not be able to participate in activities, however Resident #5 can still listen, especially to activities like live music. He/She stated that Resident #106 was a singer and loved music, especially classical. Observation on 5/29/24 at 1:53 p.m. of the dining room revealed that there was a musician playing music for residents. Observation on 5/29/24 at 1:55 p.m. in Resident #106's room revealed that Resident #106 was awake in her wheelchair watching television. Observation on 5/30/24 at 9:00 a.m. in Resident #106's room revealed that Resident #106 was awake in bed with the television off and no music playing. Interview on 5/30/24 at 12:09 p.m. with Resident #106's family revealed that when he/she arrived, Resident #106 was resting in bed. He/she stated that they noticed there was a music activity going on in the dining room yesterday and they said no one came into the room and asked if Resident #106 wanted to go. He/She stated that he/she would like Resident #106 to be asked, and the resident would decide if they felt up to going or not. Review on 5/30/24 of Resident #106's medical diagnoses revealed that Resident #106 had a diagnosis of advanced Parkinson's disease with Dementia. Review on 5/30/24 of Resident #106's Recreation Comprehensive Assessment, dated 1/19/24, and completed by Resident #106's family revealed the following: -Very important to listen to music; -Interested in pet visits; -Very important to do things with groups of people, likes to socialize or just be present during group activities; -Very important to watch or listen to television. Review on 5/30/24 of Resident #106's current activity care plan revealed that Resident #106 enjoyed listening to classical music, watching television, to participate in music performances, and to go outside when the weather was nice. Review on 5/30/24 of Resident #106's March, April, and May's activity participation record revealed no documented activity participation. Interview on 5/30/24 at 12:30 p.m. with Staff F (Director of Activities) confirmed the above findings. Staff F stated he/she was not sure what Resident #106 preferences because he/she did not do his/her recreation assessment. Interview further revealed that if a resident declined an activity when asked to go, it would be documented on the resident's activity participation record. Interview on 5/30/24 at 12:30 p.m. with Staff G (Activity Aid) revealed that Resident #106 was not asked to go to the live music activity the day prior by Staff G. Staff G stated that he/she started working at the facility in the beginning of May and was unaware of what Resident #106 liked to do for activities. Interview on 5/30/24 at 1:00 p.m. with Staff H (Licensed Nursing Assistant) revealed that Resident #106 liked to watch television. Interview further revealed that Resident #106 was not asked to go to group activities. Review on 5/30/24 of the facility's policy titled, Program Design, revision dated 4/1/18, revealed: .2. The Recreation Department will create a program environment that supports a person's wellbeing and wellness. 3. Group, individual, and independent programs are reflective of the resident's/patient's comprehensive assessments and care plans and the preferences of each resident/patient and will be adapted to ensure participation Review on 5/30/24 of the facility's policy titled, Resident's/Patient's Choice, revision dated 4/1/18, revealed: .2. Residents/Patients will be invited to attend activities and will be provided the opportunity to participate in structured and individual programs. 3.1 Preferences for individuals who have dementia will be determined through communication with the resident/patient, family, friends, and caregivers. 3.2 Assistance will be provided for residents/patients who wish to participate but are not able to get to activities on their own. 4. Resident/Patients who prefer not to participate in structured activities will be offered alternatives and necessary support/resources for meaningful individual pursuit of leisure interests .

Based on observation, interview, and record review it was determined that the facility failed to maintain infection control practices in regards to cleaning equipment during wound care in 1 out of 1 observations of pressure ulcer care observed in a final sample of 23 residents (Resident Identifier is #27). Findings include: Review on 5/31/24 of Resident #27's Skin and Wound Evaluation, dated 5/28/24, revealed that Resident #27 had a Deep Tissue Pressure Injury to the right dorsum hallux of the foot, measuring 0.1 by 0.4 by 0.5 centimeters. Review on 5/31/24 of Resident #27's May 2024 Treatment Administration Record revealed the following treatment orders: Cleanse pressure injury to right foot base of great toe with [wound cleanser], pat dry. Cover with oil emulsion to wound bed only, cover with non adherent foam and .wrap with a gauze bandaged roll every 3 days with a start date of 4/26/24. Cleanse [NAME] injuries to right calf with wound cleanser, pat dry, skin repair cream to dry periwound, apply oil emulsion if open area exist, cover with [foam dressing] . wrap with a gauze bandaged roll every 3 days with a start date of 4/19/24. Observation on 5/31/24 at 1:30 p.m. of Staff B (Licensed Practical Nurse) provided wound care to Resident #27's right lower leg/foot area and revealed that there was a bandaged roll, dated 5/28/24, that wrapped the resident's right calf and foot. Staff B cut the bandaged roll with clean scissors and removed the dirty dressings, revealing three different wounds; one to the right hallux (big toe joint) area, and two areas on the lower leg/calf. It was observed that there was serosanguineous drainage to the right hallux dripping down the foot. Staff B placed the dirty scissors on the clean field, removed his/her gloves and washed their hands. Further observation of the wound care revealed that Staff B used the dirty scissors to cut an oil emulsion dressing to the wound bed size, and placed it directly to the right hallux area wound bed. Staff B then used the same scissors to cut a non border foam dressing and bandage roll to cover the oil emulsion dressing. Further observation revealed Staff B also used the same dirty scissors to cut the oil emulsion dressing to the wound bed size to the 2 wounds on the calf. Interview on 5/31/24 at 2:00 p.m. with Staff B confirmed that he/she did not disinfect the scissors between the dirty and the clean dressing change. Staff B stated that he/she would have cleaned the scissors if they had touched the wound bed. Interview on 5/31/24 at 2:30 p.m. with Staff D (Director of Nursing) confirmed that he/she would expect that the scissors would be cleaned between the dirty and clean dressing change. Review on 6/3/24 of the Centers for Disease Control and Prevention's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, retrieved on 6/3/24 from https://www.cdc.gov/infection-control/hcp/core-practices/index.html, revealed: .Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered . The practices outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care . The core practices in this document should be implemented in all settings where healthcare is delivered. These venues include both inpatient settings (e.g., acute, long-term care) . 5f. Reprocessing of Reusable Medical Equipment References and resources . Maintain separation between clean and soiled equipment to prevent cross contamination . 37488

Based on observation, record review, and interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 3 of 23 residents reviewed for MDS in a final sample of 23 residents (Resident Identifiers are #40, #45, and #112). Findings include: Resident #45 Observation on 5/29/24 at approximately 10:00 a.m. revealed Resident #45 in bed with a tracheotomy and ventilator in place. Review on 5/31/24 of Resident #45 Significant Change MDS, with an Assessment Reference Date (ARD) of 3/18/24, revealed O0110F1B not selected for an invasive ventilator during the 14 day look back period (3/4/24 through 3/18/24). Review on 5/31/24 of Resident #45's provider orders revealed an order for ventilator settings during the 14 day look back period. Interview on 5/31/24 at approximately 10:20 a.m. with Staff C (Reimbursement Coordinator) confirmed the above findings. 37488 Resident #40 Review on 5/30/24 of Resident #40's MDS with an ARD of 4/30/24, section P0100- Restraints and Alarms revealed that the section Used in Bed; A. Bed rail was coded with a #2, indicating it was used daily. Observation on 5/30/24 at approximately 10:30 a.m. of Resident #40's bed revealed a bed rail on the side of the bed that was against the wall. Review on 5/30/24 of Resident #40's Bed Rail Evaluation, dated 3/2/24, revealed that Resident #40 utilizes two 1/4 upper rails on the bed for mobility and transfers. Interview on 5/31/24 at 8:30 a.m. with Staff C confirmed the above findings. Staff C further confirmed that Resident #40 does not have a restraint. 47129 Resident #112 Review on 5/31/24 of Resident #112's progress note dated 3/18/24 revealed that Resident #42 was being discharged to home. Review on 3/27/24 of Resident #112's Discharge - return not anticipated MDS, with an ARD date of 3/19/24, revealed under section A210507, Identification Information: Discharge Status: 07: Inpatient Psychiatric Facility was coded indicating that Resident #42 was discharged to the psychiatric hospital. Interview on 5/31/24 at 9:38 a.m. with Staff C revealed that Resident #112 was discharged to home and not the psychiatric hospital. Staff C confirmed that the MDS dated [DATE], was coded incorrectly.

Based on interview, record review, and policy review it was determined that the facility failed to properly assess the resident after a fall for 1 of 1 residents reviewed for accidents (Resident Identifier is #1). Findings include: Review on 1/4/24 of Resident #1 Brief Interview for Mental Status (BIMS) dated 9/8/23 revealed a score of 15 which indicated that Resident #1 was cognitively intact. Further review of Resident #1's physician's orders revealed the following order for an anticoagulant for Resident #1: Apixaban 5 mg [milligrams], 1 tablet by mouth every 12 hours for anticoagulant, start date 10/13/22. Interview on 1/4/24 at approximately 9:15 a.m. with Resident #1 revealed that he/she was being transported to an appointment on 11/28/23 by Staff D (Wheelchair Van Driver) via the facility wheelchair van. Interview further revealed that Resident #1 had on a waist seat belt but not a shoulder seat belt when the incident occurred. Resident #1 stated that a car pulled out in front of them and Staff D slammed on the brakes causing him/her to land on the floor of the van with Resident #1's feet tangled under the seat. Resident #1 also stated that Staff D did call the facility. Resident #1 revealed that Staff D asked a pedestrian outside of the van for help getting Resident #1 off of the van floor and back into his/her wheelchair. Interview on 1/4/24 at approximately 10:15 a.m. with Staff D revealed that Resident #1 only used a waist and not a shoulder belt at the time of the incident. Staff D further stated that Resident #1 preferred the waist restraint loose. On the way to Resident #1's appointment, Staff D had to slam on the brakes to avoid hitting another car. Staff D entered an adjacent parking lot and received assistance from a pedestrian to return Resident #1 to his/her wheelchair. Resident #1 was on the floor of the van with a contusion and bruising around the left eye, abrasions to the left knuckle, and a small skin tear on the scalp. Staff D called the facility and spoke with Staff A (Unit Clerk/Scheduler), who directed Staff D to return to the facility with Resident #1. Staff D stated he/she returned to the facility with Resident #1. Further interview revealed that Staff D was never informed prior to the incident about using a shoulder belt for transportation of residents. Review on 1/4/24 of the discharge summary from the local hospital, dated 11/28/23, revealed that Resident #1 .presented via EMS [Emergency Medical Services] for concern of head injuries after abrupt stop in a bus traveling to an appointment . was discharged back to the facility with the following issues: 4 separate areas of swelling, contusion to the left brow, periorbital area, right periorbital area, and left frontal area. 38218 Interview on 1/4/23 at approximately 9:45 a.m. with Staff A (Unit Clerk) revealed that he/she received a phone call from Staff D stating that Resident #1 was going to be late for his/her appointment due to the above incident. Staff A stated that he/she directed Staff D to come back to the facility. Interview on 1/4/23 at approximately 10:00 a.m. with Staff B (Nurse Practitioner) revealed that he/she was not in the facility when Resident #1 returned from the incident on the van. Staff B stated that he/she was notified upon Resident #1's return to the facility and sent Resident #1 to the hospital for evaluation. Staff B also revealed that with the injuries that Resident #1 had he/she would have expected emergency services to be called at the scene of the incident and for Resident #1 to be evaluated by emergency personnel. Interview on 1/4/23 at approximately 11:00 a.m. with Staff C (Licensed Practical Nurse) he/she revealed that Resident #1 returned to the facility and he/she immediately notified the on call provider and obtained an order to send the resident to the hospital for an evaluation. Review on 1/4/23 of the facility policy titled, OPS100 Accidents/Incidents, Revision Date 10/24/22 revealed: . Process 1. Response: 1.1 If an employee witnesses a patient accident/incident, the employee will: .1.1.2 Stay with individual and summon help; 1.1.3 Do Not move the individual until a physician/advanced practice provider (APP), nurse, or EMS (Emergency Medical Services) has evaluated them for possible injuries Review on 1/4/23 of the facility policy titled, NSG215 Falls Management, Revision Date 8/7/23 revealed: . Purpose . To evaluate the patient for injury post-fall and provide appropriate and timely care. . 5. Post-Fall Management 5.1 Evaluate the patient for injury. . Review on 1/4/23 of the facility policy titled, SH413 Vehicle Safety, Revision Date 4/15/23 revealed: . Seat belt use is mandatory in all company vehicles. . Authorized drivers and staff who accompany residents to outings, appointments, etc. will be provided education on vehicle safety, ., and use of wheelchair tie downs upon orientation, annually, with a change of vehicle, and as needed. . Review on 1/4/23 of the facility policy titled, Procedures to follow after a vehicle accident, undated revealed: . Contact emergency authorities immediately. . Review on 1/4/23 of Resident #1's diagnosis list revealed the following new diagnosis that occurred due to the van incident on 11/28/23: 1. Laceration without foreign body of other part of head, subsequent encounter, Onset Date 11/28/23 2. Contusion of eyeball and orbital tissues, left eye, subsequent encounter, Onset Date 11/28/23 3. Contusion of eyeball and orbital tissues, right eye, subsequent encounter, Onset Date 11/28/23 4. Unspecified injury of face, subsequent encounter, Onset Date 11/28/23 5. Other Fracture of upper and lower end of unspecified fibula, initial encounter for closed fracture, Onset Date 12/4/23 6. Other Fracture of upper and lower end of unspecified fibula, subsequent encounter for closed fracture with routine healing, Onset Date 12/4/23 7. Nondisplaced Fracture of fifth metatarsal bone, right foot, subsequent encounter for fracture with routine healing, Onset Date 12/4/23 Review on 1/4/24 of the facility provided education with staff for falls, safety management and the use of the shoulder belt for residents in wheelchairs on 11/30/23.

Based on interview and record review, it was determined that the facility failed to ensure residents with pressure ulcers had documentation of weekly assessments that contained measurements and descriptions of the pressure ulcers for 2 out of 5 residents reviewed for pressure ulcers (Resident Identifiers are #2 and #3). Resident #2 Review on 8/23/23 of Resident #2's weekly wound evaluations of their facility acquired Stage 3 pressure ulcer on their coccyx revealed the following: 8/23/23 Coccyx Stage 3 measurements 1.06 cm (centimeters) x (by) 1.52 cm; 8/10/23 Coccyx Stage 3 measurements 4.44 cm x 0.81 cm, progress stalled; 7/17/23 Coccyx Stage 3 measurements 2.9 cm x 0.5 cm, progress stalled; 6/28/23 Coccyx Stage 3 measurements 3.41 cm x 0.74 cm, progress stable; 6/9/23 Coccyx Stage 3 measurements 2.31 cm x 1.05 cm, progress stable; 5/24/23 Coccyx Stage 3 measurements 0.61 cm x 0.58 cm, progress improving. Interview on 8/23/23 at approximately 1:45 p.m. with Staff B (Director of Nursing) confirmed that Resident #2 was missing a total of 8 of the last 13 weeks. Resident #3 Review on 8/23/23 of Resident #3's weekly wound evaluations of their facility acquired Stage 3 pressure ulcer to their right heel revealed the following: 8/22/23 Right heel Stage 3 measurements 0.73 cm x 1.11 c.m.; 8/15/23 Right heel Stage 3 measurements 0.48 cm x 0.24 cm, progress improving; 8/8/23 Right heel Stage 3 measurements 0.86 cm x 0.8 cm, progress improving; 8/1/23 Right heel Stage 3 measurements 0.6 cm x 0.37 cm, progress improving; 7/21/23 Right heel Stage 3 measurements 1.04 cm x 0.59 cm, progress stable; 7/12/23 Right heel Stage 3 measurements 0.66 cm x 1.01 cm, progress improving; 7/7/23 Right heel Stage 3 measurements 1.03 cm x 1.06 cm, progress improving; 6/23/23 Right heel Stage 3 measurements 1.2 cm x 1.13 cm, progress stalled; 6/17/23 Right heel Stage 3 measurements 0.44 cm x 0.41 cm, progress stable; 6/9/23 Right heel Stage 3 measurements 0.66 cm x 0.57 cm, progress improving; 6/1/23 Right heel Stage 3 measurements 0.62 cm x 0.73 cm, progress improving. Interview on 8/23/23 at approximately 2:15 p.m. with Staff B confirmed that Resident #3's weekly wound documentation was missing a total of 2 of the last 13-weeks. Review on 8/23/23 of facility policy titled Skin Integrity and Wound Management, revised on 2/1/23, revealed .6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds .

Based on record review, interview, and policy review it was determined that the facility failed to prevent a significant medication error for 1 of 5 residents reviewed for medication errors (Resident Identifier #1). Findings Include: Review on 8/23/23 at 8:30 a.m. of Resident #1's progress note dated 7/3/23 by Staff C (Nurse Practitioner) revealed that Resident #1 had an order for Torsmemide (diuretic) 20 milligram (mg) two times a day that had been discontinued by Staff A (Registered Nurse) on 5/24/23 as he/she thought it was a duplicate order. Review on 8/23/23 of Resident #1's Medication Administration Record (MAR) from 5/23/23 to 7/31/23 revealed that there was no order for Tormedmide from 5/24/23 to 7/3/23 and restarted 7/4/23. Resident #1 had not received the medication during that time period. Further review of the MAR revealed that the resident was taking Tormedmide for edema/congestive heart failure. Interview on 8/23/23 at 2:00 with Staff A (Registered Nurse) confirmed that they had discontinued the order without a physician's order as he/she thought it was a duplicate order.

Based on interview and record review, it was determined that the facility failed to follow physician's orders for 4 out of a final sample of 35 residents. (Resident identifiers are #112, #56, #94 and #10). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. [NAME], Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #112 Interview on 5/9/23 at approximately 9:00 a.m. with Resident #112 revealed that he/she did not feel that their pain was being controlled. Review on 5/9/23 of Resident #112's medical record revealed that Resident #112 was admitted to the facility on [DATE]. Review on 5/9/23 of Resident #112's April and May 2023's Medication Administration Record (MAR) revealed an order for Acetaminophen Tablet 325 milligrams (mg), give 2 tablets by mouth every 4 hours as needed for mild pain. Further review revealed that Resident #112 was administered the following as needed doses with the following pain levels: pain level of 6: 4/16, 4/19, 4/24, 4/27 (2 doses), 5/2, 5/4, 5/8 (2 doses) pain level of 7: 4/13, 4/14, 4/20 (2 doses), 4/21, 4/28, 5/6, 5/10 pain level of 8: 5/2 and 5/4 Interview on 5/11/23 at approximately 1:15 p.m. with Staff C (Nurse Practitioner) revealed that he/she would expect for mild pain the numeric value would be 1-3. Resident #94 Review on 5/9/23 of Resident #94's May 2023 MAR revealed the following physician's order: IV [intravenous]: Implanted Port Non-Valved Flush when NOT accessed 20 ml [milliliters] Normal Saline followed by 5 ml Heparin 10 U [Unit]/ml every day shift every 30 day(s) for implanted port. Further review of the mentioned IV flush order revealed that it was scheduled to be done on 5/3/23. Interview on 5/9/23 at approximately 10:15 a.m. with Staff D (Director of Nurses) confirmed that Resident #94's port was not being utilized, and it was not flushed on 5/3/23. Resident #56 Review of [NAME] A. [NAME] and [NAME], Fundamentals of Nursing, 7th Edition, (St. [NAME], Missouri, Mosby, Inc., 2009), pg. 708, reveals Give all routinely ordered medications within 60 minutes of the times ordered (30 minutes before or 30 minutes after the prescribed time). Interview on 5/9/23 at approximately 9:30 a.m. with Resident #56 revealed that he/she goes to Dialysis 3 times a week (Monday, Wednesday and Friday). Resident #56 leaves the facility at approximately 6:00 a.m. and returns to the facility between 10:30 a.m. to 11:00 a.m. Review on 5/9/23 of Resident #56's April and May 2023 MARs revealed a physician's order for Hydralazine Hydrochloric Acid (HCL) 25 mg tablet, give 2 tablets 3 times a day, that was scheduled to be administered at 10:00 a.m., 2:00 p.m. and 8:00 p.m. Further review of the Resident #56's April and May 2023 MAR revealed that Hydralazine 25 mg was administered on the following times: 4/28/23 10:00 a.m. dose was administered at 11:43 a.m. 4/29/23 10:00 a.m. dose was administered at 11:31 a.m. 4/30/23 10:00 a.m. dose was administered at 12:07 p.m. 5/1/23 10:00 a.m. dose was administered at 12:07 a.m. 5/2/23 10:00 a.m. dose was administered at 11:35 a.m. 5/7/23 10:00 a.m. dose was administered at 11:24 a.m. Interview on 5/11/23 at approximately 11:15 a.m. with Staff D revealed that the physician should have been notified to change the times on dialysis days. Interview on 5/11/23 at approximately 11:45 a.m. with Staff C revealed that he/she would have expected to be notified of the above findings. Review on 5/11/23 of the facility policy titled, 6.2 Medication Administration Times, Revision Date 1/1/22 revealed: .2. Facility should commence medication administration within sixty (60) minutes before the designated times of administration and should be completed by sixty (60) minutes after the designated times of administration . 43408 Resident #10 Review on 5/11/23 of Resident #10's medical record revealed they were admitted on [DATE]. Further review of Resident #10's medical record revealed an active physician's order, initiated on 4/18/23, to obtain a weight every Thursday on night shift for 4 weeks, then once a month. Review on 5/11/23 of Resident #10's weights revealed a weight on 4/21/23 recorded. Further review of Resident #10's medical record revealed no other weights had been documented since admission on 4/18/23. Interview on 5/11/23 at approximately 2:00 p.m. with Staff A (Unit Manager) confirmed that the weekly weights for Resident #10 had not been obtained as ordered. Review on 5/11/23 of facility policy titled Weights and Heights, revised on 6/15/22, revealed .Patients are weighed upon admission and/or readmission, then weekly for four weeks and monthly thereafter .