Every finding on record at Palm City Nursing & Rehab Center

Based on observations, interviews and record reviews, the facility failed to prepare and serve foods in a form to meet the needs of the residents with orders for a pureed diet. The deficient practice had the potential to affect 11 residents with orders for puree diets. The findings included:1). During an observation of lunch served to the residents in their rooms and in the Dining Room on the 200 unit, on 01/12/26 at 12:12 PM, it was noted that the pureed vegetables appeared to be pooling on the plate and running into the other foods on the plate and had a liquid consistency.During an observation in the kitchen, on 01/12/2026 at 1:20 PM of the pureed vegetable, the Surveyor requested a serving of the pureed vegetable be placed on a plate. Staff A, Cook, dipped a scoop into the 1/6 sized 6 inch deep container on the hot holding unit and tilted the scoop and the puree vegetables poured out of the scoop. During the observation, the Certified Dietary Manager (CDM) acknowledged that the pureed vegetables should have been at a thicker consistency. 2). During an observation, on 01/13/26 at 7:18 AM, of breakfast served to the residents in their rooms and in the Bistro on the 200 unit, it was noted that the pureed eggs and pureed sausage appeared to be pooling on the plate and had a liquid consistency. During an observation in the kitchen, on 01/13/2026, at 7:27 AM, the Surveyor requested a serving of the pureed eggs and pureed sausage be placed on a plate. Staff A placed a serving of each on the plate and the foods pooled together and was the consistency of a thick liquid. During the observation, the CDM acknowledged that the pureed eggs and sausage should have been at a thicker consistency.

Based on observations, interviews and record reviews, the facility failed to respond to and resolve grievances voiced by residents and members of the Resident Council, including Residents #21, 2, 9, 26, 74, 89, 127. The findings included:During an interview, on 01/12/26 at 11:04 AM, with Resident #127, when asked about the food served in the facility, Resident #127, with a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact, sated that the food is served cold for all meals. During an interview, on 1/13/26 at 9:30 AM, with Resident #21, when asked about the food served in the facility, Resident #21, with a BIMS score of 15, stated, the food is cold like it just came out of the refrigerator when I get it. During an interview, on 1/12/26 at 12:00 PM, with the Resident Council President, when asked about any grievances voiced by the members of the Resident Council, the President stated that the Resident Council and the Food Committee had been voicing concerns related to the temperature of the food served to the residents in their rooms for several months. During a review of the Grievance Log, Resident Council Meeting minutes, and Food Committee Meeting minutes, on 01/13/2026 at 7:08 AM it was noted that there was a grievance related to 'Dietary' on 09/22/25 by the Resident Council. There were no other grievances documented by or on behalf of the Resident Council or the Food Committee. During a follow up interview, on 01/13/26 at 9:59 AM, with the Resident Council President, the President reviewed the documented minutes and stated that there should have been more documented due to the residents have been complaining about the food for four months. The Resident Council President stated, the Certified Dietary Manager (CDM) documents the minutes for the Food Committee and the Activities Director documents minutes for the Resident Council meeting.During an interview, on 01/14/26 at 10:29 AM, with members of the Resident Council, including Residents #2, with a BIMS score of 15, , Resident #9, with a BIMS score of 15, Resident #25, with a BIMS score of 15, Resident #74, documented as alert and oriented, and Resident #89, with a BIMS score of 14, when asked about the concerns voiced related to the food served in the facility, Resident #89 stated, it doesn't go too far after that. Referring to voicing concerns. Resident #89 elaborated by saying that the food is usually 'cold to lukewarm' and had been a problem for as long as he had been a resident. Resident #2 stated that the concern had been mentioned at every meeting and that there had been no solution to the grievance. The other residents in attendance acknowledged and agreed with the statements made by the residents. During an observation of breakfast served to the residents in their rooms and in the Bistro (room used for dining on the unit). On 01/15/26 at 8:09 AM, one of the food carts was already on the unit and there were no staff serving from the cart, a second cart arrived to the 200 unit by the Bistro and one staff member began serving from the cart. It was noted that the food was transported using an insulated cambro cart with no additional heat source. There were 3 CNAs serving from the cart. The CDM agreed that the staff, including Staff B, CNA, Staff C, CNA, Staff D, CNA, and Staff E, showed no urgency to deliver the meals from the carts as the last meal was served at 8:49 AM. During an interview, on 01/15/26 at 9:09 AM with the CDM, when asked about the concerns voiced by the Resident Council and Food Committee, the CDM replied, they have been complaining about it since I have been here. When they complain, I report it to Administrator and Regional Food Service Director. We documented during our quarterlies how long it takes to pass the trays. The temperature has dropped and it does take what we saw just now. The residents say that breakfast and dinner are taking too long to serve and the food is getting cold. When asked if there had been any follow up with the residents to get their input to the concerns, the CDM stated that there was no follow through.During an interview, on 01/15/26 at 9:13 AM, with the Activities Director, when asked about the policy for grievances, the Activities Director replied, Anything that turns into a grievance, turns into a grievance process. I report to the Social Worker. When asked about the grievances related to food voiced by the Resident Council and Food Committee, the Activities Director replied, We have a food committee, whenever they say something during Resident Council it is passed along to the Social Worker. They say that the food is too cold by the time it gets to them. Sometimes the delivery times take a little too long. During an interview, on 01/15/26 at 9:36 AM, with the Social Services Director, when asked about the grievances voiced by the Resident Council and the Food Committee, the Social Services Director replied, A lot of food concerns, food is cold, I know they do a lot of temperature checks, they are trying to get the trays out early. Management was helping pass out trays. During an interview, on 01/15/26 at 10:04 AM, with the Administrator, when asked about resolving grievances, the Administrator replied, The policy for Resident Council is that we do not list grievances in the minutes, but we do individual grievances. She (the Activities Director) goes to Resident Council with Blank grievances, and she initiates the grievance from the meeting.

Based on interview and record review the facility failed to obtain informed consent for residents prescribed psychotropic medications for 2 of 5 residents reviewed for unnecessary medication's, affecting Resident #83 and Resident #128. The findings included: Review of the facility's policy titled, Psychotropic Medication Assessment and Monitoring with a revised date of 08/2023 included in part the following: Under section titled Fundamental Information: All medications included in the psychotropic medication definition may affect brain activities associated with mental process and behavior. Risks associated with psychotropic medications still exist regardless of the indication for their use, therefore the requirements pertaining to psychotropic medications apply to the four categories of drugs (anti-psychotic, anti-depressant, anti-anxiety and hypnotic) without exception. Under section titled, Procedure included to obtain Psychoactive Medication Consent signed by the resident/resident representative. 1) Record review for Resident # 128 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Fracture right femur, Parkinson's, Repeated Falls, Dementia, Depression, UTI, Anxiety, and Acute Posthemorrhagic anemia. Review of the Physician's Orders for Resident # 128 revealed in part the following: An order dated 01/11/26 for Hydroxyzine HCl Oral Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety and an order dated 01/14/26 for Sertraline HCl Tablet 100 MG Give 1 tablet by mouth in the morning for depression. An interview was conducted on 01/15/26 at 11:30 AM with the Director of Nursing (DON) who was asked about informed consent for psychotropic medications, she said the nurse would obtain the consent and it would be uploaded through another computer system into the resident's electronic medical record under the Miscellaneous section. The DON added that if there are any psychotropic medications added, discontinued or changed they would need to obtain a new consent. The DON was notified that the consent for Resident #128 was not located under the miscellaneous section, and she agreed to have the medical records staff look for the original paper signed consent. During an interview conducted on 01/15/26 at 2:15 PM with the DON who was asked about the Psychoactive Medication Consent for Resident #128 she acknowledged that they did not have an informed consent for the psychotropic medications the resident was prescribed. 2) Record review for Resident #83 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Aftercare Following Joint Replacement Surgery, Parkinson's Disease, Major Depressive Disorder, and Unspecified Dementia. The Minimum Data Set, dated [DATE] documented in Section C a Brief Interview of Mental Status score of 12 indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #83 revealed in part the following: An order dated 12/25/25 for Mirtazapine (Remeron) oral tablet 15mg give 1 tablet by mouth at bedtime for Depression (an anti-depressant medication) An order dated 12/31/25 for Quetiapine Fumarate (Seroquel) oral tablet 25mg give 0.5 tablet by mouth two times a day for Dementia (an antipsychotic medication). Review of Resident #83's medical record included only one Psychoactive Medication Consent dated 12/31/25 and documented only Seroquel 25mg 0.5 tab BID (twice daily). During an interview conducted on 01/15/26 at 11:00 AM with the Director of Nursing (DON who was asked about informed consent for psychotropic medications, she said the nurse would obtain the consent and it would be uploaded through another computer system into the resident's electronic medical record. The DON added that if there are any psychotropic medications added, discontinued or changed they would need to obtain a new consent. During an interview conducted on 01/15/26 at 1:45 PM with the Director of Nursing (DON) who was asked about the Psychoactive Medication Consent for Resident #83, she acknowledged the resident only had one Psychoactive Medication Consent dated 12/31/25 and only listed Seroquel 25MG o.5 tab BID (twice daily). The DON acknowledged the resident was on more than one psychotropic medication and did not have an informed consent for all of the psychotropic medications the resident was prescribed.

Based on policy review, observation, record review, and staff and resident interviews, the facility failed to ensure meals were provided to residents in a timely manner and failed to address staff-voiced grievances related to tray pass, for 3 of 7 residents reviewed for food concerns (Residents #127, #109, and #108).Findings included: Policy titled grievances, dated 08/2023, indicated to support each resident's right to voice grievance and to ensure that a grievance has been received, the center will actively work through to a conclusion while communicating progress to the resident and/or anyone working on their behalf in a timely manner. Any resident, or anyone acting on their behalf, may file a grievance with the center or other agency or entity that hears grievances. When a resident, or anyone acting on their behalf, a staff member shall encourage and assist the resident, or person acting on the resident's behalf, to file a grievance with the center using the grievance report. Grievances may be submitted orally or in writing; they may be anonymously. The resident, or anyone acting on their behalf submitting the grievance, should be encouraged to utilize the grievance report. When a grievance is submitted orally, the center employee accepting the grievance must document it on the grievance report. 1. Clinical record review revealed Resident #109 was admitted on [DATE] with diagnosis included gastroesophageal reflux disease (GERD). The admission MDS dated [DATE] documented a BIMS score of 14, indicated the resident was cognitively intact.Review of the care plan, reviewed by the facility on 11/21/25, identified Resident #109 as being at risk for alteration in gastrointestinal status related to diverticulosis, chronic pancreatic enzyme deficiency, and GERD.On 01/12/26 at 11:14 AM, during an interview, Resident #109 stated, The place is good, the people are very professional, very caring, but reported that the food was served cold most of the time. The resident rated the facility overall as a B+ or an A. 2. Clinical record review revealed Resident #108 was admitted on [DATE] with diagnosis included depression. The quarterly MDS assessment dated [DATE] documented a BIMS score of 14, indicated the resident was cognitively intact.On 01/12/26 at 11:15 AM, an interview was conducted with Resident #108, the spouse and roommate of Resident #109. Resident #108 reported that the facility's food was served cold. 3. Clinical record review revealed Resident #127 was admitted on [DATE] with diagnoses including cancer. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15, demonstrated the resident was cognitively intact. On 01/12/26 at 11:04 AM, Resident #127 stated that the facility's food was served cold for all meals.Review of the facility grievance log revealed the following documented complaints for Resident #127:02/18/25: Complaint that food was always cold when served and that the resident was not permitted to use the microwave to heat food brought in.12/02/25: Complaint that food was cold when served. 4. On 01/14/26 at 7:59 AM, observation of breakfast tray pass on the 100 unit revealed one Certified Nursing Assistant (CNA) passing trays to residents in the front hallway. The CNA then left multiple trays unattended on the food cart in the hallway.Approximately 15 minutes later, a second CNA passed several trays and then left the unit. At 8:27 AM, a third CNA (Staff H) arrived to assist with tray pass for residents located in the back hallway. Tray service for the unit was completed at approximately 8:46 AM, resulting in a tray pass duration of nearly one hour.During the observation, an interview was conducted with Staff H regarding the prolonged tray pass time. Staff H stated, I can't handle all this alone. I keep asking for help, but it's like it goes in one ear and out the other. I have three residents to feed and have to pass trays to the rest. All my residents are total care; I have to cut up everything and help set up trays. It takes a long time. On 01/15/26 at 9:30 AM, an interview was conducted with Staff I, the Unit Manager. Staff I was informed of the extended tray pass time and residents' complaints of cold food. Staff I confirmed that Staff H had previously requested assistance and acknowledged she had occasionally helped pass trays and feed residents. When asked whether Staff H's concerns had been documented as a grievance or elevated to the interdisciplinary team for resolution, Staff I stated no grievance had been filed on behalf of Staff H. Staff I stated staff were aware she was available for assistance and had been instructed to ask for help when needed. Staff I also acknowledged she had heard residents complain about food being served cold. On 01/15/26 at 9:01 AM, a subsequent interview with Staff H revealed that other CNAs typically passed trays only to their assigned residents and left trays for her assigned residents on the food cart. On 01/15/26 at 10:42 AM, an interview was conducted with the Director of Nursing (DON), who was made aware of the residents' complaints regarding cold food and the lack of staff assistance during tray pass. On 01/15/26 at 11:49 AM, an interview was conducted with the Dietetic Technician, who was informed of residents' complaints regarding cold food and the observed length of time required to complete tray pass on the 100 unit (rooms 125-139).

Based on record review and interviews, the facility failed to ensure that a pharmacy recommendation accepted by the physician was processed and implemented for 1 of 5 residents reviewed for unnecessary medications (Resident #108).Findings included: Clinical record review revealed Resident #108 was admitted to the facility on [DATE] with diagnoses that included depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.Review of the physician order dated 12/11/24 showed an order for Vitamin D 25 mcg (1000 units), five tablets by mouth once daily for vitamin supplementation.Review of the care plan dated 03/01/25 documented Resident #108 was receiving palliative care related to a diagnosis of occlusion of the right vertebral artery. Interventions included administering medications as ordered.A pharmacy medication regimen review conducted in August 2025 included a recommendation to monitor the resident's 25-hydroxyvitamin D level on the next convenient lab day and adjust the vitamin D dose accordingly. The rationale stated that a target 25-hydroxyvitamin D concentration of at least 30 ng/mL may be beneficial for fall and fracture prevention. In adults, 25-50 mcg (1000-2000 units) by mouth once daily is generally accepted as maintenance dosing. The recommendation further noted that treatment of secondary hyperparathyroidism in chronic kidney disease requires individualized dosing and monitoring.The attending physician accepted the pharmacy recommendation and ordered a vitamin D level. However, review of the clinical record lacked documented evidence that the vitamin D level was obtained. The most recent vitamin D level on record was dated 03/27/25.A subsequent pharmacy review conducted in November 2025 documented that the prescriber had accepted the August 2025 pharmacy recommendation to order a vitamin D level; however, the order had not yet been processed. The pharmacist requested the facility process the accepted pharmacy recommendation and update the medical record accordingly. Review of the clinical record continued to lack documented evidence that the vitamin D level was obtained.On 01/15/26 at 10:49 AM, an interview was conducted with the Director of Nursing (DON), who acknowledged that the pharmacy recommendations from August 2025 and November 2025 related to obtaining a vitamin D level for Resident #108 were not processed.

Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 9.38% with 3 medication errors identified while observing a total of 32 opportunities, affecting Residents #14 and #108.The findings included: 1. On 01/13/26 at 9:52 AM, medication administration was observed with Staff J, Licensed Practical Nurse (LPN). During the observation, Staff J removed Aspirin 81 mg from the medication cart instead of the ordered 325 mg. As Staff J entered the resident's room and prepared to administer the medication, the surveyor stopped the administration and instructed the nurse to review the order. Staff J acknowledged he had selected the incorrect dose. Staff J searched the medication cart for Aspirin 325 mg and was unable to locate it. He then secured the cart and stated he would check central supply. At 10:13 AM, Staff J returned and stated, They don't have the 325 mg. I'm going to call the doctor. We got to put it on hold. The medication was not administered as ordered during the observed medication pass.There was a physician order for: Vitamin D 25 mcg (1000 units), give 5 tablets by mouth. During observation, Staff J administered only 1 tablet of Vitamin D 25 mcg (1000 units). At 11:12 AM, an additional interview and side-by-side medication review was conducted with Staff J. When questioned regarding the Vitamin D order, Staff J acknowledged he was required to administer 5 tablets and confirmed the medication was administered incorrectly. 2. On 01/14/26 at 9:06 AM, medication administration was observed with Staff K, Registered Nurse (RN).Review of the MAR revealed an active order for: Vitamin B12 1000 mcg, give 1 tablet by mouth. During the observed medication pass, Staff K failed to administer the Vitamin B12 as ordered.Immediately after the administration, at 9:40 AM, the surveyor returned to the medication cart to reconcile the medications administered. The surveyor identified the omission of Vitamin B12. Staff K acknowledged the medication was omitted.On 01/15/26 at 9:25 AM, an interview was conducted with Staff I, Unit Manager, who was informed of the three medication errors observed involving two licensed nurses.On 01/15/26 at 10:42 AM, an interview was conducted with the Director of Nursing (DON), who confirmed awareness of the three medication errors identified during medication administration observations.

Based on observations, interviews and record reviews, the facility failed to prepare foods in a manner to preserve the nutritive value. The findings includedDuring the initial kitchen tour, on 01/12/26 at 8:54 AM, accompanied by the Certified Dietary Manager (CDM), it was noted that there was a 6-inch deep one third sized hotel pan of carrots that were being hot held on the cook top range. Staff A, Cook, stated that the carrots were for lunch on this day and that she finished cooking the carrots and placed them on the range at 8:45 AM. The CDM acknowledged that the carrots would be held more than 3 hours before being plated and served. Staff A stated that they were prepared so that they would be soft for the residents to eat them. Staff A stated that the carrots typically would only take about 20 minutes to cook. While continuing the initial kitchen tour, it was noted that there was a a full sized 6-inch deep hotel pan of mixed vegetables in the steamer. Staff A stated that the vegetables were for the lunch meal to be served this day. At the time of the observations, the CDM acknowledged that holding the carrots and the mixed vegetables for extended amounts of time would diminish their nutritional value.

Based on observation, interview, and record review, the facility failed to provide food in accordance with residents stated preferences for 2 of 7 residents reviewed for food concerns. This failure involved Residents #37 and #127.The findings included: 1.Clinical record review revealed Resident #127 was admitted on [DATE] with diagnoses including cancer. The quarterly MDS assessment dated [DATE] documented a BIMS score of 15, indicating the resident was cognitively intact. Review of the care plan dated 11/18/25 indicated Resident #127 was at risk for decreased nutritional status, dehydration, and weight loss, and included an intervention to cater to her food preferences and textures to increase intake.On 01/14/26 at 8:22 AM, an observation was conducted of Resident #127. During the observation, the resident was upset and stated she was not going to eat the food provided. She stated, My everyday breakfast is fried eggs, and they gave me scrambled eggs; I hate scrambled eggs. Observation revealed Resident #127 received a scrambled egg sandwich with bacon on wheat bread. Review of the meal ticket indicated the resident's breakfast preference was fried egg with wheat bread every morning (no toast, no cheese). 2.Clinical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including malnutrition. The quarterly Minimum Data Set (MDS) assessment with a reference date of 10/07/25 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the care plan dated 10/09/25 indicated Resident #37 was at nutritional risk related to variable intake and severe protein-calorie malnutrition.On 01/14/26 at 8:55 AM, an observation was conducted of Resident #37. During the observation, the resident was upset and stated, I requested fried egg, but they insist on sending me scrambled eggs. I've had the dietitian in my room so many times regarding this.On 01/15/26 at 11:49 AM, during an interview with the dietetic technician, she was made aware of Resident #37's concern regarding receiving scrambled eggs instead of fried eggs, as well as Resident #127 receiving scrambled eggs instead of her stated preference for fried eggs.

Based on observations, interviews, and record review, the facility failed to maintain medication error rate less than 5% for 2 of 32 opportunities identified while observing medication pass affecting Residents #32 and #99. The medication error rate was calculated to be 6.25 % (percent). The findings included: Review of the facility's procedural guidelines, titled, Medication Pass and Med Pass with Medication Cart, with an updated date of 06/28/23, included, in part, the following: Purpose: To assure the most complete and accurate implementation of physician's orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Guidance Steps in the Procedure: 7. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the center. For example, if the medication is ordered for 8:00 AM, it must be given between 7:00 AM and 9:00 AM in order to be considered timely. 1. Record review for Resident #32 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Dementia and Other Seizures. Review of the Physician's order for Resident #32 revealed an order dated 07/03/24 for Depakote Sprinkles Delayed Release [DR] 125mg give 2 caps by mouth three times a day for seizures. On 07/15/24 at 4:30 PM, a medication (med) pass observation was conducted with Staff M, Registered Nurse (RN), who was working on the odd side west unit med cart. The RN proceeded to administer Divalproex (Depakote) DR 125mg 2 caps by mouth to Resident #32. Review of the Medication Administration Record (MAR) documented the resident had received the last dose of Depakote at 2:00 PM on 07/15/24. During an interview conducted on 07/15/24 at 4:35 PM with Staff M, who stated she has worked at the facility since November 2023, when asked about medication administration times, she said she had an hour before and an hour after the medication is scheduled to be given. During an interview conducted on 07/15/24 at 5:35 PM with the Director of Nursing (DON) who was asked about med administration times, what specifically Prior indicated, the DON stated they are more liberal with their medication times and Prior would indicate prior to bedtime. When asked to clarify if there was a time frame associated with the Prior to bedtime, she said it could be from 5:00 PM to 8:00 PM depending on when the resident goes to bed. When asked if they keep a log of when a resident goes to bed, she said no they do not. When brought to her attention, the Person-Centered Medication Administration Schedule indicated prior to bed is 6:00 PM to 10:00 PM. She said let's look at a specific resident. Upon the DON reviewing the medication order for Resident #32 for Divalproex DR (Delayed Release) 125mg under the scheduling details, it listed the 'prior to bedtime frame' as 6:00 PM to 10:00 PM. 2. Record review for Resident #99 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Essential (Primary) Hypertension, Peripheral Vascular Disease, and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of the Physician's orders for Resident #99 revealed an order dated 05/30/24 for Lisinopril 10mg give 1 tablet by mouth one time a day for hypertension. Review of the Medication Administration Record (MAR) for Resident #99 revealed Staff F, RN, marked 9, indicating other see nurse progress note, on 07/18/24 for the medication Lisinopril. Review of the nurse progress notes for Resident #99 for 07/18/24 revealed no nurse progress note. On 07/18/24 at 8:30 AM, a med pass observation with Staff F, RN, who was working on the odd side west unit med cart. The RN proceeded 'to hold' the medication Lisinopril 10mg for Resident #99 after obtaining a blood pressure of 114/73. There were no blood pressure parameters to hold the medication. During an interview conducted on 07/18/24 at 11:55 AM with Staff F, who was asked if there were any parameters to hold the blood Lisinopril for Resident #99, he said no. When asked why he held the Lisinopril for Resident #99, he stated it was nursing judgement call. During an interview conducted on 07/18/24 at 12:20 PM with the Director of Nursing (DON) who was asked if she would consider a medication given outside of the 1 hour before or 1 hour after a scheduled time or time frame (prior or upon), the DON said she could not say. When asked if it would be considered following the physician's orders, she said it may be considered not following the doctor's orders. When asked about holding a blood pressure medication for a resident without parameters to hold the medication, she said the nurse would need to do an assessment and would need to know the baseline blood pressure. When asked about Resident #99 and holding the blood pressure medication Lisinopril for a blood pressure of 114/73, she said she would call the doctor to see if the blood pressure medication should be held.

Based on observations, interviews and record reviews, the facility failed to develop and implement care plans related resident's noncompliance with fluid restrictions and failed to develop and implement care plans to encourage staff and resident to adhere to fluid restrictions for 1 of 5 sampled residents reviewed for Nutrition / Hydration, Resident #10. The findings included: Record review revealed Resident #10 was admitted to the facility on [DATE] and admitted to Hospice on 06/18/24. Review of the resident's most recent complete assessment, a Significant change Minimum Data Set (MDS), dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Resident #10's diagnoses )DX) at the time of the assessment included: Coronary Artery Disease, Heart Failure, Hypertension, Hypernatremia, Hyperlipidemia, Arthritis, Osteoporosis, Cardiac Murmur, Muscle weakness, Need for assistance with personal care, Difficulty in walking, Symbolic dysfunctions, Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction, Encounter for palliative care. Review of Resident #10's orders included: Fluid Restriction: 1000ml - every shift for NURSING - Day: 120ml; Evening: 120ml; Night: 60ml; DIETARY - Breakfast: 360ml; Lunch:180ml; Dinner: 160ml - 06/01/24 with a start date of 06/02/24. On 07/16/24 at 8:14 AM, Resident #10 was observed in bed sleeping with assorted fluids, including bottled beverages and two 16-ounce foam cups of water on the overbed table, dresser and an additional table to resident's right side of bed. During an interview, on 07/16/24 at 1:55 PM, with the Registered Dietitian (RD/LD), when asked about the fluid restrictions, the RD/LD replied, she was not seen by me, she was seen by the previous dietitian, that restriction would come from cardiology or nephrology. On 07/17/24 at approximately 8:30 AM, Resident #10 was observed in bed with a 16-ounce foam cup for hydration on the overbed table, and additional fluids throughout the room. Resident #10 refused to be interviewed. During an interview, on 07/17/24 at 10:33 AM, with the Director of Nursing (DON) and the Staff Development Coordinator, when asked about the fluids and cups of water in the resident's room while the resident had ordered fluid restrictions, the DON stated that she needed to be in contact with the physician that ordered the restrictions. The DON further stated, She is on Hospice, and she is very noncompliant, she is even refusing her meds and stuff. Her daughter brings that stuff (referring to bottles of soda and beverages). I talked to the hospice nurse today and told her that she was noncompliant, she said that she would reach out to the doctor about the fluid restrictions. During an interview, on 07/17/24 at 12:05 PM with the Nurse Practitioner (NP), when asked about the fluid restrictions for Resident #10, the NP replied, Hospice was supposed to have discontinued the fluid restrictions. She was on Lasix in the hospital and is not compliant with her medications. On 07/18/24 at 7:31 AM, Resident #10 was observed in bed awake, responsive and declined to be interviewed. During an interview, on 07/18/24 at 9:21 AM, with Staff A, Licensed Practical Nurse (LPN), when asked about providing hydration to the residents, Staff A replied, all staff do hydration, the CNAs [Certified Nursing Assistnats] are responsible for passing hydration at the beginning of the shift. She is no longer on restrictions (confirmed as of 07/17/24). During an interview, on 07/18/24 at 9:31 AM, with Staff D, CNA, when asked about Resident #10 having orders for fluid restrictions, Staff D stated that she was not aware of the restrictions and was providing hydration during the week. On 07/18/24 11:11 AM, the DON stated the facility did not have a policy to address fluid restrictions, we go by what the doctor's order is. Further review of Resident #10's health records revealed there was no care plan to address the resident's fluid restrictions and no care plan to address the resident and family being noncompliant with the fluid restrictions, while the resident's care plan for Nutrition/hydration contradicted the resident's fluid restrictions. Resident #10's care plan for nutrition and hydration, initiated on 09/15/22, documented, Resident is at risk for decreased nutritional status & dehydration r/t [related to] recent hospitalization for non pressure chronic ulcer to LLE [left lower extremity] with cellulitis / MRSA [Methicillin Resistant Staph Aures], TIA, Anemia, Osteoporosis BMI [Basil Mertabolic Index] <23 06/19/24 admitted on Hospice services DX: Cerebral Atherosclerosis. Interventions to the care plan included: o Encourage PO [oral] fluids Date Initiated: 09/15/2022 Created on: 09/15/2022 Created by: name (RN) o Observe for s/s [signs and symptoms] dehydration: i.e. poor skin turgor, dry mucous membranes, labs, concentrated urine, elevated temps and sudden changes in cognition and behaviors Date Initiated: 09/15/2022 Created on: 09/15/2022. During an interview, on 07/18/24 at 9:21 AM, with Staff A, LPN, when asked about Resident #10's fluid restrictions, Staff A replied, her daughter and granddaughter are always here. All staff do hydration, the CNAs are responsible for passing hydration at the beginning of the shift. She is no longer on restrictions. Fluid restrictions were confirmed, by record review, to be discontinued on 07/17/24 after surveyor intervention. During an interview, on 07/18/24 at 9:44 AM, with Staff B, MDS Coordinator, when asked about Resident #10's care plan, Staff B replied, when I do the admission assessment it triggers the interim care plans (baseline care plans) and then we develop them and personalize the care plan from there. The MDS Coordinator acknowledged the lack of a care plan for the resident and family's noncompliance. When asked about the care plan for nutrition / hydration contradicting the fluid restrictions, the Staff B replied, I took out the Encourage the PO fluid intake yesterday. During an interview, on 07/18/24 at 11:11 AM, the Director Of Nursing stated the facility did not have a policy to address fluid restrictions, we go by what the doctor's order is.

Based on record review and interview, the facility failed to ensure narcotic medications removal was documented in the medication administration records (MARs) for 3 of 6 sampled residents reviewed for medications (Residents #88, #10 & #46). The findings included: On 07/18/24 at 11:26 AM, during the medication storage review process six (6) residents were selected for review. Three of those residents had discrepancies in their records. Record review revealed Resident #88 had physician orders of Tramadol 50 mg every 8 hours as needed for pain. The controlled medication utilization record was compared against the July 2024 Medication Administration Records (MARs), revealing there were discrepancies. The controlled medication utilization record showed the Tramadol was removed on 07/01/24 at 11:02 AM, and 07/07/24 at 3 AM but there was no documentation in the MARs to reflect this removal and administration to the resident. Record review revealed Resident #10 had physician order of Lorazepam 0.5 mg every 4 hours as needed for anxiety. The controlled medication utilization record was compared against the July 2024 MARs, and revealed there was a discrepancy. The controlled medication utilization record showed the Lorazepam was removed on 07/13/24 at 6:50 PM, but there was no documentation in the MARs to reflect this removal and administration to the resident. Record review revealed Resident #46 had physician order of Alprazolam 0.25 mg by mouth once a day as needed for anxiety. The controlled medication utilization record was compared against the July 2024 MARs, and revealed there was a discrepancy. The controlled medication utilization record showed the Alprazolam was removed on 07/17/24 at 7:36 PM, but there was no documentation in the MARs to reflect this removal and administration to the resident. On 07/18/24 at 12:01 PM, an interview was held with the Director Of Nursing (DON). She was made aware of the findings related to the lack of documentation for the narcotic removal.

Based on observations, interviews and record reviews, the facility failed to monitor weights appropriately and failed to ensure weights are accurate for 2 of 5 sampled residents reviewed for nutrition, Residents #29, and #78; and failed to adhere to fluid restrictions for 1 of 5 sampled residents reviewed for Nutrition, Resident #10. Th findings included: The facility's policy, titled, Weight Measurements, with a reference date of 08/2023, documented, in part, the following: Frequency of Measurements and Calculations: Residents are weighed weekly, monthly, or according to physician orders. Residents should be weighed at the same time of day, in similar clothing and using the same scale. Any significant or progressive loss or gain is noted and reported to the resident's attending physician, family, or responsible party and documented in the medical record. Note all new admits are weighed weekly for 30 days. 1. Record review revealed Resident #29 was admitted to the facility on [DATE]. Review of the resident's most recent complete assessment, a quarterly Minimum Data Set (MDS), dated [DATE], Resident #29 had a Brief Interview for Mental Status (BIMS) score of 05, indicating a severe cognitive impairment. The document revealed: Setup or clean up assistance for dining. The resident's diagnoses (DX) at the time of the assessment included: Anemia, Coronary Artery Disease, Heart Failure, Hypertension, Obstructive Uropathy, Hyperlipidemia, Non-Alzheimer's dementia, Chronic Lung Disease, Presence of cardiac pacemaker, Paroxysmal Atrial Fibrillation, Mood disorder, GERD (Gastroesophageal Reflux Disease), Osteoarthritis, Muscle weakness, Overactive bladder, Lack of coordination, Cognitive communication deficit. The MDS documented that the resident did not have any swallowing disorders and no dental concerns. Review of Resident #29's care plan for nutrition, initiated on 01/17/24 with a revision date of 04/23/24, documented, Resident is at risk for decreased nutritional status and dehydration r/t [related to] chronic kidney disease and atherosclerotic heart disease. The goal of the care plan was documented as, Resident will be free from significant weight changes through the review date. Resident will continue to tolerate diet. Continue plan of care. Date Initiated: 01/17/2024. Revision on: 02/06/2024. Target Date: 07/29/2024. Interventions to the care plan included: o RD/DTR [Registered Dietician / Doctor] to evaluate as needed. Date Initiated: 01/17/2024 o Weights as ordered. Date Initiated: 01/17/2024. Resident #29's physician's orders included: Regular diet, Regular texture - 01/23/24 Weights every 30 days - 07/07/24. Further review of the resident's electronic health record (EHR) revealed that there were no orders for nutritional supplements. Resident #29's weights taken in the facility were documented as the following: 07/11/24 - 137 lbs (pounds), sit down scale. 07/07/24 - 139 lbs, sit down scale. 04/19/24 - 235 lbs, with wheelchair. 04/12/24 - 165 lbs, sit down scale. 04/03/24 - 165 lbs, sit down scale. 03/02/24 - 172 lbs, sit down scale. 01/17/24 - 187 lbs, sit down scale. Resident #29's weight according to a hospital transfer form (3008) documented a weight of 198 lbs. on 01/17/24. A Nutrition Risk Screen, dated 01/23/24 documented Resident #29's weight as 187 lbs. A Physician / Practitioner Progress note, dated 05/02/24, documented a weight of 187 lbs. A Physician Consult note, dated 07/02/24 documented that the resident was alert and oriented x 3. A Physician / Practitioner Visit Note, dated 07/03/24, documented a weight of 235 lbs. During review of the resident's documented weights, the following were noted: Resident #29 was not weighed per facility protocol of weekly for the first four weeks after admission of 01/17/24. Resident #29 was not weighed from 01/17/24 to 03/02/24. There was a 70-pound weight gain documented from 04/12/24 to 04/19/24, with no verification (re-weight) done to ensure the weights were accurate. There were no weights documented from 04/19/24 to 07/07/24. There was a 96-pound weight loss documented from 04/19/24 to 07/07/24, with no verification done to ensure the weights were accurate. Further review of the resident's record revealed: The documented weight loss was not identified by the facility. There were no interventions implemented to address weight loss. There was no documentation of the resident refusing to be weighed. During an interview, on 07/15/24 at 9:54 AM when Resident #29 was asked of any concerns with weight loss, Resident #29 stated that he had lost 15 pounds and is trying to get the weight back. The resident stated, Breakfast is good. Lunch and dinner, sometimes good sometimes bad, depends on who is in the kitchen. I don't like certain vegetables. You can only get what they have - sometimes they offer substitutions. Resident #29 further stated that he had no diet restrictions. The resident stated, There isn't usually anything else that I can get for a meal. When asked about being assessed by the Dietitian, Resident #29 replied, I don't know the Dietitian, I haven't seen one. My daughter brings me things that I like. During an interview on 07/17/24 at 12:10 PM, with the Nurse Practitioner (NP), when asked about the resident voicing concerns about the 15-pound weight loss, the NP replied, the daughter refused any type of stimulant after we found a weight loss. The weights that I use are from the documentation in the record. 2. Record review revealed Resident #78 was admitted to the facility on [DATE]. Review of the resident's most recent assessment, a Quarterly MDS dated [DATE], Resident #78 had a BIMS score of 14, indicating that the resident was cognitively intact. The MDS documented the resident required setup or clean up assistance for eating. Resident #78's diagnoses at the time of the assessment included: Anemia, CAD, Hypertension, PVD (Peripheral Vascular Disease), Hyperlipidemia, Malnutrition, Depression, Chronic Lung Disease, Acute Metabolic Acidosis, partial Intestinal Blockage. Muscle weakness, Difficulty in walking, Thrombocytosis, Allergic Rhinitis, Interstitial Pulmonary Disease, Intussusception, and Osteoarthritis. The MDS documented that Resident #78 had weight loss and was not on a prescribed weight loss regimen. Resident #78's care plan for nutrition, initiated on 07/20/23 with a revision date of 03/13/24, documented, Resident is at risk for decreased nutritional status & dehydration r/t recent hospitalization for compression fracture of L-4, cancer, COPD, CKD (Chronic Kidney Disease), Depression, and Small Bowel Obstruction. He is currently experiencing a significant weight loss which occurred during hospitalization . The goal of the care plan was documented as, Resident will be free from significant weight changes through the review date. Date Initiated: 07/20/2023 Revision on: 04/18/2024 Target Date: 10/14/2024. Interventions to the care plan included: Weights as ordered Date Initiated: 03/05/24 Created on: 07/20/23. Revision on: 03/05/24. Weights as ordered Date Initiated: 02/25/24 Created on: 02/25/24. Resident #78's diet orders included: Regular diet, Regular texture - double portions w-B [with breakfast] - 03/13/24. Fortified Foods with meals - 03/13/24. Nutritional Treat with meals for nutritional support w L/D [with lunch and dinner]- 06/14/24. Further review of the resident's orders revealed no order for monitoring weights. Resident #78's weights were documented as follows: 07/11/24 - 159 pounds 06/11/24 - 164 pounds 03/05/24 - 172 pounds 02/25/24 - 187 pounds 01/15/24 - 179 pounds. During the review of the resident's weights, the following were noted: There were no weights documented between 03/05/24 and 06/11/24 - more than three months. There was no documentation of resident refusing weights. On 01/15/2024, the resident weighed 179 lbs. On 07/11/2024, the resident weighed 159 pounds which is a -11.17 % Loss. The weight loss was not identified by the facility. There were no interventions implemented to address weight loss, except for 03/13/24 and 06/14/24. During an interview, on 07/15/24 at 3:30 PM, with Resident #78, when asked of any concerns with weight loss or gain, Resident #78 replied, I got weighed a couple of weeks ago. I was somewhere around 170 pounds and now I am down in the 150s. 3. During an interview, on 07/16/24 at 2:03 PM with the Registered Dietitian, when asked about assessing a resident for weight loss, the Registered Dietitian replied, we are a contract company, I don't know what happened to the previous dietitian, I never got to meet her, I only am able to follow up with what she has done. When asked about the facility's protocols for monitoring residents' weights, the Registered Dietitian replied, the protocol is when they are first admitted , they are to be weighed, once a week for the first four weeks that they are here. When I am here, I run a weight report from the day that I am there to the previous month. If it is not me, I go back 6 months in my report. Anyone that meets my significant criteria (5%, 7%, 10%) I will follow up with them. We are to do that every month. When the Registered Dietitian was shown the documentation of the residents' weights, the Registered Dietitian acknowledged that the residents should have been reweighed on several occasions and that there should have been some interventions based on the reweights. During an interview, on 07/17/24 at 10:20 AM, with the Staff Development Coordinator (SDC), when asked of the responsibility for weighing the residents, the SDC replied, all of the CNAs are responsible for weights, we put the numbers on the board and the nurses tell them. If we need re-weights, it is put on the board. There is a paper at the beginning of the month for the list of residents that need to be weighed and re-weighted. If it is out of 2-3 pounds change, then reweights are done. Whatever the weight was, we do a reweight to validate that the weight is correct. We try to make sure that they are weighed by the same method, clothing, time of day. We try to do the re-weight if not the same day, within 24 hours. During an interview, on 07/18/24 at 8:47 AM, with Staff C, CNA, when asked about weighing the residents, Staff C replied, there is a list - once a month we get a list, and we give the weights to the nurse. During an interview, on 07/18/24 at 9:13 AM, with Staff A, LPN, when asked about documenting the weights, Staff A replied, I normally compare to the previous one and we document, if we have to do a re-weight, we tell the dietitian and the Director of Nursing (DON) if they lose weight, we check to make sure it is correct and compare to the previous one. Staff A acknowledged that there were multiple opportunities that Resident #29 should have been re-weighed and there was no documentation for the missing weights. 4. Record review revealed Resident #10 was admitted to the facility on [DATE] and admitted to Hospice on 06/18/24. Review of the resident's most recent complete assessment, a Significant change Minimum Data Set (MDS), dated [DATE], Resident #10 had a Brief Interview for Mental Status score of 13, indicating the resident was 'cognitively intact'. Resident #10's diagnoses at the time of the assessment included: Coronary Artery Disease, Heart Failure, Hypertension, Hypernatremia, Hyperlipidemia, Arthritis, Osteoporosis, Cardiac Murmur Muscle weakness, Need for assistance with personal care, Hereditary and idiopathic neuropathy, Difficulty in walking, Symbolic dysfunctions, Personal history of Transient Ischemic Attack (TIA) and Cerebral Infarction, and Encounter for palliative care. Resident #10's orders included: Fluid Restriction: 1000ml - every shift for NURSING - Day: 120ml; Evening: 120ml; Night: 60ml; DIETARY - Breakfast: 360ml; Lunch: 180ml; Dinner: 160ml - 06/01/24 with a start date of 06/02/24. On 07/16/24 at 8:14 AM, Resident #10 was observed in bed sleeping with assorted fluids, including bottled beverages and two 16-ounce foam cups of water on the over bed table, dresser and an additional table to resident's right side of bed. During an interview, on 07/16/24 at 1:55 PM, with the Registered Dietitian (RD/LD), when asked about the fluid restrictions, the RD/LD replied, she was not seen by me, she was seen by the previous dietitian, that restriction would come from cardiology or nephrology. On 07/17/24 at approximately 8:30 AM, Resident #10 was observed in bed with 16-ounce foam cup for hydration on the overbed table, and additional fluids throughout the room. On 07/17/24 at 10:33 AM, an interview with the Director of Nursing (DON) revealed the resident is noncompliant and family bring in bottles of soda and beverages to the resident. On 07/17/24 at 12:05 PM, an interview with the Nurse Practioner (NP) revealed, Hospice was supposed to have d/c [discontinued] the fluid restrictions. She was on Lasix in the hospital and is not compliant with her medications. Provided documentation of education related to fluid restrictions. During an interview, on 07/18/24 at 9:21 AM, with Staff A, LPN, when asked about providing hydration to the residents, Staff A replied, all staff do hydration, the CNAs are responsible for passing hydration at the beginning of the shift. She [Resident #10] is no longer on restrictions (confirmed as of 07/17/24). During an interview, on 07/18/24 at 9:31 AM, with Staff D, CNA, when asked about Resident #10 having orders for fluid restrictions, Staff D stated that she was not aware of restrictions and was providing hydration during the week. On 07/18/24 11:11 AM, the DON stated the facility did not have a policy to address fluid restrictions, we go by what the doctor's order is.

Based on observations, interviews and record review, the facility failed to ensure ongoing care to prevent infection prevention for 1 of 1 sampled resident reviewed for indwelling urinary catheter (Foley) care as evidenced by lack of documentation (Resident #90). The findings included: Review of the facility's policy, titled, Catheter Care and Services, with a revised date of 06/2024 included, in part, the following: A resident with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible. Under Section titled Documentation: Assessments/evaluations, care plans, orders and or nursing measures as appropriate. Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set (MDS) for Resident #90 dated 06/18/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment. In Section H under Indwelling catheter (including suprapubic catheter and nephrostomy tube) is answered 'yes'. Review of the Certified Nursing Assistant (CNA) Tasks for Resident #90 from 07/08/24 to 07/17/24 revealed no documentation to indicate indwelling urinary catheter care was provided. Review of the Care Plan for Resident #90 dated 06/07/24 with a focus on the resident has Indwelling Catheter r/t [related to] Neurogenic bladder and is at risk for complications. The goal for the Resident to have decreased risk of s/s [signs and symptoms] of a UTI [Urinary Tract Infection] & [and] other complications r/t catheter through review date. The interventions included: Catheter care with warm water & soap. Review of the Physician's Orders for Resident #90 revealed an order dated 06/06/24 for Diagnosis for Indwelling Catheter: neurogenic bladder. Review of the current Physician's Orders for Resident #90 revealed no orders for indwelling urinary catheter (Foley) care. On 07/17/24 at 2:01 PM, an observation of indwelling urinary (Foley) catheter care provided to Resident #90 performed by Staff H, Certified Nursing Assistant (CNA), and assisted by the Registered Nurse Staff Development Coordinator was with no concerns. During an interview conducted on 07/17/24 at 9:15 AM with Staff J, Licensed Practical Nurse (LPN), the LPN stated she has worked at the facility for 2 months. When asked how often Foley care is provided, she said it is provided daily by the CNAs. When asked where they document the Foley care, she said it would be under tasks and it would pop up under tasks for the CNA to (prompt) them to document. During an interview conducted on 07/17/24 at 3:21 PM with Staff K, Certified Nursing Assistant (CNA), Staff K stated he has worked at the facility for [AGE] years. When asked where they document Foley care, he said they do not document Foley care, it is in the care plan. When asked if he provides Foley care, he said every day, on every shift. When asked where this is documented, he said it is documented under incontinence care that the resident has a Foley. During an interview conducted on 07/17/25 at 3:33 PM with Staff B, MDS (Minimum Data Set) coordinator, she stated she has worked at the facility for [AGE] years. When asked where a CNA would document Foley care, she said it would be in the task section. When asked where the Foley care documentation is for Resident #90, she said it is in Tasks under the toileting / brief change. When asked what options the CNA have to document, she said they can document incontinence care provided showing the resident has a Foley (indwelling catheter). When asked where the CNA can document actual Foley care provided, she acknowledged there is no place for the CNA to document Foley care provided. She said it is on the Kardex under bowel and bladder; it has catheter care with warm water and soap. She stated she enters the intervention on the care plan and attaches it to the CNA Kardex. During an interview conducted on 07/18/24 at 8:40 AM with Staff I, CNA, she stated she has worked at the facility for 6 months. When asked about providing care for residents with indwelling urinary (Foley) catheter, she said we provide the care at least once a shift and she does it every time the resident goes to the bathroom or is incontinent. When asked where she documents the catheter care, she said there is no option to document the catheter care, there is no option to document. There was no documented evidence Resident #90 was provided Foley care.

Based on interviews and record review, the facility failed to follow physicians' orders by not administering medications timely for 3 of 3 sampled residents reviewed for residents who received Parkinson's medications, affecting Residents #21, #25, and #310. The findings included: Review of the facility's procedural guidelines, titled, Medication Pass and Med Pass with Medication Cart, with an updated date of 06/28/23, included, in part, the following: Purpose: To assure the most complete and accurate implementation of physician's orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Guidance Steps in the Procedure: 7. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the center. For example, if the medication is ordered for 8:00 AM, it must be given between 7:00 AM and 9:00 AM in order to be considered timely. 1. Record review for Resident #310 revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 05/17/24. Resident #310's diagnoses included Parkinson's Disease Without Dyskinesia Without Mention of Fluctuations, Hereditary and Idiopathic Neuropathy, Muscle Weakness, Unspecified Lack of Coordination Review of the Minimum Data Set (MDS) for Resident #310 dated 05/17/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 13, indicating an intact cognitive response. Revie of the Physician's Orders for Resident #310 revealed an order dated 05/01/24 for Entacapone Oral Tablet 200 MG Give 1 tablet by mouth five times a day for Parkinson's give with carbidopa-levodopa. Review of the Physician's Orders for Resident #310 revealed an order dated 05/01/24 Ropinirole HCl Oral Tablet 1 MG Give 1 tablet by mouth three times a day for Parkinson's Review of the Physician's Orders for Resident #310 revealed an order dated 05/01/24 for Sinemet Oral Tablet 25-100 MG (Carbidopa-Levodopa) Give 1 tablet by mouth five times a day for Parkinson's give with Entacapone. Review of the time stamp administration of Entacapone, Sinemet (Carbidopa-Levodopa) and Ropinirole from 05/02/24 to 05/08/24 for Resident #310 revealed the following: For the medication Entacapone: 05/02/24 scheduled 8:00 AM given at 9:06 AM 05/02/24 scheduled 4:00 PM given 5:24 PM 05/03/24 scheduled 8:00 AM given 9:05 AM 05/03/24 scheduled 12:00 PM given 1:01 PM 05/04/24 scheduled 4:00 PM given 6:08 PM 05/06/24 scheduled 8:00 AM given 9:08 AM 05/06/24 scheduled 4:00 PM given at 6:08 PM 05/07/24 scheduled 4:00 PM given 5:45 PM 5/08/24 scheduled 4:00 PM given 7:02 PM. For the medication Sinemet (Carbidopa-Levodopa): 05/02/24 scheduled 8:00 AM given at 9:06 AM 05/02/24 scheduled 4:00 PM given 5:24 PM 05/03/24 scheduled 8:00 AM given 9:05 AM 05/03/24 scheduled 12:00 PM given 1:01 PM 05/4/24 scheduled 4:00 PM given 6:08 PM 05/06/24 scheduled 8:00 AM given 9:08 AM 05/06/24 scheduled 4:00 PM given at 6:08 PM 05/07/24 scheduled 4:00 PM given 5:46 PM 5/08/24 scheduled 4:00 PM given 7:02 PM. For the medication Ropinirole: 05/02/24 scheduled 2:00 PM given 3:05 PM 05/03/24 scheduled 6:00 PM given 7:34 PM 05/08/24 scheduled 6:00 PM given 8:09 PM. In summary, the documentation indicated the medication was not given timely (more than 1 hour before or 1 hour after scheduled time) on several occasions and as late as 2 hours and 2 minutes. During a telephone interview conducted on 07/15/24 at 11:05 AM with the spouse of Resident #310 who was asked about the resident's Parkinson's medications, the spouse stated the resident was prescribed a medication for restless leg syndrome with his Parkinson's medications and it affected the resident in a negative way. When asked to explain what this meant, the spouse stated they (facility) had to cut back on the Carbidopa Levodopa because he was having peak doses episode of dyskinesia with limbs flailing all over the place and the mobility was not what it was before being admitted to the facility. When asked about the medications being administered in a timely manner, the resident and the spouse stated the medications were often given late. 2. Record review for Resident #21 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Dementia and Parkinsonism. Review of the MDS for Resident #21 dated 05/07/24 documented in section C, a BIMS could not be completed due to the resident is rarely / never understood. Review of the Physician's Orders for Resident #21 revealed an order dated 11/13/23 for Mirapex Tablet 1 MG (Pramipexole Dihydrochloride) give 1 tablet by mouth three times a day for Parkinson's Review of the Physician's Orders for Resident #21 revealed an order dated 11/13/23 for Carbidopa-Levodopa Tablet 25-100 MG give 1 tablet by mouth three times a day for Parkinson's Disease. Review of the time stamp administration of Carbidopa-levodopa and Mirapex for Resident #21 revealed the following: For the medication Carbidopa-Levodopa: 07/01/24 scheduled for 7:00 AM given 8:39 AM 07/02/24 scheduled 4:00 PM given 5:17 PM 07/03/24 scheduled 4:00 PM given 5:24 PM 07/05/24 scheduled 4:00 PM given 5:09 PM 07/06/24 scheduled 4:00PM given 6:34 PM 07/10/24 scheduled 4:00 PM given 5:49 PM 07/11/24 scheduled 4:00 PM given 7:42 PM 07/12/24 scheduled 11:00 AM given 1:48 PM 07/15/24 scheduled 11:00 AM given 1:21 PM. For the medication Mirapex: 07/05/24 scheduled 2:00 PM given 3:07 PM 07/13/24 scheduled Upon R (6:00 AM -10:00 AM) given 11:11 AM 07/15/24 scheduled Upon R (6:00 AM -10:00 AM) given at 1:23 PM. In summary, the documentation indicated the medication was not given timely (more than 1 hour before or 1 hour after scheduled time) on several occasions and as late as 1 hour and 34 minutes. 3. Record review for Resident #25 revealed the resident was originally admitted to the facility on [DATE] with most recent readmitted [DATE]. The resident's diagnoses included: Dementia and Parkinsonism Review of the MDS for Resident #25 dated 07/11/24 documented in Section C, a BIMS score of 6 indicating severe cognitive impairment Review of the Physician's Orders for Resident #25 revealed an order dated 04/09/24 for Carbidopa-Levodopa Oral Tablet 25-100 MG (Carbidopa-Levodopa) give 1 tablet by mouth every 6 hours for Parkinsons. Review of the time stamp for Ropinirole and Carbidopa-Levodopa for Resident #25 revealed the following: For the medication Carbidopa-Levodopa: 07/02/24 scheduled 6:00 PM given 7:55 PM 07/04/24 scheduled 12:00 AM given 1:03 AM 07/04/24 scheduled 12:00 PM given 1:36 PM 07/05/24 scheduled 12:00 PM given 2:38 PM 07/06/24 scheduled 6:00 PM given 7:12 PM 07/07/24 scheduled 12:00 PM given at 1:06 PM 07/09/24 scheduled 12:00 AM given at 1:17 AM 07/09/24 scheduled 12:00 PM given 1:49 PM 07/09/24 scheduled 6:00 PM given 7:17 PM 07/10/24 scheduled 12:00 AM given 1:04 AM 07/10/24 scheduled 12:00 PM given 1:01 PM 07/10/24 scheduled 6:00 PM given 7:25 PM 07/11/24 scheduled 12:00 PM given 1:03 PM. In summary, the documentation indicated the medication (med) was not given timely (more than 1 hour before or 1 hour after scheduled time) on several occasions and as late as 1 hour and 38 minutes. During an interview conducted on 07/17/24 at 9:15 AM with Staff J, Licensed Practical Nurse (LPN), Staff J stated she has worked at the facility for 2 months. When asked about med administration times, she said some meds have a specific time to be given and we have a 1 hour window prior and 1 hour window after to give the medication. She said some meds have an upon time and that has a bigger window to give the med but still have 1 hour prior and 1 hour after to give the medication. If for some reason a medication was given late, she said she would notify the doctor and document a reason why it was not given in a progress note. During an interview conducted on 07/17/24 at 9:45 AM with Staff L, LPN, was asked about med administration times. The LPN said we have 1 hour before and 1 hour after the medication is scheduled to give the medication. When asked if a medication is given late what she does, she said she would document why the medication was given late. During an interview conducted on 07/18/24 at 12:20 PM with the Director of Nursing (DON), the DON was asked if she would consider a medication given outside of the 1 hour before or 1 hour after a scheduled time or time frame (prior or upon), the DON said she could not say. When asked if it would be considered 'following the physicians' orders', she said it may be considered not following the doctors' orders.

Based on observations, interviews and record review, the facility failed to secure medications at the bedside for 2 of 115 residents (Resident #72 & #83); failed to secure medication during medication administration (Resident #102); and failed to secure the medication cart while unattended for 1 of 5 med carts The findings included: Review of the facility's procedural guidelines, titled, Medication Storage Room, with an updated date of 06/28/24, included the following, in part: Under Medication Storage Area: Medication storage areas are secure when not under direct supervision of a nurse. 1. Record review for Resident #72 revealed the resident was admitted originally on 07/03/23 with most recent readmission on 11/25/23 and diagnoses that included: Type 2 Diabetes Mellitus without Complications, Bilateral Primary Osteoarthritis of Knee, and Spinal Stenosis. Review of the Minimum Data Set (MDS) assessment for Resident #72 dated 06/10/24 revealed in Section C, a Brief Interview of Mental Status (BIMS) score of 14 indicating an intact cognitive response. Record review for Resident #72 revealed no Self-Administration of Medication Evaluation. On 07/15/24 10:20 AM, an observation was made of Resident #72 lying in bed with a box of medications on a table across from the foot of her bed. In the box, there was a bag of Vicks Vapocool cough drops, Opcon-A eye allergy relief drops, and a bottle of Ibuprofen. On 07/16/24 at 9:30 AM, a second observation was made of Resident #72 lying in bed with a box of medications on a table across from the foot of her bed. In the box, there was a bag of Vicks Vapocool cough drops, Opcon-A eye allergy relief drops, and a bottle of Ibuprofen. On 07/17/24 at 9:58 AM, a side by side observation was made with Staff L, Licensed Practical Nurse (LPN), of Resident #72 lying in her bed with a box of medications including Vicks Vapocool cough drops, Opcon-A eye allergy relief drops, and a bottle of Ibuprofen. An interview was conducted on 07/15/24 at 10:20 AM with Resident #72 who was asked about the medications. She said she 'does not use them all of the time, some things she has not used for a year.' Resident #72 said the staff know about the medications and it is all right for her to have them because she does not use them much. An interview was conducted on 07/17/24 at 9:58 AM with Staff L who acknowledged Resident #72 had medications at the bedside and she should not have the meds at the bedside. Staff L said this was a very good observation and thanked the surveyor for bringing it to her attention. She sais she would address this immediately with the unit manager and the resident. 2. Record review for Resident #83 revealed the resident was originally admitted to the facility on [DATE] with readmission on 01/30/24 with diagnoses that included: Unspecified Dementia, Unspecified Symptoms and Signs Involving Cognitive Functions and Awareness, Cognitive Communication Deficit, Gastro-Esophageal Reflux Disease without Esophagitis. Review of the MDS assessment for Resident #83 dated 06/20/24 revealed in Section C, a BIMS score of 6, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #83 revealed an order dated 12/28/23 for a 'Regular diet Regular texture.' On 07/15/24 at 10:30 AM, an observation was made of Resident #83 sleeping in bed with the nightstand top drawer open and inside the drawer were Ricola cough drops. Photographic Evidence Obtained. On 07/16/24 at 9:20 AM, a second observation was made of Resident #83 sitting up in bed eating breakfast with the nightstand top drawer was open and inside were the Ricola cough drops. On 07/17/24 at 9:55 AM, a side by side observation was made with Staff L, LPN, of Resident #83 lying in her bed with the nightstand next to bed and the top drawer was open. Three (3) Ricola cough drops were inside. Staff L immediately removed the cough drops. An interview was conducted on 07/17/24 at 9:56 AM with Staff L who was asked about the cough drops at the bedside for Resident #83. She said this is a problem, the resident should not have these at the bedside, and she is on a soft diet. Staff L acknowledged the resident should not have the cough drops at the bedside, as they are a medication. 3. Record review for Resident #102 revealed the resident was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Diseases (COPD), and Chronic Respiratory Failure with Hypoxia. Review of the Physician's orders for Resident #102 revealed an order for Umeclidinium-Vilanterol (Anoro Ellipta) Inhalation Aerosol Powder Breath Activated 62.5-25mcg/ACT 1 puff inhale orally one time a day for COPD. On 07/17/24 at 9:05 AM, during a medication pass observation with Staff J, LPN, for Resident #102 after administering medications including Anoro Ellipta, she left the Anoro Ellipta inhaler on dresser across from the resident (out of the LPN's sight) while she went into the resident's bathroom to throw trash away and wash hands. An interview was conducted on 07/17/24 at 9:15 AM with Staff J who stated she has worked at the facility for 2 months. When asked why she left the inhaler on the dresser out of her sight while washing hands in the resident's bathroom, she said she did not want to bring the medication into the bathroom to cause any kind of cross contamination. When asked could she have put the inhaler on the resident's overbed table and rolled the overbed table to the bathroom doorway so she could keep the inhaler in her sight while washing her hands, she said yes. She acknowledged she should have kept the inhaler in her sight at all times. Staff J stated when asked about residents having medications at the bedside, that residents are not allowed to have medications at the bedside, if she saw medications at the bedside for a resident, she would ask her supervisor what to do, all medications should be locked up. 4. On 07/17/24 from 8:18 AM to 8:20 AM, an observation was made of the med cart left unlocked and unattended outside of room [ROOM NUMBER]. An interview was conducted on 07/17/24 at 8:22 AM with Staff A, LPN, who stated she has worked at the facility at the facility for 11 months. When asked if the med cart located outside of room [ROOM NUMBER] was assigned to her today, she said yes. When asked about the med cart being unlocked and left unattended, she said she is not supposed to leave the cart unlocked when she is away from the cart. Staff A LPN acknowledged she left the med cart unlocked and unattended.

Based on clinical and administrative record review and staff interview, the facility must ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. This is evidenced by the facility failure to follow the physician order for pain management for 1 of 3 sampled residents reviewed for pain management, Resident # 1. The findings included: Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Aftercare following Joint Replacement surgery, unilateral primary Osteoarthritis, left hip, Multiple Sclerosis, Takotsubo Syndrome, Chronic Pain Syndrome, and Muscle Spasm. Review of the 09/27/23 Minimum Data Set Assessment (MDS) documented Resident #1's Pain Assessment identifed the resident has had pain or hurting anytime in the last 5 days. The resident frequently experienced pain or hurting over the last 5 days and the pain has limited her day to day activities. The resident rated her pain level over the past five days at seven (7) on the pain scale of 0-10, with zero being no pain and ten being as the worst pain. The facility identified a problem, initiated 09/21/23, that the resident has acute/chronic pain related to recent left total hip replacement, muscle spasms an chronic pain syndrome. She is at risk for constipation due to decreased mobility, use of narcotic medication, and history of constipation. The interventions included Analgesics as ordered; Discuss with resident the need to request pain medications before pain becomes severe; Evaluate characteristics of pain: location, severity on a scale of 0-10, and frequency; Monitor for side effects of pain medication; Note any change in usual activity attendance patterns or refusal to attend activities related to sign and symptoms or complaints of pain/discomfort; and Observe for signs of relief/effectiveness with interventions. Further review of the physician orders and the Medication Administration Record (MAR) revealed the staff failed to follow the physician orders regarding the resident's pain medication. The physician prescribed for the resident to receive Oxycontin ER (Extended Release) 20 mg every 12 hours routinely. The physician's order was transcribed as every 12 hours as needed. The resident was also prescribed Oxycodone 10 mg i. r. (Immediate Release) give 2 tablets every 4 hours as needed for severe pain. The facility failed to administer the Extended-release medication as prescribed, as follows: In September 2023, the resident should have received 19 doses from September 21 - September 30. The resident received 10 doses of the routinely prescribed medications which were documented as removed to be administered, according to the Controlled Medication Utilization Record as follows: 09/22/23 - 6:15 AM and 9:16 PM (15 hours) 09/23/23 - 2:29 AM - no further doses given on 09/23/23 09/24/23 - 3:41 PM 09/25/23 - 2:09 PM 09/26/23 - 11:23 PM 09/27/23 - 6:01 PM 09/28/23 - 9:45 PM 09/29/23 - 9:44 AM 09/30/23 - 10:29 AM. In October 2023, the resident should have received 17 doses from October 1 - October 9. The resident received only 10 doses as follows: 10/01/23 - 12:10 PM 10/02/23 - 12:49 AM and 1:43 PM 10/03/23 - 6:18 PM 10/04/23 - 10:00 AM 10/05/23 - 8:12 AM 10/06/23 - 8:50 AM 10/07/23 - 9:55 AM 10/08/23 - 7:45 AM 10/09/23 - 12:59 AM. A telephone interview was conducted on 10/24/23 in the morning with Resident #1, who expressed that her pain medication was not given correctly. She stated the staff failed to give her one pain pill every 12 hours as it was ordered and the other pain medication was to be administered in between, if the routine medication didn't maintain the pain but they kept giving her the 'as needed' medication which acted immediately but wasn't long acting so she expressed that she had to keep asking for pain medication. An interview was conducted on 10/24/23 at 3:20 PM with the Licensed Practical Nurse (LPN), Staff A. Staff A confirmed she transcribed the medication incorrectly. The facility staff continued to administer the medication incorrectly for the entire 19-day admission for Resident #1, despite that the pharmacy label documented the medication was written as prescribed by the physician.

Based on observation, record review, policy review, and interview, the facility failed to ensure medication reconciliation of controlled substances were accurate for 3 of 4 sampled residents reviewed, Residents #7, 84, and 86. The findings included: A review of the facility policy, titled, Nurses' Medication Storage Room Guidelines, revealed, in part, that there is an accurate record of receipt and disposition of drugs. A review of the facility policy, titled, Medication Pass Guidelines revealed, in part, record the name, dose, route, and time of the medication on the Medication Administration Record (MAR). Initial the record after the medication is administered to the resident. Record the reason for not administering if not administered. a. On 04/27/23 at approximately 11:30 AM, an observation of the medication cart on the 200 wing, east even cart, with Staff A, Licensed Practical Nurse (LPN), revealed Resident #86 had an order for Oxycodone 5 milligrams (mg) every 4 hours as needed (PRN) for pain. A review of the medication count was correct. A review of the Controlled Medication Utilization Record revealed the Oxycodone was signed out on 04/19/23 at 0600 (6:00 AM). A subsequent review of the Medication Administration Record (MAR) did not have documentation of the Oxycodone being administered at that date and time. b. On 04/27/23 at approximately 12:15 PM, an observation of the medication cart on the 100 wing, west odd cart with Staff B, a Licensed Practical Nurse (LPN) revealed Resident #7 had an order for Norco 5-325 mg every 6 hours as needed (PRN) for pain. A review of the medication count was correct. A review of the Controlled Medication Utilization Record revealed the Norco was signed out on 04/27/23 at 0304 (3:04 AM). A subsequent review of the Medication Administration Record (MAR) did not have documentation of the Norco being administered to the resident at that date and time. c. On 04/27/23 at approximately 12:15 PM, an observation of the medication cart on the 100 wing, west odd cart with Staff B, an LPN revealed Resident #84 had an order for Norco 5-325 mg every 6 hours as needed (PRN) for pain. A review of the medication count was correct. A review of the Controlled Medication Utilization Record revealed the Norco was signed out on 04/25/23 at 1500 (3:00 PM) and 1505 (3:05 PM). A subsequent review of the Medication Administration Record (MAR) revealed documentation of the Norco being administered on 04/25/23 at 1504 (3:04 PM). Staff B, LPN stated that possibly this was documented as being removed twice, but when the count was reviewed, it was correct. Staff B, LPN was unable to explain the reason for the mediation being removed and not documented in the record. On 04/27/23, at approximately 2:00 PM, a review of the above findings was reviewed with the Director of Nursing.

Based on record review, interview, and policy review, the facility failed to ensure timely review and follow-up of pharmacy recommendations for 3 of 5 sampled residents, Resident #12, #72 and #75. The findings included: Review of the policy. titles, '9.1 Medication Regimen Review' revised 03/03/20, documented in part, 7. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR (Monthly Regimen Review) and the Director of Nursing to act upon the recommendations contained within the MRR. 7.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. 8. Facility should alert the Medical Director where MRRs are not addressed by the attending physician in a timely manner. 11. The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. 1. Review of the pharmacist's Consultant Report (report that documented the Medication Regimen Review/MRR) dated 03/01/23, revealed Resident #12 received the medication Methotrexate weekly for Arthritis but did not receive a Folic Acid supplement. This report recommended the addition of Folic Acid 1 mg (milligram) daily for Resident #12. This Consultation Report was signed by the physician on 03/18/23 with agreement to the pharmacy recommendation. Review of the record revealed a current order dated 03/17/23 for Folic Acid 400 mcg (micrograms), which was less than half the pharmacist's recommended dose and physician agreement, to be given daily as the supplement. This order was entered into the electronic record by the Unit Manager. During an interview on 04/28/23 at 10:35 AM, the Unit Manager was asked about the discrepancy between the pharmacy recommendation and the current order. The Unit Manager explained that the Folic Acid 400 mcg dose was part of their formulary, or stock medication. The Unit Manager stated she discussed the dose with the physician who agreed to use the stock medication. Review of the record and further review of the pharmacy recommendation lacked evidence for the use of the lower dose of medication. The Unit Manager agreed she failed to enter notation in the medical record related to the change from the pharmacy recommendation. 2. Review of the pharmacist's Consultant Report dated 12/14/22 revealed Resident #72 had a low TSH (thyroid stimulating hormone) level on 11/01/22, and was currently receiving Levothyronxine (medication for the thyroid) 112 mcg daily. This report recommended the reduction of the resident's Levothyroxine to 100 mcg daily, and to obtain a follow-up TSH in 6 to 8 weeks. The Consultation Report for December 2022 was signed by the physician on 03/07/23, with a handwritten note already completed. Review of the orders revealed the Levothyronxine 112 mcg dose was discontinued on 03/13/23, and changed to 110 mcg that same day, nearly three months after the pharmacist's recommendation. The orders also lacked the 6 to 8 week follow-up TSH order. During an interview on 04/27/23 at 12:57 PM, the Unit Manager was shown the December 2022 pharmacist's Consultation Report. The Unit Manager agreed the dose of Levothyroxine was changed on 03/13/23, and was unable to locate a follow-up TSH in 6 to 8 weeks. 37970 3. A review of the pharmacy recommendations for Resident #75 revealed the pharmacy consultation report completed for December 1 through December 31, 2022, was not responded to in a timely manner by the resident's physician. The recommendation for a Lipid Panel and CMP (comprehensive metabolic panel) was not acknowledged by the resident's physician until 03/27/23 and the labs were completed on 03/28/23. On 04/28/23 at approximately 10:15 AM, the Director Of Nursing provided QAPI (Quality Aurance and Performance Improvement) review that identified a concern with timeliness of physician addressing pharmacy recommendations date 04/20/23 although they were aware of concern in March 2023. There was no evidence of a complete full house audit documented. The pharmacy recommendations used as examples for full house audit were faxed on 04/25/23, according to stamped date on the faxed forms but dated on PIP (Performance Improvement Plan) as being completed on 04/24/23.

Based on observation, interview, record review, and policy review, the medication error rate was 7.4 percent. Two (2) medication errors were identified while observing a total of 27 opportunities, affecting 2 of 11 sampled residents observed, Residents #158 and #81. The findings included: 1. Review of the policy, titled, Eye Drops revised 04/25/17, documented, in part, Procedure: . 10. Pull lower lid gently downward to expose conjuctival sac [area of inner lower eye lid]. Instill eye drop per order in conjunctival sac. A medication pass observation was made on 04/26/23 beginning at 9:24 AM with Staff C, Licensed Practical Nurse (LPN), for Resident #158. The LPN obtained the medication Cyclosporin ophthalmic emulsion 0.05%, an antibiotic eye drop, to instill into the resident's left eye. Upon administration of the eye drop, the LPN stated, 'gonna go in the corner,' and administered the eye drop into the inner corner of the residents left eye, directly over the tear duct. During an interview on 04/26/23 at 9:33 AM, when asked why she administered the eye drop in the corner of the resident's eye, the LPN explained another nurse had taught her the drop would spread out over the eye better if placed in the corner of the resident's eye. 2. Review of the policy, titled, Subcutaneous Injection (page 17 of 18 of the Medication Administration policy), documented, in part, Insulin Injection: Assure type of insulin, unit dosage and syringe is correct. Guidance Steps in the Procedure: 1. Verify physician's orders. A medication pass observation was made on 04/26/23 beginning at 3:30 PM with Staff D, LPN, for Resident #81. The LPN obtained the resident's blood sugar level and verbalized the reading to be 288 [mg/dl]. The LPN returned to the medication cart and entered the blood sugar reading into the electronic medical record (EMR). The LPN obtained the resident's Lispro insulin via insulin pen, showed the surveyor she had dialed 4 units, and verbally confirmed the amount to administer was 4 units. Upon return to the resident's room, Staff D stated, I have your insulin for you . four units. The LPN again confirmed the blood sugar level was 288, retrieving the reading again from the glucometer (the device used to measure the blood sugar level). Review of the record revealed the current order for the Lispro insulin dated 01/23/23, was for the insulin to be administered as per a sliding scale. This order documented, should the blood sugar level be between 250 and 299, the nurse should administer 6 units of Lispro insulin. During an interview on 04/26/23 at 4:20 PM, when asked if she administered any additional medications or insulin to Resident #81, since the medication pass observation of 3:30 PM, Staff D stated she had not. Staff D was asked to look at the current sliding scale order for the Lispro insulin, and she confirmed the order documented to give 6 units of insulin for a blood sugar level of 288. The LPN stated when she put the blood sugar reading of 288 into the computer, the electronic medical record auto populated the dosage to administer as 4 units, not 6 units as per order. During a subsequent interview on 04/26/23 at 4:40 PM, Staff D explained she looked back at her entry in the electronic Medication Administration Record (MAR) and noted she entered an incorrect blood sugar level of 248, instead of 288, and that was why the electronic MAR told her to give the 4 units. Further review of the electronic MAR revealed the LPN had entered a blood sugar level of 228, instead of the actual blood sugar level of 288.

Based on facility policy review, record review and interview, the facility failed to follow physicians' orders for obtaining and sending urine specimens for urinalysis and urine cultures for residents with a documented change in condition and physicians' orders. This failure affected 2 of 3 sampled residents reviewed for urinary tract infection ([CONDITION(S)]), Resident #1 and #2. The findings included: A urinalysis (UA) is a test of urine used to detect a wide range of disorders such as urinary tract infection ([CONDITION(S)]). A urine culture and sensitivity (C&S) is a test that can detect bacteria and microorganisms in urine to determine the appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Facility policy, titled, Physicians Orders, dated 10/24/2017, documented, Physicians orders are obtained to provide a clear direction in the care of the resident. 1. Record review for Resident #1 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) resident assessment, dated 06/16/22, documented Resident #1 as being severely cognitively impaired requiring extensive assistance to total care for all activities of daily living except eating which required supervision. A care plan, dated 06/12/22, documented Resident #1 was at risk for dehydration with an intervention to do labs as ordered. Review of the clinical record documented the following: On 06/14/22 at 2:00 PM, Staff C, Licensed Practical Nurse (LPN), documented, notified by CNA (certified nurse assistant), blood observed in urine. On 06/14/22 at 4:23 PM, Staff D, Advanced Registered Nurse Practitioner (ARNP) documented the staff had noted hematuria (blood in the urine) today and ordered a urinalysis and urine culture to be done. On 06/14/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/16/22 at 3:34 PM, Staff C, LPN, documented, Increased sleepiness observed by patient's son and writer, MD (physician) on file notified. On 06/16/22 at 7:47 PM, Staff B, LPN, documented Resident #1 was observed with a change of condition and the healthcare provider was notified. Staff B documented, at the family request, the resident was sent to the emergency room for further evaluation and treatment. On 08/08/22 at 12:00 PM, further record review of Resident #1 revealed no documentation of the urinalysis or urine culture results. On 08/04/22 at 12:45 PM, interview with the Director of Nurses (DON) regarding the urinalysis and urine culture results for Resident #1 that were ordered on 06/14/2022 revealed the urinalysis and urine culture ordered on 06/14/22 for Resident #1 were never done. 2. Record review for Resident #2 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility baseline resident's assessment documented Resident #2 as being moderately cognitively impaired requiring extensive assistance for all activities except eating which requires supervision. A care plan, dated 07/31/22, documented Resident #2 was at risk for dehydration with an intervention to do labs as ordered. Review of the clinical record revealed the following: On 08/04/22 at 1:03 PM, Staff A, ARNP, documented, Interval History: pleasant female received in dayroom, very lethargic, difficult to arouse. Ordered UA and Urine Culture and CXR (chest Xray) given recent hx (history). On 08/04/22, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/05/22 at 1:52 PM, Staff A ordered a Straight Cath (temporarily inserting a tube into the bladder to obtain a urine specimen) for Urinalysis and Urine Culture for evaluation of urinary tract infection. On 08/08/22 at 12:20 PM, record review of Resident #2 revealed no documentation of urinalysis or urine culture results. On 08/04/22 at 1:00 PM, interview with the DON, with the Regional Nurse Consultant present, regarding the urinalysis and urine culture results for Resident #2 ordered on 08/04/22 and 08/05/22, revealed the urinalysis and urine culture ordered on 08/04/22 and 08/05/22 for Resident #2 was never done or sent to the lab. During an interview on 08/08/22 at 2:18 PM with the Administrator, the Regional Nurse Consultant and the DON, the DON stated she was going to initiate a Quality Assessment and Performance Improvement Plan regarding urine lab tests ordered.