Every finding on record at Providence St Elizabeth Care Center

Based on interview and record review, the facility failed to provide care in accordance with professional standards of care for one of three sampled residents (Resident 1) when the facility failed to:1. Implement the Registered Dietitian's (RD - a credentialed food and nutrition expert who uses evidence-based science to help people improve their health, manage diseases, and create personalized meal plans) recommendations and doctors' orders after Resident 1 was noted with a Change of Condition (COC), on 3/9/2026, of 4 pounds (lbs. - a unit of measurement) in one (1) month.2. Obtain weekly weights for Resident 1 after Resident 1 was noted with a COC, dated 3/9/2026, of a 4 lbs. weight loss in 1 month.These deficient practices had the potential for Resident 1 to experience weight variance (fluctuation). Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted Resident 1 on 12/2/2024 with diagnoses including dysphagia (difficulty swallowing), hypothyroidism (a common condition where the butterfly-shaped thyroid gland in the neck is underactive and does not produce enough thyroid hormones), and muscle weakness (generalized). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/10/2026, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated that Resident 1 required partial assistance (helper does less than half the effort) with toileting, showering, required supervision (helper providers verbal cues and or touching, stead and or contact guard assistance) oral hygiene, upper and lower body dressing, putting on and taking off footwear, and personal hygiene and required setup or clean-up assistance (helper sets up or cleans up, resident completes activity) with eating. During a review of Resident 1's Weight and Vitals Summary, from 1/1/2026 to 4/30/2026, the Weight Vital Summary indicated:- 1/7/2026: 137 lbs.- 2/3/2026: 133 lbs. - 3/4/2026: 129 lbs. - 4/2/2026: 129 lbs. During a review of Resident 1's care plan (CP), created on 8/22/2025 and revised on 12/5/2025, the CP for Resident 1 indicated risk for nutritional compromise related to dysphagia, chronic disease and metabolic demands, with increased risk for malnutrition, aspiration, weight loss, and poor healing if not managed properly. The CP interventions included diet as ordered by the physician and Resident 1 prefers to use sippy cup at bedside. During a review of Resident 1's Order Summary Report (OSR), dated 9/16/2025, the OSR indicated Consistent Carbohydrate (CCHO - a structured eating plan designed to manage blood sugar levels, primarily for people with diabetes [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing] or prediabetes) diet regular level 7 texture (Easy to chew [EC] - soft, tender foods that require minimal effort to chew and swallow), thin liquids, add fortified (are everyday foods that have extra vitamins and minerals added to them during manufacturing to make them more nutritious) cereal in the morning, add fortified soup for lunch and dinner for diabetes.During a review of Resident 1's RD Note, dated 3/4/2026, at 6:44 p.m., the RD indicated Resident 1's weight at 129 lbs. decreased 7.1 % in three months and four lbs. in one month. Resident 1 is on CCHC level 7 diet with fortified cereal breakfast, fortified soup for lunch and dinner with variable intake. Recommended weekly weight for two weeks. During a review of Resident 1's Nutrition Interdisciplinary Team (IDT - a regular, collaborative gathering where professionals from different fields [such as doctors, nurses, social workers, and therapists] meet to discuss a resident's care) Review, dated 3/6/2026, at 3:18 p.m., the Nutrition IDT Review indicated Resident 1's weight at 129 lbs., decreased 7.1% in three months, 4 lbs. in one month. The review indicated Resident 1 was on CCHO, level 7 diet with fortified cereal for breakfast, fortified soups for lunch and dinner with variable intake and recommended weekly weights for two weeks.During a review of Resident 1's Nursing Notes, dated 3/6/2026, at 4:06 p.m., the Nursing Notes indicated Resident 1 was seen by the RD with new recommendations that included weekly weights for two weeks, doctor made aware and in agreement, noted and carried out. During a review of Resident 1's COC, dated 3/9/2026, at 2:08 p.m., the COC indicated Resident 1 had weight loss. The COC Summarized observation, evaluation, and recommendation indicated Resident 1 was noted with weight loss of four pounds in one month. The COC indicated Resident 1's oral intake was variable from 25 to 100 % of meals. The COC indicated the doctor was notified on 3/9/2026 at 3 p.m. with the recommendation for an RD consultation.During a review of Resident 1's CP, created on 3/9/2026, the CP indicated Resident 1 has weight loss of four pounds in one month related to diuretic (a medication that helps your body get rid of excess water and salt [sodium] by increasing the amount of urine produced by the kidneys) use and variable oral intake. The CP indicated interventions including monitor and evaluate any weight loss, and RD consult. During an interview on 4/2/2026 at 1:12 p.m. with Restorative Nursing Assistant (RNA) 1, RNA 1 stated she (RNA 1) is the one that does the weekly and monthly weights for the residents. RNA 1 stated, for Resident 1, she (Resident 1) obtains the monthly weights and the Director of Nursing (DON) is the one who inputs the weight in the computer. During a concurrent interview and record review on 4/2/2026 at 4:22 p.m. with the DON, Resident 1's Nurses Notes were reviewed. The DON stated when the RD comes out, they make recommendations, then the nurse will contact the doctor to ensure they are okay with recommendations. The DON reviewed Resident 1's Nursing Notes, dated 3/6/2026, at 4 :06 p.m., and the DON stated the doctor was agreeable to plan. The DON stated the nurse should have input an order for weekly weights then communicate with the RNA to ensure weights were done weekly. The DON stated this was not done. The DON stated monitoring and interventions would be missed because there was no order input for weekly weights. The DON stated weekly weights are performed to ensure weights are stable. The DON stated if there was a COC for weight loss, the facility will implement interventions. The DON stated there is potential for weight variance for Resident 1 if the facility did not follow the RD's and doctors' recommendations. During a review of the facility's Policy and Procedures (P&P) titled, Nutrition Status Management, last reviewed on 3/19/2026, the P&P indicated it is the policy of this facility to assess each resident's nutritional status and needs, including medications and medical conditions to ensure that all residents maintain acceptable parameters of nutritional status, such as body weight and other available data, unless the resident's clinical condition demonstrates that this is not possible.2. Dietary Evaluation:b. If there is a significant change in the residents' condition related to weight or nutrition, the RD will make recommendations to offer additional nutrition to those residents including all high-risk residents. c. The IDT and or RD will monitor and evaluate the resident's response or lack of response to the interventions; and revising or discontinuing the approaches or justifying the continuation of current approaches. 3. Clinical Evaluation:b. Any resident weight that varies from the previous reporting period by more than 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the IDT to determine the cause of weight loss/gain and intervention required.c. The nurse will notify physicians, family and or resident of weight loss and or resident of weight loss and or gain with interventions.d. Any resident meeting the criteria for weight loss and any resident at risk will be weighted weekly with the weight entered into POC/PCC (Point of Care/Point Click Care - a type of electronic medical record). Weekly weights will be reviewed by the RD/designee.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of three sampled residents (Resident 2) when on 4/1/2026 at 8:22 a.m., Resident 2 was observed in the facility's Rehab Room with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) that was not covered with a dignity cover (a fabric, cloth, or vinyl sleeve designed to cover the external urine collection bag).This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing (a person's overall mental and social health, combining how they feel inside [emotions] with how they relate to others and their environment) and loss of dignity. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 3/21/2026 with diagnoses including retention of urine, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dependency on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).During a review of Resident 2's Order Summary Report (ORS), dated 3/21/2026, the OSR indicated:- Change indwelling catheter soiled, clogged, leaking, dislodged as needed.- Indwelling catheter 16 French (16 Fr - a standard size, for urinary catheter) with 10 milliliters (ml - unit of measurement) to closed drainage system due to urinary retention. - Indwelling catheter care every shift.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 3/27/2026, the MDS indicated Resident 2 had the ability to understand and be understood. The MDS indicated that Resident 2 had an indwelling catheter.During an observation on 4/2/2026 at 8:22 a.m. in the facility's Rehab Room, observed Resident 2 sitting up in his (Resident 2) wheelchair. Resident 2 was observed with a urinary catheter with red tinted urine and no observation of a dignity cover. During a concurrent observation and interview on 4/2/2026 at 8:24 a.m. of Resident 2 with the Director of Staff Development (DSD), the DSD stated Resident 2 did not have dignity cover on his (Resident 2) urinary catheter.During an interview on 4/2/2026 at 3:15 p.m. with the DSD, the DSD stated Resident 2 did not have a dignity cover on his (Resident 2) urinary catheter. The DSD stated Resident 2 should have a dignity cover, the dignity cover is for the resident's privacy and dignity. The DSD stated if the residents do not have dignity cover, they will not have any privacy, and it will affect their dignity. During an interview on 4/2/2026 at 3:47 p.m. with the Director of Nursing (DON), the DON stated Resident 2 should have been provided with a dignity cover. The DON stated as far as she (DON) is aware, Resident 2 had not refused to have a dignity cover for his (Resident 2) urinary catheter. The DON stated if residents are not provided with a dignity cover for their urinary catheter, there is potential for dignity and privacy issues with Resident 2. The DON stated Resident 2 may not feel comfortable showing what is in his (Resident 2) urinary catheter bag.During a review of the facility's policy and procedures (P&P) titled, Resident Rights, Dignity and Privacy, last reviewed on 3/19/2026, the P&P indicated it is the policy of this facility that all residents be treated with kindness, dignity and respect. 4. Privacy of a Resident's body shall be maintained during toileting, bathing and other activities of personal hygiene, except when staff assistance is needed for Resident's safety.

Based on interview and record review, the facility failed to implement its policies and procedures related to nursing staff competency for one of four sampled residents (Resident 1), by:1.Failing to provide an individualized care plan related to discharge which specifically covered the needs of Resident 1' care, with the inclusion of responsible party.2. Failing to provide discharge instructions and teachings to Resident 1 or responsible party prior to discharge.3. Failing to ensure Resident 1 was not discharged to home with an intravenous ([IV] an access point for administering medication directly into the bloodstream) still intact.Resident 1 was discharged home on [DATE]. On 12/26/2026, the Assistant Director of Nursing (ADON) went to Resident 1's home to provide teaching and remove Resident 1's IV needle.These deficient practices denied Resident 1 and responsible party the preparation needed for a safe transition in returning home.Cross reference F551 & F627 Findings:During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 12/1/2025 with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone in the leg or knee near an artificial joint, often caused from a fall), type 2 diabetes mellitus (a chronic condition leading to high blood sugar due to insulin resistance), history of falling, difficulty in walking, and retention of urine (the inability to empty urine from the body). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), date unreadable, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting needs, showering or bathing, and assistance when dressing items below the waist including footwear.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:- 12/25/2025: Discharge Destination: Home with home health servicesDuring an interview on 1/7/2026 at 1:54 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 remembered discharging Resident 1 with an IV. LVN 1 stated, For someone being discharged with an IV, I would assume it's for more treatment. The access site can lead to an infection, or possible bleeding. If uncontrolled bleeding, it can result in the need for emergency care.During a phone interview on 1/7/2026 at 2:20 p.m. with Resident 1's Responsible Party 3 (RP 3), RP 3 stated I kept telling them my mother is not ready for discharge. RP 3 also stated, We felt the discharge was incompetent, the most unorganized discharge, I have never seen a more unorganized, unsafe discharge in my life. She (Resident 1) was discharged home with an intravenous port on her arm. They didn't give discharge instructions to anybody. RP 3 also stated, I did not receive any information on how to appeal the case.During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 1/12/2026 at 12:36 p.m., the ADON stated Resident 1 was discharged to home on [DATE]. The ADON stated, For the discharge planning process, per policy, the discharge planning process shall: Provide and document sufficient preparation and orientation to residents, in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the facility. For the foley catheter (a thin tube inserted into the bladder to continuously drain urine into an external bag, used when retaining urine), it only discusses teaching done on the date of discharge, there was no documentation on the IV, it does not discuss the resident (Resident 1), or family understood the teaching. It should have been documented if the resident (Resident 1) or family understood the teaching, if the teaching was provided. It is a lot of information on the date of discharge, but it was common practice. The failure of the discharge order also does not include the resident (Resident 1) being discharged with an IV to home and also the foley catheter. The standard practice is the resident/or family is discharged order summary which includes all the orders while the resident was residing at the facility. The transfer discharge report does not include any foley catheter or the relevant information or about the IV. For the policy of discharge planning process, we have no documentation that considers caregiver/support person availability and capacity to perform required care, there is no documentation to prove return demonstration and understanding. The ADON stated, For care plans, a person-centered care plan would be specific to the resident and their needs. The resident's (Resident 1) care plan on Foley Catheter removal did not disclose resident or family teaching on interventions. The foley catheter was reinserted on 12/18/2025 and there was a care plan for the foley catheter. It included the intervention of monitor for signs and symptoms of urinary tract infection (UTI), but it does not talk about catheter care. So, the failure includes not involving the family in how to care for the foley catheter. The ADON stated, For the discharge care plan, the wish to return to home does not discuss education to the family or involvement of the family so that they would be better prepared for the discharge. ADON stated going to Resident 1's home on [DATE] around 3 p.m. to give instructions with the foley catheter, to remove the IV, and the Responsible Party 1 (RP 1) asking the ADON to assist in cleaning Resident 1. The ADON stated assisted RP 1 in providing hygiene care to Resident 1 at home. The ADON stated, This is not the standard of practice to do this after the discharge from the facility. The failure here was the resident (Resident 1) and family were not provided enough instructions to prepare them for the discharge. For staff competency in general, we would need to provide thorough in-services training on how to properly discharge a resident.During an interview with the Director of Nursing (DON) on 1/12/2026 at 3:22 p.m., For competency, for nursing staff competency, based on our policy, we failed in communication with the resident (Resident 1) and family for the resident's needs. On 12/26/2025, the ADON went to the home to provide teaching on the foley catheter and to remove the IV line. So, the failure was to adequately educate family on training and return demonstration of understanding and the clarification with the physician of discharging the resident with an IV.During a review of the facility provided policy & procedure (P & P) titled, Comprehensive Resident Centered Care Plan with last revision date of 4/2025, the P & P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The P & P also stated, The facility will provide the resident and resident representative, if applicable, advance notice of care planning conference to encourage resident and/or resident representative participation. Care conference may be in the form of face-to-face meeting, conference calls or video conferencing. If practicable, the reason will be documented in the medical record.During a review of the facility provided P & P titled, Discharge Planning Process, with last revised date of 4/2025, the P & P indicated, It is the policy of this Facility that the discharge planning process focuses on the resident's discharge goals, involving the residents as active partners. The discharge process should effectively transition them to post discharge care and minimize clinical or other factors which are related to the possibility of a readmission. The policy also indicated the procedure:The Facility's discharge planning process shall:Provide and document sufficient preparation and orientation to residents, in a form and manner the resident can understand, to ensure safe and orderly transfer or discharge from the facility.Ensure that the discharge needs of each resident are identified on admission, and that a discharge plan for each resident is developed and implemented in a timely manner.Include regular reevaluation of residents to identify changes that require modifications of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.Address the resident's goals and treatment preferencesDocument that a resident has been asked about their interest in receiving information regarding returning to the community.During a review of the P & P titled Nursing Staff Competency with last revised date of 6/2025, the P & P indicated, It is the policy of this facility to have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The P & P also indicated, The competency in skills and techniques necessary to care for residents' needs include but not limited to:Resident RightsPerson Centered CareCommunication

Based on interview and record review, the facility failed to implement its policies and procedures related to comprehensive care planning for one of four sampled residents (Resident 1) by: 1.Failing to provide an individualized care plan related to discharge which specifically covered the needs of Resident 1's care, with the inclusion of Resident 1's responsible party. 2. Failing to provide discharge instructions or teachings to Resident 1 or responsible party prior to discharge. 3. Failing to ensure Resident 1 was not discharged to home with an intravenous ([IV] an access point for administering medication directly into the bloodstream) still intact. Resident 1 was discharged to home on [DATE]. On 12/26/2026, the Assistant Director of Nursing (ADON) went to the home of Resident 1 to provide teaching and remove Resident 1's IV needle and dressing. These deficient practices denied Resident 1 and responsible party the preparation, training, and interventions needed for a safe discharge back to Resident 1's home setting. Cross reference F627 & F726Findings:During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 12/1/2025 with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone in the leg or knee near an artificial joint, often caused from a fall), type 2 diabetes mellitus (a chronic condition leading to high blood sugar due to insulin resistance), history of falling, difficulty in walking, and retention of urine (the inability to empty urine from the body). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), date unreadable, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting needs, showering or bathing, and assistance when dressing items below the waist including footwear.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:- 12/25/2025: Discharge Destination: Home with home health servicesDuring an interview on 1/7/2026 at 1:54 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 remembered discharging Resident 1 with an IV. LVN 1 stated, For someone being discharged with an IV, I would assume it's for more treatment. The access site can lead to an infection, or possible bleeding. If uncontrolled bleeding, it can result in the need for emergency care.During a phone interview on 1/7/2026 at 2:20 p.m. with Resident 1's Responsible Party 3 (RP 3), RP 3 stated I kept telling them my mother is not ready for discharge. RP 3 also stated, We felt the discharge was incompetent, the most unorganized discharge, I have never seen a more unorganized, unsafe discharge in my life. She (Resident 1) was discharged home with an intravenous port on her arm. They didn't give discharge instructions to anybody.During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 1/12/2026 at 12:36 p.m., the ADON stated Resident 1 was discharged to home on [DATE]. The ADON stated, For the discharge planning process, per policy, the discharge planning process shall: Provide and document sufficient preparation and orientation to residents, in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the facility. For the foley catheter (a thin tube inserted into the bladder to continuously drain urine into an external bag, used when retaining urine), it only discusses teaching done on the date of discharge, there was no documentation on the IV, it does not discuss the resident (Resident 1), or family understood the teaching. It should have been documented if the resident (Resident 1) or family understood the teaching, if the teaching was provided. It is a lot of information on the date of discharge, but it was common practice. The failure of the discharge order also does not include the resident (Resident 1) being discharged with an IV to home and also the foley catheter. The standard practice is the resident/or family is discharged order summary which includes all the orders while the resident was residing at the facility. The transfer discharge report does not include any foley catheter or the relevant information or about the IV. For the policy of discharge planning process, we have no documentation that considers caregiver/support person availability and capacity to perform required care, there is no documentation to prove return demonstration and understanding. The ADON stated, For care plans, a person-centered care plan would be specific to the resident and their needs. The resident's (Resident 1) care plan on foley catheter removal did not disclose resident or family teaching on interventions. The foley catheter was reinserted on 12/18/2025 and there was a care plan for the foley catheter. It included the intervention of monitor for signs and symptoms of urinary tract infection (UTI), but it does not talk about catheter care. So, the failure includes not involving the family in how to care for the foley catheter. ADON stated, For the discharge care plan, the wish to return to home does not discuss education to the family or involvement of the family so that they would be better prepared for the discharge. The ADON stated going to Resident 1's home on [DATE] around 3 p.m. to give instructions with the foley catheter, to remove the IV, and the Responsible Party 1 (RP 1) asking the ADON to assist in cleaning Resident 1. ADON stated assisting RP 1 in providing hygiene care to Resident 1 at home. ADON stated, This is not the standard of practice to do this after the discharge from the facility. The failure here was the resident (Resident 1) and family were not provided enough instructions to prepare them for the discharge. For staff competency in general, we would need to provide thorough in-services training on how to properly discharge a resident.During an interview with the Director of Nursing (DON) on 1/12/2026 at 3:22 p.m., the DON stated a comprehensive person-centered care plan includes individual focus, the goals, and the interventions. The DON stated, for Resident 1's discharge care plan, We failed to conduct a comprehensive care plan as it was not specific or did not specify the goals needed to have the resident ready for discharge. For the interventions, it does not show family involvement or types of education needed in order for the resident (Resident 1) and family to discharge the resident to home. Per policy on Comprehensive Resident centered care plan, the objectives we had were not measurable.During a review of the facility provided policy & procedure (P & P) titled, Comprehensive Resident Centered Care Plan, with last revision date of 4/2025, the P & P indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The P & P also stated, The facility will provide the resident and resident representative, if applicable, advance notice of care planning conference to encourage resident and/or resident representative participation. Care conference may be in the form of face-to-face meeting, conference calls or video conferencing. If practicable, the reason will be documented in the medical record.During a review of the facility provided P & P titled, Discharge Planning Process, with last revised date of 4/2025, the P & P indicated, It is the policy of this Facility that the discharge planning process focuses on the resident's discharge goals, involving the residents as active partners. The discharge process should effectively transition them to post discharge care and minimize clinical or other factors which are related to the possibility of a readmission. The policy also indicated the procedure:The Facility's discharge planning process shall: Provide and document sufficient preparation and orientation to residents, in a form and manner the resident can understand, to ensure safe and orderly transfer or discharge from the facility.Ensure that the discharge needs of each resident are identified on admission, and that a discharge plan for each resident is developed and implemented in a timely manner.Include regular reevaluation of residents to identify changes that require modifications of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.Address the resident's goals and treatment preferencesDocument that a resident has been asked about their interest in receiving information regarding returning to the community.

Based on interview and record review, the facility failed to implement its policies and procedures related to discharge planning for one of four sampled residents (Resident 1). The facility received a Notice of Medicare Non-Coverage ([NOMNC] a form from the Centers of Medicare & Medicaid services that skilled nursing facilities must provide to residents informing them Medicare-covered services are ending, and the right to appeal or contest the decision). The facility failed:1.To provide the NOMNC notice to Resident 1 or responsible party, which included the process of how to file an appeal.2. To provide discharge instructions or teachings to Resident 1 or responsible party.3. To develop an individualized care plan specifically covering the needs of Resident 1 with the inclusion of responsible parties.4. To ensure Resident 1 was not discharged to home with an intravenous ([IV] an access point for administering medication directly into the bloodstream) still intact.These deficient practices posed a serious risk for infection related to Resident 1's intact IV, the possibility of worsening health conditions, lack of care at home, or the potential need for rehospitalization of Resident 1. Cross reference F551. Findings:During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 12/1/2025 with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone in the leg or knee near an artificial joint, often caused from a fall), type 2 diabetes mellitus (a chronic condition leading to high blood sugar due to insulin resistance), history of falling, difficulty in walking, and retention of urine (the inability to empty urine from the body). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), date unreadable, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting needs, showering or bathing, and assistance when dressing items below the waist including footwear.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:- 12/25/2025: Discharge Destination: Home with home health servicesDuring a review of Resident 1's Notice of Medicare Non-Coverage (NOMNC) letter, dated 12/22/2025, the notice indicated Resident 1's Medicare coverage of current skilled nursing facility ended on 12/24/2025, with a discharge date scheduled for 12/25/2025. The notice included a contact number and the instructions on how to ask for an immediate appeal:Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the above date.The form also indicated the facility did not physically provide the notice to Resident 1 or the responsible party(s) of Resident 1 as the signature section had a note which read, Temporarily incapacitated.During an interview on 1/7/2026 at 1:54 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 remembered discharging Resident 1 with an IV. LVN 1 stated, For someone being discharged with an IV, I would assume its for more treatment. The access site can lead to an infection, or possible bleeding. If uncontrolled bleeding, it can result in the need for emergency care.During a phone interview on 1/7/2026 at 2:20 p.m. with Resident 1's Responsible Party 3 (RP 3), RP 3 stated I kept telling them my mother is not ready for discharge. RP 3 also stated, We felt the discharge was incompetent, the most unorganized discharge, I have never seen a more unorganized, unsafe discharge in my life. She (Resident 1) was discharged home with an intravenous ([IV] an access point for administering medication directly into the bloodstream) port on her arm. They didn't give discharge instructions to anybody. RP 3 also stated, I did not receive any information on how to appeal the case.During a concurrent interview and record review on 1/8/2026 at 1:18 p.m. with Admissions Coordinator 1 (AC 1), Resident 1's progress note titled, Administrative Note, dated 12/22/2025 at 10:25 a.m., inputted by AC 1, was reviewed. AC 1 stated Resident 1 wanted to have her responsible party(s) to make decisions on Resident 1's behalf. During a concurrent progress note titled, Administrative Note, dated 12/22/2025 at 10:25 a.m. inputted by AC 1, indicated a phone conversation with RP 3 indicating, The insurance is issuing a last cover day of date 12/24/2025 with a discharge (DC) date 12/25/2025. Explained options: Like DC home, care giver resources and the right to appeal if felt that she wasn't ready to DC to a lower level. Stated that she will appeal. The note also indicated, Patient was given a copy of NOMNC that was left on bedside and the number to appeal. During further interview with AC 1, AC 1 stated, On the note, the family wanted to file an appeal. We failed to obtain a signature form the family that they received the NOMNC notice.During an interview with Admissions Director (AD 1) on 1/9/2026 at 2:11 p.m., AD 1 stated, They (resident/responsible party) have to sign that they received a copy, because it is acknowledging that they received the NOMNC. The NOMNC has the information including multiple languages and explains that they have the right to appeal, which is the right to appeal the day before the last cover day, normally by noon. AD 1 also stated, We cannot file the appeal on the resident or the family's behalf, it has to be from the resident or responsible party. If someone was never given the NOMNC, you can't file an appeal, because you wouldn't know what phone number to call. They would also request a Medicare identification number. If it cannot be provided, then the appeal cannot be started. AD 1 stated, The failure was not obtaining a signature from the resident (Resident 1) or from the responsible party, which prevents them to file an appeal or extending the resident's stay with this facility. AD 1 also stated, I am not too familiar with the 30 day notice. I have never heard of the 30 day notice, and I have worked on admission since 2017.During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 1/12/2026 at 12:36 p.m., ADON stated Resident 1 was discharged to home on [DATE]. On the NOMNC dated 12/22/2025 and per progress note dated 12/22/2025 at 10:25am, it stated that after providing instructions, the family member stated they would appeal. It also stated, Patient (Resident 1) was given a copy of the NOMNC that was left on bedside and the number to appeal. A review of the NOMNC indicated the resident did not sign because the documentation indicated the resident was Temporarily Incapacitated. The ADON stated, The failure was that there were no other steps taken to prove the NOMNC was given to the resident or family, because we don't have a signed copy that the resident (Resident 1) or family acknowledged receiving the NOMNC. The NOMNC offers the resident and family the right to appeal as it contains the phone number to file the appeal and the instructions. Because they were not provided with a copy of the NOMNC that shows how to file an appeal, the failure was that the resident (Resident 1) and family were not given a copy of the NOMNC, so they wouldn't know how to file an appeal. ADON stated, For the discharge planning process, per policy, the discharge planning process shall: Provide and document sufficient preparation and orientation to residents, in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the facility. For the foley catheter (a thin tube inserted into the bladder to continuously drain urine into an external bag, used when retaining urine), it only discusses teaching done on the date of discharge, there was no documentation on the IV, it does not discuss the resident (Resident 1), or family understood the teaching. It should have been documented if the resident (Resident 1) or family understood the teaching, if the teaching was provided. It is a lot of information on the date of discharge, but it was common practice. The failure of the discharge order also does not include the resident (Resident 1) being discharged with an IV to home and also the foley catheter. The standard practice is the resident/or family is (provided the) discharged order summary which includes all the orders while the resident was residing at the facility. The transfer discharge report does not include any foley catheter or the relevant information or about the IV. For the policy of discharge planning process, we have no documentation that considers caregiver/support person availability and capacity to perform required care, there is no documentation to prove return demonstration and understanding. ADON stated, For the NOMNC policy provided, the provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate they received the notice and understands that the termination decision can be disputed. The failure was, since the family never received the NOMNC letter, they pretty much cannot dispute the decision to possibly extend the Resident's stay here in the facility and extend the insurance coverage. The ADON stated, For care plans, a person-centered care plan would be specific to the resident and their needs. The resident's (Resident 1) care plan on Foley Catheter removal did not disclose resident (Resident 1) or family teaching on interventions. The foley catheter was reinserted on 12/18/2025 and there was a care plan for the foley catheter. It includes the intervention of monitoring for signs and symptoms of UTI, but it does not talk about catheter care. So, the failure includes not involving the family in how to care for the foley catheter. ADON stated, For the discharge care plan, the wish to return to home does not discuss education to the family or involvement of the family so that they would be better prepared for the discharge. The ADON stated going to Resident 1's home on [DATE] around 3 p.m. (note: facility discharged Resident 1 on 12/25/2026) to give instructions with the foley catheter, to remove the IV, and the Responsible Party 1 (RP 1) asking the ADON to assist in cleaning Resident 1. The ADON stated assisting RP 1 in providing hygiene care to Resident 1 at home. The ADON stated, This is not the standard of practice to do this after the discharge from the facility. The failure here was the resident (Resident 1) and family were not provided enough instructions to prepare them for the discharge. For staff competency in general, we would need to provide thorough in-services training on how to properly discharge a resident.During a review of the facility provided policy and procedure (P & P) titled, Resident Rights with last reviewed date of 6/2025 indicated, It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The P & P also indicated The Resident has the right:To be encouraged and assisted throughout his or her stay in the center.To receive appropriate advanced notice (usually thirty days written notice) or any involuntary transfer or discharge from the Nursing Center as required by law.During a review of the facility provided P & P titled Medicare Notice of Non-Coverage (NOMNC) with last revised date of 11/30/2023 indicated, Medicare providers are responsible for the delivery of the NOMNC. Providers may formally delegate the delivery of the notices to a designated agent such as a courier service; however, all the requirements of valid notice delivery apply to designated agents. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed.During a review of the facility provided P & P titled Comprehensive Resident Centered Care Plan with last revision date of 4/2025 indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The P & P also stated, The facility will provide the resident and resident representative, if applicable, advance notice of care planning conference to encourage resident and/or resident representative participation. Care conference may be in the form of face-to-face meeting, conference calls or video conferencing. If practicable, the reason will be documented in the medical record.During a review of the facility provided P & P titled Discharge Planning Process with last revised date on 4/2025, indicated, It is the policy of this Facility that the discharge planning process focuses on the resident's discharge goals, involving the residents as active partners. The discharge process should effectively transition them to post discharge care and minimize clinical or other factors which are related to the possibility of a readmission. The policy also indicated the procedure:The Facility's discharge planning process shall:Provide and document sufficient preparation and orientation to residents, in a form and manner the resident can understand, to ensure safe and orderly transfer or discharge from the facility.Ensure that the discharge needs of each resident are identified on admission, and that a discharge plan for each resident is developed and implemented in a timely manner.Include regular reevaluation of residents to identify changes that require modifications of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.Address the resident's goals and treatment preferencesDocument that a resident has been asked about their interest in receiving information regarding returning to the community.

Based on interview and record review, the facility failed to account for and update the personal belongings for one of four sampled residents (Resident 1). This deficient practice increased Resident 1's risk for loss of personal belongings while residing in the facility. Findings:During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 12/1/2025 with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone in the leg or knee near an artificial joint, often caused from a fall), type 2 diabetes mellitus (a chronic condition leading to high blood sugar due to insulin resistance), history of falling, difficulty in walking, and retention of urine (the inability to empty urine from the body). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), date unreadable, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting needs, showering or bathing, and assistance when dressing items below the waist including footwear. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order: - 12/25/2025: Discharge Destination: Home with home health services During an interview and concurrent record review with the Director of Nursing (DON) on 1/12/2026 at 3:22 p.m., the DON stated, On discharge, the resident/responsible party gets a copy of the discharge summary, the list of medications, any follow up order, and the inventory. The importance of the inventory shows if there were any items missing or important items to make sure it goes home with resident (Resident 1) and family. During a concurrent record review with DON of Resident 1's document titled, Inventory of Personal Effects, the DON stated, The resident's (Resident 1) inventory is not complete. Why, because upon admission, it was not signed by a facility representative upon admission on [DATE]. Now, upon discharge, it is also not completed as it was not signed by the resident or family representative. The resident (Resident 1) was discharged [DATE], but the signature on facility representative (unknown signer) says 12/26/2025. For the inventory, we failed to have the facility representative and the resident or representative sign the form to certify the belongings were present and that they were received or taken home upon discharge.During a review of a facility provided policy and procedure (P & P) titled, Personal Effects, Inventory of, with last revised date of 6/2025, the P & P indicated, It is the policy of the facility to take responsible steps to protect the personal property of the residents. Procedures:On AdmissionWhen a resident is admitted to the facility, an inventory of the resident's personal effects shall be done by a staff member of the facility. The inventory should include the recording of all personal clothing, valuable articles, etc. which are brought into the facility with the resident and retained by the resident. These personal effects shall be recorded on the Inventory of Personal Effects form.Following completion of the inventory, the indicated form shall be signed by the resident and responsible party and by the staff member.The original copy shall be retained in the resident's health record and a photocopy given to the resident or his/her responsible party. On DischargeUpon discharge of a resident from the facility, the resident or responsible party shall date and sign the Certificate of Receipt on Discharge section of the form in conjunction with a staff nurse in order to certify that the resident's personal effects were received.A photocopy of this completed original form shall then be given to the resident or responsible party.

Based on interview and record review, the facility failed to implement its policies and procedures related to residents and or responsible party notification rights for one of four sampled residents (Resident 1). The facility received a Notice of Medicare Non-Coverage ([NOMNC] a form from the Centers of Medicare & Medicaid services that skilled nursing facilities must provide to residents informing them Medicare-covered services are ending, and the right to appeal or contest the decision) notice for Resident 1, which included the process of how to file an appeal, but Resident 1 nor the responsible party(s) of Resident 1 were not provided the notice. This deficient practice denied Resident 1 and the responsible party the rights to make informed decisions related to Resident 1's care, the rights to stay in the facility, and discussion and implementation of safe discharge planning needs. Cross reference F627. Findings: During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 12/1/2025 with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone in the leg or knee near an artificial joint, often caused from a fall), type 2 diabetes mellitus (a chronic condition leading to high blood sugar due to insulin resistance), history of falling, difficulty in walking, and retention of urine (the inability to empty urine from the body). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), date unreadable, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting needs, showering or bathing, and assistance when dressing items below the waist including footwear. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order: - 12/25/2025: Discharge Destination: Home with home health services During a review of Resident 1's Notice of Medicare Non-Coverage (NOMNC) letter, dated 12/22/2025, the notice indicated Resident 1's Medicare coverage of current skilled nursing facility ended on 12/24/2025, with a discharge date scheduled for 12/25/2025. The notice included a contact number and the instructions on how to ask for an immediate appeal:Ask for the appeal as soon as possible. You must ask for a timely appeal no later than noon of the day before the above date. The form also indicated the facility did not physically provide the notice to Resident 1 or the responsible party(s) of Resident 1 as the signature section read, Temporarily incapacitated. During a phone interview on 1/7/2026 at 2:20 p.m. with Resident 1's Responsible Party 3 (RP 3), RP 3 stated I kept telling them my mother is not ready for discharge. RP 3 also stated, We felt the discharge was incompetent, the most unorganized discharge, I have never seen a more unorganized, unsafe discharge in my life. She (Resident 1) was discharged home with an intravenous ([IV] an access point for administering medication directly into the bloodstream) port on her arm. They didn't give discharge instructions to anybody. RP 3 also stated, I did not receive any information on how to appeal the case. During a concurrent interview and record review on 1/8/2026 at 1:18 p.m. with Admissions Coordinator 1 (AC 1), Resident 1's progress note titled Administrative Note, dated 12/22/2025 at 10:25 a.m. inputted by AC 1, was reviewed. AC 1 stated Resident 1 wanted to have her responsible party(s) to make decisions on Resident 1's behalf. Resident 1's progress note titled Administrative Note, dated 12/22/2025 at 10:25 a.m. inputted by AC 1 indicated a phone conversation with RP 3 indicating, The insurance is issuing a last cover day of date 12/24/2025 with a discharge (DC) date 12/25/2025. Explained options: Like DC home, care giver resources and the right to appeal if felt that she wasn't ready to DC to a lower level. Stated that she will appeal. The note also indicated, Patient was given a copy of NOMNC that was left on bedside and the number to appeal. During further interview with AC 1, AC 1 stated, On the note, the family wanted to file an appeal. We failed to obtain a signature from the family that they received the NOMNC notice. During an interview with Admissions Director (AD 1) on 1/9/2026 at 2:11 p.m., AD 1 stated, They (resident/responsible party) have to sign that they received a copy, because it is acknowledging that they received the NOMNC. The NOMNC has the information including multiple languages and explains that they have the right to appeal, which is the right to appeal the day before the last cover day, normally by noon. AD 1 also stated, We cannot file the appeal on the resident or the family's behalf, it has to be from the resident or responsible party. If someone was never given the NOMNC, you can't file an appeal, because you wouldn't know what phone number to call. They would also request a Medicare identification number. If it cannot be provided, then the appeal cannot be started. AD 1 stated, The failure was not obtaining a signature from the resident (Resident 1) or from the responsible party, which prevents them to file an appeal or extending the resident's stay with this facility. AD 1 also stated, I am not too familiar with the 30-day notice. I have never heard of the 30-day notice, and I have worked on admission since 2017. During a review of the facility provided policy and procedure (P & P) titled, Resident Rights with last reviewed date of 6/2025 indicated, It is the policy of this facility that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The P & P also indicated The Resident has the right:To be encouraged and assisted throughout his or her stay in the center.To receive appropriate advanced notice (usually thirty days written notice) or any involuntary transfer or discharge from the Nursing Center as required by law.During a review of the facility provided P & P titled Medicare Notice of Non-Coverage (NOMNC) with last revised date of 11/30/2023 indicated, Medicare providers are responsible for the delivery of the NOMNC. Providers may formally delegate the delivery of the notices to a designated agent such as a courier service; however, all the requirements of valid notice delivery apply to designated agents. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed.

Based on interview and record review, the facility failed to implement its policies and procedures related to documentation for one of four sampled residents (Resident 1). Resident 1 was discharged home on [DATE]. On 1/6/2026, while onsite at the facility, the State Survey Agency (SSA) identified newly added documentation on Resident 1's files added on same date, 1/6/2026.This deficient practice resulted to inaccurate account of Resident's 1 records. Cross reference F726. Findings:During a review of Resident 1's admission Record, undated, the admission Record indicated the facility originally admitted Resident 1 on 12/1/2025 with diagnoses including periprosthetic fracture around internal prosthetic left knee joint (a broken bone in the leg or knee near an artificial joint, often caused from a fall), type 2 diabetes mellitus (a chronic condition leading to high blood sugar due to insulin resistance), history of falling, difficulty in walking, and retention of urine (the inability to empty urine from the body). During a review of Resident 1's History and Physical (H&P - a comprehensive assessment of a resident's medical condition), date unreadable, the H&P indicated Resident 1 had the capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/6/2025, the MDS indicated Resident 1's cognitive functioning (the ability to think, learn, remember, use judgment, and make decisions) was with moderate impairment. The MDS also indicated Resident 1 needed substantial/maximal assistance (helper does more than half the effort) for toileting needs, showering or bathing, and assistance when dressing items below the waist including footwear.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following physician's order:- 12/25/2025: Discharge Destination: Home with home health servicesDuring a phone interview with Responsible Party 2 (RP 2) on 1/7/2026 at 2:20 p.m., RP 2 stated Resident 1 was not ready to be discharged home. RP 2 stated, There was a lot of stuff we didn't know, and we were not prepared for. It was unsafe, having an IV ([IV] an access point for administering medication directly into the bloodstream) and not knowing what we do with the catheter (a thin tube inserted into the bladder to continuously drain urine into an external bag, used when retaining urine).During an interview and concurrent record review with Social Worker (SW) on 1/8/2026 at 2:21 p.m., SW stated, I input a note on 1/6/2026 at 1:20 p.m. This was for the effective date of 12/22/2025 at 12:51 p.m. The resident (Resident 1) was discharged on Christmas day, 12/25/2025. It is not our standard of practice to document weeks later after a discharge of the resident (Resident 1). I failed to document when it happened, I should have documented it within 72 hours. I don't believe this is believable because the creation date of the note was when you (State Survey Agency) started the investigation. During a concurrent record review with SW indicated a Progress Note created on 1/6/2026 at 1:20 p.m. with the effective date 12/22/2025 at 12:51 p.m. indicating, Family expressed concerns regarding the patient's readiness for discharge. SSD (SW) discussed alternative placement and care options, including remaining at the facility under private pay status or transitioning to a boarding care. The family declined options and decided to proceed with home discharge.During an interview and concurrent record review with the Assistant Director of Nursing (ADON) on 1/12/2026 at 12:36 p.m., the ADON stated, Per policy, any pertinent entry or missed or not written in a timely manner, a late entry should be used to record. Identify the late entry as a Late entry. Enter the current date and time, do not try to give the appearance that the entry was made on a previous date or an earlier time. The more time that passes, the less reliable the entry becomes. The ADON stated, For the discharge summary and post discharge plan of care, when I went to the home on [DATE], the family was not provided the documentation on 12/25/2025 (date of Resident 1's discharge), it was given to them when I visited on 12/26/2025. The failure there was that it provides information on the home health agency, ombudsman's (an advocate for residents of nursing homes) number, and it shows a history of the resident (Resident 1) during their time in the facility. For the documentation, I did not place this as a late entry. I documented it on 1/6/2026. The ADON indicated the investigation start date was on 1/6/2026. ADON stated, The failure here was me not documenting on the day I went to the home.During an interview and concurrent record review with the Director of Nursing (DON) on 1/12/2026 at 3:22 p.m., the DON stated, The failure was the staff failed to timely document communication to resident (Resident 1) and family.A review of the facility provided policy & procedure (P & P) titled, Guidelines for Handling Corrections, Errors, Omissions, and Other Documentation Problems/Documentation in a Long-Term Care Record with last revised date of 11/2024, indicated, Occasionally, documentation issues or errors arise, necessitating changes or clarifications. It is essential to follow the correct procedures when addressing these situations. The P & P indicated:Making a Late EntryWhen a pertinent entry was missed or not written in a timely manner, a late entry should be used to record the information in the health record.Identify the new entry as a late entryEnter the current date and time - do not try to give the appearance that the entry was made on a previous date or an earlier time.Identify or refer to the date and incident for which late entry was writtenIf the late entry is used to document an omission, validate the source of additional information as much as possible (where did you get information to write late entry). For example, use of supporting documentation on other facility worksheets or forms.When using late entries document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes.Entering an AddendumAn addendum is another type of late entry that is used to provide additional information in conjunction with a previous entry. With this type of correction, a previous note has been made and the addendum provides additional information to address a specific situation or incident. With an addendum, additional information is provided, but would not be used to document information that was forgotten or written in error. When making an addendum-Document the current date and timeWrite addendum and state the reason for the addendum referring back to the original entry.Identify any sources of information used to support the addendumWhen writing an addendum, complete it as soon after the original note as possible.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate was below five (5) percent (%) for two of five sampled residents (Residents 1 and 69) during the Medication Administration Facility Task conducted on 12/30/2025. The facility had seven (7) medication errors out of 29 observed opportunities on 12/30/2025 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely), resulting in an overall medication error rate of 24.14%. The facility failed to:1. Obtain a physician's order to crush Resident 1's medications for administration via gastrostomy tube (g-tube, also known as an enteral tube - a soft tube inserted through the abdominal wall directly into the stomach, providing a way to deliver nutrition, fluids and medicine for individuals with swallowing difficulties). 2. Ensure Licensed Vocational Nurse 1 (LVN 1) flushed the g-tube with at least 15 milliliters (ml - a unit of measure for volume) of purified water between the administration of each of the following medications, as ordered by Resident 1's physician: a. Acetaminophen (a medication used as a pain reliever and fever [abnormally high body temperature] reducer)b. Methocarbamol (a medication used to treat muscle spasms [sudden, involuntary, and often painful tightening or contraction of one or more muscles] and stiffness caused by muscle or bone conditions and injuries)c. Multiple Vitamins-Minerals tablet (a dietary supplement containing essential nutrients the body needs to work properly and stay healthy).d. Potassium Chloride 10% solution (an electrolyte [essential minerals that help balance the level of fluid in the body] supplement used to treat or prevent low levels of potassium [an essential mineral and electrolyte vital for nerve signals, muscle contractions {including the heart}, fluid balance, and blood pressure {BP} regulation] in the blood)e. Phenobarbital (medication that slows down the brain and central nervous system [CNS - made up of the brain and spinal cord, serves as a processing center that manages everything your body does], primarily used to control seizures [also known as epilepsy, a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking {movement}, blank stares, and loss of consciousness {a temporary state where a person becomes unaware of themselves and their surroundings}]). f. Miralax (also known as polyethylene glycol 3350, a medication used to treat occasional constipation [problem with passing stool]). 3. Ensure LVN 1 administered at least eight ounces (oz. - unit for measuring weight or liquid volume) of water with Resident 1's Potassium Chloride solution as ordered by the physician. These deficient practices had the potential to cause Resident 1's g-tube to become clogged due to medication buildup or drug incompatibility (refers to the undesirable reaction between two or more medicines, or a drug and a solution, causing changes in appearance, stability, safety or effectiveness, when the solutions are combined in the same syringe, tubing, or bottle) which may alter drug effects, reduce medication effectiveness, or result in overdosing from residual medication. These failures placed Resident 1 at risk for poor medication absorption, gastrointestinal (GI- relating to the stomach and the intestines [long, tube-shaped organ in the abdomen]) complications, ineffective treatment, potential seizure activity, hospitalization, and even death.4. Ensure Licensed Vocational Nurse 2 (LVN 2) administered a medication in accordance with the physician's prescribed orders when LVN 2 failed to measure Resident 69's heart rate (HR) prior to administering Amlodipine (a medication used to treat high BP) on 12/30/2025 during the 9 a.m. routine medication pass. This deficient practice had the potential to result in delayed care and treatment and mismanagement of Resident's 69's hypertension (abnormally high blood pressure) placing Resident 69 at risk for signs and symptoms of cardiac complications, including dizziness (feeling unsteady and feeling like you might faint) leading to falls, shortness of breath, and chest pain. On 12/31/2025 at 3:20 p.m., while onsite at the facility, the State Survey Agency (SSA), during the facility's annual recertification survey, identified an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) under 42 CFR S483.45(f)(1) Medication error rates are not 5% or greater. The Administrator (ADM) and the Director of Nursing (DON) were notified on 12/31/2025 at 3:20 p.m. of the IJ situation, due to the facility's failure to maintain a medication error rate below 5% by having seven (7) medication errors out of 29 observed opportunities on 12/30/2025 during the 9 a.m. routine medication pass, resulting in an overall error rate of 24.14%.On 1/2/2026 at 2:38 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 12/30/2025 at 2:20 p.m., upon notification of the IJ, the facility's pharmacist a person who is professionally qualified to prepare and dispense medicinal drugs and advise on their use) conducted a medication regimen review (a thorough, ongoing evaluation of all medications a resident takes) for Resident 1 and recommended obtaining a phenobarbital level (a test that measures the concentration of phenobarbital in the bloodstream). 2. On 12/30/2025 at 4 p.m., the DON initiated a change of condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) monitoring and care plan for Resident 1.3. On 12/30/2025 at 4 p.m., the ADM had a one-on-one (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) discussion with LVN 1 to address identified root-cause issues, including lack of proficiency despite prior training and inability to recall medication administration procedures. 4. On 12/30/2025 at 4:50 p.m., Resident 1's was assessed by Resident 1's attending physician. 5. On 12/30/2025 at 5:30 p.m., Licensed Vocational Nurse 4 (LVN 4) administered Resident 1's medication in place of LVN 1.6. On 12/30/2025 at 7 p.m., all available licensed nurses, including LVN 1, received in-service (refers to on the job training and education for staff to update their skills, learn new procedures, meet regulatory requirements and stay current with best practices for resident care) training from the DON on medication administration via g-tube. 7. On 12/31/2025 at 4 p.m. the Minimum Data Set Nurse (MDSN) initiated a change of condition and updated the care plan for Resident 69.8. On 12/31/2025 at 7 p.m., the facility's pharmacy nurse consultant provided LVN 1 with one-on-one in-service education, including skills verification and competency assessment related to medication administration in accordance with the facility's policy and procedure (P&P) titled, Policy and Procedure: General Guidelines for Administering Medications Via Enteral Tube.9. On 12/31/2025, between 6 p.m. to 9 p.m., all available licensed nurses received in-service education and completed one-on-one medication administration skills competency validation through return demonstration, discussion, and question-and-answer with the pharmacy nurse consultant.10. Beginning 12/31/2025, LVN 1 and any licensed nurse observed to lack medication administration proficiency will be removed from medication administration duties until competency is demonstrated by successfully administering medications to at least five residents or a minimum of 25 medications with a medication error rate of no greater than five percent (5%), as observed by the DON.11. Any licensed nurses who were unavailable on 12/31/2025 will receive in-service education and skills competency validation from the DON, Pharmacy Consultant (PC), or designee regarding the P&P titled, General Guidelines for Administering Medications Via Enteral Tube and Administration Procedures For All Medications prior to working their next scheduled shift. All licensed nurses will complete in-service and skill check by 1/6/2026.12. Beginning on 12/31/2025, medication administration skills checks and competency assessments for all licensed nurses will be conducted monthly for three months by the pharmacy nurse consultant. All shifts, including nights, weekends, and holidays, will be included.13. On 1/1/2026, Resident 1's preliminary laboratory results (outcome of test indicating a resident's health status) were communicated to Resident 1's physician, who ordered phenobarbital 40 milligrams (mg - a unit of measure for weight) twice a day via g-tube, iron (a medication used to treat and prevent low blood levels of iron, a vital mineral essential crucial for bodily functions like growth and energy) 300 mg via g-tube daily, phenobarbital level in one week, and a complete blood count (CBC - a blood test that measures and evaluates red blood cells [which carry oxygen], white blood cells [which fight infection], and platelets [which help blood to clot {prevent excessive bleeding when injured}) and iron level (refers to the amount of iron in the blood) in six weeks.14. On 1/1/2026, LVN 1 was placed on a Performance Improvement Plan and will not administer medications until medication proficiency is demonstrated, as determined by the DON.15. The Administrator will be reporting the results of the pharmacy consultant skills check and competency as well as the medication pass observation audits to the Quality Assurance (QA) committee for review and further recommendations as needed to ensure substantial compliance. Substantial compliance will be demonstrated by three consecutive monthly QA meetings with medication error rates of less than 5%. If substantial compliance is not achieved after three months, further actions will be initiated by the QA committee, and all nurses will continue to receive skills check competency and medication pass observation audits monthly for medication administration by the pharmacy consultant nurse and DON until such time facility is in substantial compliance.On 1/2/2026 at 4:30 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to maintain a medication error rate below 5% by having seven (7) medication errors out of 29 observed opportunities on 12/30/2025 during the 9 a.m. routine medication pass, resulting in an overall error rate of 24.14% was no longer present. The SSA removed the IJ situation, while onsite, on 1/2/2026 at 4:30 p.m. in the presence of the ADM and DON. Cross-reference F760.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 12/2/2025, with diagnoses including epilepsy, hemiplegia (total paralysis [loss of ability to move] of the arm, leg, and trunk on the same side of the body) and hemiparesis (a medical condition that causes weakness on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels [tubular structure carrying blood through the tissues and organs] that supply it). During a review of Resident 1's History and Physical (H&P – a comprehensive assessment of a resident's medical condition), dated 12/5/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/8/2025, the MDS indicated the resident rarely to never demonstrated the ability to make self-understood and understand others and had severely impaired cognitive skills (a significant decline in thinking, memory, and reasoning that makes it impossible for a person to live independently or perform daily tasks). The MDS further indicated the resident required a feeding tube and was prescribed a high-risk anticonvulsant medication (a type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain). During a review of Resident 1's Order Summary Report (OSR – a document that provides a consolidated, current list of all medications prescribed for a resident) for December 2025, the OSR indicated the following Physician Orders: a. Dated 12/11/2025. Acetaminophen oral tablet 325 mg. Give two tablets via g-tube three times a day for pain management not to exceed (NTE) three grams (gm- a unit of mass [weight]) of Acetaminophen from all sources within a 24-hour period. b. Dated 12/3/2025. Methocarbamol oral tablet 750 mg. Give two tablets via g-tube three times a day for muscle spasms. c. Dated 12/2/2025. Multiple Vitamins-Minerals tablet. Give one tablet via g-tube one time a day for supplement. d. Dated 12/3/2025. Potassium chloride 10% oral solution, 20 milliequivalent (meq - a unit of measurement) per 15 ml. Give 15 ml via g-tube one time a day for potassium supplement, give with at least 8 oz. of water. e. Dated 12/2/2025. Phenobarbital oral tablet 30 mg. Give one tablet via g-tube two times a day for seizure. f. Dated 12/2/2025. Polyethylene Glycol 200 Liquid (Polyethylene Glycol 200) [sic – entry appears erroneous]. (Polyethylene Glycol 200 was possibly entered in error, as Polyethylene Glycol 3350 {Miralax} was observed during Medication Administration Facility Task on 12/30/2025). Give 17 gm via g-tube one time a day every Mon, Tue, Thu, and Fri for bowel management. Mix with four to eight oz. of water (prior to administration) and give via g-tube; Hold if with loose bowel movement (BM). g. Dated 12/2/2025. Enteral feeding order: Flush the feeding tube every shift with at least 15 ml of purified water between each medication. Flush one final time with at least 15 ml purified water after all medications are administered. The OSR for December 2025 reviewed on 12/30/2025 did not indicate a physician order for medications to be crushed before administration via g-tube. During a review of Resident 1's Care Plan (CP) Report titled, Impaired neurological function related to complex central nervous system disorders and neuromuscular (relating to nerves and muscles) impairment., initiated on 12/30/2025, the CP indicated an intervention to administer phenobarbital and methocarbamol as ordered and to monitor the resident's (Resident 1) therapeutic response and observe for adverse effects (an undesired effect of a drug or other type of treatment). During an observation on 12/30/2025 at 8:31 a.m., with LVN 1, during the Medication Administration Facility Task, observed LVN 1 in front of Resident 1's room preparing for the morning (9 a.m.) medication pass. LVN 1 removed the following medications from the medication cart: 1. Acetaminophen 325 mg oral tablets.2. Methocarbamol 750 mg oral tablets. 3. Multiple Vitamins-Minerals one tablet. 4. Potassium Chloride oral solution 20 meq/15 ml (10%).5. Phenobarbital 30 mg oral tablet6. Miralax 17 gm packet. LVN 1 crushed two 325 mg Acetaminophen tablets and placed them into a medication cup. LVN 1 crushed two 750 mg Methocarbamol tablets and placed them into a medication cup. LVN 1 crushed one Multiple Vitamins-Minerals tablet and placed it into a medication cup. LVN 1 poured 15 ml of Potassium Chloride oral solution 20 meq/15 ml into a medication cup. LVN 1 crushed one 30 mg Phenobarbital tablet and placed it into a medication cup. LVN 1 mixed the Miralax packet with approximately four to eight oz. of water in a drinking cup. LVN 1 donned (put on) a gown, mask, and gloves and placed the prepared medications on the bedside (place next to a resident's bed) table. LVN 2 identified Resident 1 using the armband and Point Click Care (PCC- an electronic healthcare record system). LVN 1 checked the g-tube placement by checking for residuals and listening for gurgling sounds using a stethoscope (a medical tool that helps healthcare providers listen to internal body sounds, like heartbeats, breathing, and gut noises, by amplifying them through earpieces connected to a chest piece, allowing for diagnosis of heart, lung, and intestinal issues) on the abdomen while flushing air into the g-tube. LVN 1 confirmed Resident 1's g-tube placement. LVN 1 flushed the g-tube with 15 ml of water. LVN 1 then took the crushed acetaminophen tablets, poured 15 ml of water in the cup, mixed the medication using the piston syringe (a medical device with a hollow barrel and a movable plunger used to inject or withdraw fluids from the body, featuring a nozzle for attaching needles or tubing, offering precise control for applications like wound irrigation, medication delivery, or lab use) tip, aspirated (pulling back on the plunger on the piston syringe to draw up medication) the medication into the syringe and administered the medication via Resident 1's g-tube. LVN 1 repeated this process for the crushed Methocarbamol tablets and the crushed Multiple Vitamins-Minerals tablet, administering each medication via the g-tube without flushing the g-tube with at least 15 ml of purified water between each medications. LVN 1 took the crushed Methocarbamol tablets, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1's g-tube. LVN 1 took the crushed Multiple Vitamins-Minerals, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1's g-tube. LVN 1 aspirated the 15 ml of Potassium Chloride oral solution and administered the medication via piston syringe through the g-tube, LVN 1 then added 15 ml of water to the empty medication cup to wash off remaining medication, aspirated the water mixed with the remaining solution, and administered the medication via Resident 1's g-tube. LVN 1 did not follow the physician's order to administer the Potassium Chloride with at least 8 oz. of water. LVN 1 took the crushed Phenobarbital, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1's g-tube. LVN 1 took the Miralax solution and administered the medication via Resident 1's g-tube. Following medication administration, LVN 1 flushed Resident 1's g-tube with an additional 15 ml of water and re-connected the resident to the enteral feeding. LVN 1 removed her (LVN 1) gown and gloves, washed her hands, and documented the medication administration. During a concurrent interview and record review on 12/30/2025 at 9:15 a.m., with LVN 1, in front of Resident 1's room, Resident 1's OSR for December 2025 and Medication Administration Record (MAR- a document tracking every medication given to a resident, detailing the drug, dose, time, route) for 12/30/2025 were reviewed. LVN 1 stated she (LVN 1) had been working in the facility since July 2025 and could not recall being observed or evaluated for medication administration via g-tube. LVN 1 stated that when she (LVN 1) administers medication via g-tube, each medication should be prepared in a separate medication cup and should not be mixed with other medications. LVN 1 further stated that g-tube medications should be administered one at a time and that the tubing should be flushed with 15 to 30 ml of water, depending on the physician's order. LVN 1 stated that prior to medication administration, she (LVN 1) checks g-tube placement by instilling air into the tubing and listening for gurgling sounds. LVN 1 stated that if a medication is in powdered or crushed form, she (LVN 1) reconstitutes (to add liquid to a dry or powdered medication to make a solution) it by adding 15 ml of water to dissolve the medication for g-tube administration. LVN 1 stated she was supposed to pour the medication one at a time slowly through the barrel of the piston syringe by gravity for medication administration via g-tube, however, with Resident 1 she (LVN 1) decided to push the medication using the piston syringe because on a prior occasion, when she (LVN 1) was administering medications by gravity, the resident coughed and the medication spilled. LVN 1 stated each medication administration should be followed by flushing the g-tube with 10 to 15 ml of water in between. LVN 1 stated she (LVN 1) failed to flush the g-tube with 10 to 15 ml of water between medication administrations for Resident 1 and stated she forgot to perform the flushes. LVN 1 further stated that failure to flush the g-tube in between medication administration could result in clogging of the g-tube and might cause chemical and or drug interactions to Resident 1. LVN 1 stated there was a physician order within the enteral feeding orders to flush Resident 1's feeding tube with at least 15 ml of purified water between each medication. LVN 1 also stated there was a physician to give the 15 ml Potassium Chloride oral solution with at least eight oz. of water. LVN 1 stated she (LVN 1) did not administer the additional eight oz. of water when she gave the Potassium Chloride solution via g-tube. LVN 1 stated her (LVN 1) failure could result in gastric irritation for the resident. LVN 1 stated she (LVN 1) considered not flushing in between medication administration and not giving 8 oz of water with Potassium Chloride as ordered by Resident 1's physician, to be medication errors. During an interview on 12/30/2025 at 12:13 p.m., with the PC, the PC stated that when administering medications via g-tube, the licensed staff should flush the tubing between medications to ensure each medication fully passes through the tubing. The PC further stated that failure to flush the g-tube with water between medication administrations may result in potential medication interactions and potential clogging of the g-tube. The PC stated LVN 1 should have followed the physician's order to administer Potassium Chloride solution with at least eight oz. of water to prevent gastric irritation. The PC stated not following the physician's order to administer potassium chloride solution with the required amount (at least eight oz.) of water via g-tube and not flushing the g-tube with 15 ml of water in between medications constituted medication errors. During a concurrent interview and record review on 12/30/2025 at 1:07 p.m., with the DSD, LVN 1's Employee File was reviewed. The DSD stated there was no medication pass skills check list in LVN 1's file specifically for g-tube medication administration. The DSD stated he (DSD) observes licensed staff during medication passes via g-tube; however, he (DSD) has not observed LVN 1 performing g-tube medication administration at all. The DSD further stated that when he (LVN 1) observes licensed staff, he (LVN 1) does not complete any formal competency checklist. The DSD stated that during in-services, he instructs licensed staff that medications administered via g-tube should be flushed between each medication and should be given by gravity. The DSD stated the purpose of flushing the g-tube is to ensure that the medication is fully delivered and to prevent g-tube clogging. The DSD stated that not flushing the g-tube in between medication administration has the potential to result in chemical interactions between medications, which could harm the resident. The DSD also stated LVN 1 did not follow the physician's order to administer at least eight oz. of water with the Potassium Chloride solution for Resident 1, which could result in gastric irritation. The DSD stated that while new employees shadow experienced staff to ensure they are ready to care for residents in the facility, there is no formal nursing competency checklist for special procedures such as g-tube medication administration. The DSD further stated there should be a physician's order to crush medications for g-tube administration. The DSD stated there was no order on Resident 1's OSR indicating to crush medications for g-tube administration. The DSD stated it was important to obtain an order to crush medications for g-tube administration for the provider to be aware that certain medications needed to be converted to another form prior to administration. The DSD stated failure to follow the physician's order to flush the g-tube with at least 15 ml of water between medications, and failure to administer Potassium Chloride solution with at least eight oz. of water via the g-tube, constitutes a medication error. During a concurrent interview and record review on 12/30/2025 at 2:14 p.m., with the DON, Resident 1's OSR for December 2025, MAR for 12/30/2025, and CP Report titled, Impaired neurological function related to complex central nervous system disorders and neuromuscular impairment., initiated on 12/30/2025 were reviewed. The DON stated medications administered via g-tube should be flushed with 10 to 15 ml of water in between each medication to prevent g-tube clogging and potential medication interactions that could be harmful to residents. The DON stated LVN 1 failed to flush Resident 1's g-tube between medication administrations placing Resident 1 at risk for g-tube clogging and potential medication interactions. The DON further stated Potassium Chloride solution, Methocarbamol, and Phenobarbital are significant medications associated with serious potential adverse reactions (any unwanted, unpleasant, or harmful effect that happens while you are using a medicine or having another medical treatment). The DON stated LVN 1 did not administer at least eight oz. of water with Potassium Chloride solution for Resident 1, placing Resident 1 at risk for gastric distress (uncomfortable digestive issues such as bloating, abdominal pain, cramping often signaling an upset stomach). The DON stated not following the physician's order to flush the g-tube with 15 ml of water in between medication administration and not giving at least eight oz. of water with potassium chloride solution are considered medication errors that could potentially lead to hospitalization. The DON stated Resident 1's OSR did not indicate an order to crush Resident 1's medications for administration via gastrostomy tube. The DON stated that obtaining a physician's order to crush medications is essential to ensure provider awareness that certain medications require conversion to an alternative form prior to administration. During a concurrent interview and record review on 12/30/2025 at 3:10 p.m. with LVN 1, LVN 1's Medication Pass Observation Form, dated 8/5/2025 and 12/17/2025, were reviewed. LVN 1 stated she (LVN 1) barely remembers being observed during medication passes. LVN 1 authenticated her signature on 8/5/2025, however the medication pass observation dated 12/17/2025 did not include a signature line, and LVN 1 stated she (LVN 1) does not recall being observed on that date. During an interview on 12/30/2025 at 4:42 p.m., with the Medical Director (MD), the MD stated LVN 1's clinical practice was deficient, with the potential to clog Resident 1's tubing and cause possible medication interactions. The MD further stated that his (MD) order for Potassium Chloride solution should have been followed and administered with at least eight oz. to prevent gastric irritation. During a review of the PC's Drug Interaction Screening (DIS) for Resident 1, undated, the DIS identified the following medications as having potential drug interactions with corresponding Drug Interaction Risk Ratings: 1. Monitor therapy - Multivitamins/Minerals and Phenobarbital (Barbiturates – CNS depressant [medications that slow brain activity causing relaxation and drowsiness] used for seizure control)* Summary: Multivitamins/Minerals may decrease serum (clear liquid part of blood where drug levels are measured to guide dosing) concentrations of Barbiturates. * Severity: Moderate * Reliability Rating Intermediate-Low* Patient Management: Monitor for decreased serum concentrations and reduced therapeutic effects of barbiturates in patients receiving concomitant (same time) multivitamins. 2. Monitor therapy - Phenobarbital and Acetaminophen* Summary: Phenobarbital may increase the metabolism (the body's way of breaking down medications into smaller, more dissolvable in water compounds that are easier to remove) of Acetaminophen. Specifically, increasing the formation of the hepatotoxic (a condition characterized by damage to the liver caused by exposure to harmful substances, such as certain medications, toxins, or chemicals) metabolite (any substance that is produced or used during your body's natural chemical processes) may be increased. * Severity Moderate * Reliability Rating Intermediate.* Patient Management: Monitor for increased hepatotoxicity if acetaminophen is combined with phenobarbital, as liver toxicity may occur at lower acetaminophen doses when used with phenobarbital. Additionally, consider monitoring for reduced acetaminophen effectiveness. 3. Monitor therapy - Phenobarbital (CNS Depressants) and MethocarbamolSummary: CNS Depressants may increase CNS depressant effects of Methocarbamol. * Severity Moderate * Reliability Rating: Intermediate-Low* Patient Management: Caution patients that concomitant use of other CNS depressants may potentiate the CNS depressant effects of methocarbamol. During a concurrent interview and record review on 12/31/2025 at 10:06 a.m., with the DON, facility Drug References (date not specified) and Resident 1's CP Report titled, Impaired neurological function related to complex central nervous system disorders and neuromuscular impairment., initiated on 12/30/2025 were reviewed. The DON stated the pharmacy representatives who conducted medication pass observations for LVN 1 were Contracted Licensed Vocational Nurse 1 (CLVN 1) and Contracted Licensed Vocational Nurse 2 (CLVN 2). The DON stated that facility staff contact the PC for medication-related questions and that the facility does not maintain a specific drug handbook or reference resource for reviewing potential drug interactions. The DON further stated there was no care plan developed and implemented on medication administration via g-tube in Resident 1's electronic health record. The DON stated the purpose of a care plan is to ensure staff understand the proper procedures for medication administration via g-tube, however, the DON stated that the physician's order to flush the g-tube between medications should have been sufficient to guide LVN 1. The DON stated she (DON) did not believe the absence of a g-tube medication administration care plan would have altered the outcome. The DON stated LVN 1's failure to flush the g-tube between medication administration could result in g-tube clogging and increase the risk for potential drug interactions. During a concurrent interview and record review on 12/31/2025 at 12:25 p.m., with CLVN 1, LVN 1's Medication Pass Observation Form, dated 8/5/2025, was reviewed. CLVN 1 stated she (CLVN 1) conducted the Medication Pass Observation for LVN 1 on 8/5/2025. CLVN 1 stated during the observation period, there were no residents with a g-tube that LVN 1 was caring for. CLVN 1 further stated she (CLVN 1) discussed the P&P titled, General Guidelines for Administering Medication Via Enteral Tube, with LVN 1 however, no actual return demonstration of g-tube medication administration was observed. CLVN 1 stated she (CLVN 1) discussed the importance of flushing the g-tube in between medication administrations to promote drug absorption of t

Based on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 1) was free of any significant medication errors (the observed or identified preparation or administration of medications which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) when the facility failed to:A. Obtain a physician's order to crush Resident 1's medications for administration via gastrostomy tube (g-tube, also known as an enteral tube - a soft tube inserted through the abdominal wall directly into the stomach, providing a way to deliver nutrition, fluids and medicine for individuals with swallowing difficulties). B. Ensure Licensed Vocational Nurse 1 (LVN 1) flushed the g-tube with at least 15 milliliters (ml - a unit of measure for volume) of purified water between the administration of each of the following medications, as ordered by Resident 1's physician: a. Acetaminophen (a medication used as a pain reliever and fever [abnormally high body temperature] reducer)b. Methocarbamol (a medication used to treat muscle spasms [sudden, involuntary, and often painful tightening or contraction of one or more muscles] and stiffness caused by muscle or bone conditions and injuries)c. Multiple Vitamins-Minerals tablet (a dietary supplement containing essential nutrients the body needs to work properly and stay healthy).d. Potassium Chloride 10% solution (an electrolyte [essential minerals that help balance the level of fluid in the body] supplement used to treat or prevent low levels of potassium [an essential mineral and electrolyte vital for nerve signals, muscle contractions {including the heart}, fluid balance, and blood pressure {BP} regulation] in the blood)e. Phenobarbital (medication that slows down the brain and central nervous system [CNS - made up of the brain and spinal cord, serves as a processing center that manages everything your body does], primarily used to control seizures [also known as epilepsy, a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking {movement}, blank stares, and loss of consciousness {a temporary state where a person becomes unaware of themselves and their surroundings}]). f. Miralax (also known as polyethylene glycol 3350, a medication used to treat occasional constipation [problem with passing stool]). C. Ensure LVN 1 administered at least eight ounces (oz. - unit for measuring weight or liquid volume) of water with Resident 1's Potassium Chloride solution as ordered by the physician. D. Ensure Resident 1 had a care plan addressing g-tube medication administration.E. Ensure the Director of Staff Development (DSD) observed LVN 1 administering medications via g-tube to ensure LVN 1 followed the standards of practice for g-tube medication administration.These deficient practices had the potential to cause Resident 1's g-tube to become clogged due to medication buildup or drug incompatibility (refers to the undesirable reaction between two or more medicines, or a drug and a solution, causing changes in appearance, stability, safety or effectiveness, when the solutions are combined in the same syringe, tubing, or bottle) which may alter drug effects, reduce medication effectiveness, or result in overdosing from residual medication. These failures placed Resident 1 at risk for poor medication absorption, gastrointestinal (GI- relating to the stomach and the intestines [long, tube-shaped organ in the abdomen]) complications, ineffective treatment, potential seizure activity, hospitalization, and even death.2. Ensure one of one sampled resident (Resident 74) investigated during Medication Administration was free of significant medication error when:A. LVN 3 failed to administer aspirin (a medication that acts primarily as a blood thinner to help prevent blood clots) as ordered by the physician.B. LVN 3 failed to follow the physician orders when omeprazole (a medication that works by reducing the amount of acid produced in your stomach) was administered after enteral feeding (giving liquid food and nutrients directly into the digestive system [stomach or small intestine] through a soft tube when someone can't eat or swallow normally, but their gut still works) was already started. These deficient practices had the potential for Resident 74 to not receive a therapeutic dose of aspirin and omeprazole. On 12/31/2025 at 3:20 p.m., while onsite at the facility, the State Survey Agency (SSA), during the facility's annual recertification survey, identified an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) under 42 CFR S483.45(f)(2) Resident are free of any significant medication errors. The Administrator and the Director of Nursing (DON) were notified on 12/31/2025 at 3:20 p.m. of the IJ situation due to the facility's failure to ensure Resident 1 was free of any significant medication error.On 1/2/2026 at 2:38 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 12/30/2025 at 2:20 p.m., upon notification of the IJ, the facility's pharmacist a person who is professionally qualified to prepare and dispense medicinal drugs and advise on their use) conducted a medication regimen review (a thorough, ongoing evaluation of all medications a resident takes) for Resident 1 and recommended obtaining a phenobarbital level (a test that measures the concentration of phenobarbital in the bloodstream). 2. On 12/30/2025 at 4 p.m., the DON initiated a change of condition (COC - major decline or improvement in a resident's status that will not resolve without intervention) monitoring and care plan for Resident 1.3. On 12/30/2025 at 4 p.m., the ADM had a one-on-one (refers to individualized, one-on-one education provided to a single individual by a staff member or professional) discussion with LVN 1 to address identified root-cause issues, including lack of proficiency despite prior training and inability to recall medication administration procedures. 4. On 12/30/2025 at 4:50 p.m., Resident 1's was assessed by Resident 1's attending physician. 5. On 12/30/2025 at 5:30 p.m., Licensed Vocational Nurse 4 (LVN 4) administered Resident 1's medication in place of LVN 1.6. On 12/30/2025 at 7 p.m., all available licensed nurses, including LVN 1, received in-service (refers to on the job training and education for staff to update their skills, learn new procedures, meet regulatory requirements and stay current with best practices for resident care) training from the DON on medication administration via g-tube. 7. On 12/31/2025 at 7 p.m., the facility's pharmacy nurse consultant provided LVN 1 with one-on-one in-service education, including skills verification and competency assessment related to medication administration in accordance with the facility's policy and procedure (P&P) titled, Policy and Procedure: General Guidelines for Administering Medications Via Enteral Tube.8. On 12/31/2025, between 6 p.m. to 9 p.m., all available licensed nurses received in-service education and completed one-on-one medication administration skills competency validation through return demonstration, discussion, and question-and-answer with the pharmacy nurse consultant.9. Beginning 12/31/2025, LVN 1 and any licensed nurse observed to lack medication administration proficiency will be removed from medication administration duties until competency is demonstrated by successfully administering medications to at least five residents or a minimum of 25 medications with a medication error rate of no greater than five percent (5%), as observed by the DON.10. Any licensed nurses who were unavailable on 12/31/2025 will receive in-service education and skills competency validation from the DON, Pharmacy Consultant (PC), or designee regarding the P&P titled, General Guidelines for Administering Medications Via Enteral Tube and Administration Procedures For All Medications prior to working their next scheduled shift. All licensed nurses will complete in-service and skill check by 1/6/2026.11. Beginning on 12/31/2025, medication administration skills checks and competency assessments for all licensed nurses will be conducted monthly for three months by the pharmacy nurse consultant. All shifts, including nights, weekends, and holidays, will be included.12. On 1/1/2026, Resident 1's preliminary laboratory results (outcome of test indicating a resident's health status) were communicated to Resident 1's physician, who ordered phenobarbital 40 milligrams (mg - a unit of measure for weight) twice a day via g-tube, iron (a medication used to treat and prevent low blood levels of iron, a vital mineral essential crucial for bodily functions like growth and energy) 300 mg via g-tube daily, phenobarbital level in one week, and a complete blood count (CBC - a blood test that measures and evaluates red blood cells [which carry oxygen], white blood cells [which fight infection], and platelets [which help blood to clot {prevent excessive bleeding when injured}) and iron level (refers to the amount of iron in the blood) in six weeks.13. On 1/1/2026, LVN 1 was placed on a Performance Improvement Plan and will not administer medications until medication proficiency is demonstrated, as determined by the DON.14. The Administrator will be reporting the results of the pharmacy consultant skills check and competency as well as the medication pass observation audits to the Quality Assurance (QA) committee for review and further recommendations as needed to ensure substantial compliance. Substantial compliance will be demonstrated by three consecutive monthly QA meetings with medication error rates of less than 5%. If substantial compliance is not achieved after three months, further actions will be initiated by the QA committee, and all nurses will continue to receive skills check competency and medication pass observation audits monthly for medication administration by the pharmacy consultant nurse and DON until such time facility is in substantial compliance.On 1/2/2026 at 4:30 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to ensure Resident 1 was free of any significant medication error was no longer present. The SSA removed the IJ situation, while onsite, on 1/2/2026 at 4:30 p.m. in the presence of the ADM and DON. Cross-reference F759.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 12/2/2025, with diagnoses including epilepsy, hemiplegia (total paralysis [loss of ability to move] of the arm, leg, and trunk on the same side of the body) and hemiparesis (a medical condition that causes weakness on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels [tubular structure carrying blood through the tissues and organs] that supply it). During a review of Resident 1's History and Physical (H&P – a comprehensive assessment of a resident's medical condition), dated 12/5/2025, the H&P indicated Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 12/8/2025, the MDS indicated the resident rarely to never demonstrated the ability to make self-understood and understand others and had severely impaired cognitive skills (a significant decline in thinking, memory, and reasoning that makes it impossible for a person to live independently or perform daily tasks). The MDS further indicated the resident required a feeding tube and was prescribed a high-risk anticonvulsant medication (a type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain). During a review of Resident 1's Order Summary Report (OSR – a document that provides a consolidated, current list of all medications prescribed for a resident) for December 2025, the OSR indicated the following Physician Orders: a. Dated 12/11/2025. Acetaminophen oral tablet 325 mg. Give two tablets via g-tube three times a day for pain management not to exceed (NTE) three grams (gm- a unit of mass [weight]) of Acetaminophen from all sources within a 24-hour period. b. Dated 12/3/2025. Methocarbamol oral tablet 750 mg. Give two tablets via g-tube three times a day for muscle spasms. c. Dated 12/2/2025. Multiple Vitamins-Minerals tablet. Give one tablet via g-tube one time a day for supplement. d. Dated 12/3/2025. Potassium chloride 10% oral solution, 20 milliequivalent (meq - a unit of measurement) per 15 ml. Give 15 ml via g-tube one time a day for potassium supplement, give with at least 8 oz. of water. e. Dated 12/2/2025. Phenobarbital oral tablet 30 mg. Give one tablet via g-tube two times a day for seizure. f. Dated 12/2/2025. Polyethylene Glycol 200 Liquid (Polyethylene Glycol 200) [sic – entry appears erroneous]. (Polyethylene Glycol 200 was possibly entered in error, as Polyethylene Glycol 3350 {Miralax} was observed during Medication Administration Facility Task on 12/30/2025). Give 17 gm via g-tube one time a day every Mon, Tue, Thu, and Fri for bowel management. Mix with four to eight oz. of water (prior to administration) and give via g-tube; Hold if with loose bowel movement (BM). g. Dated 12/2/2025. Enteral feeding order: Flush the feeding tube every shift with at least 15 ml of purified water between each medication. Flush one final time with at least 15 ml purified water after all medications are administered. The OSR for December 2025 reviewed on 12/30/2025 did not indicate a physician order for medications to be crushed before administration via g-tube. During a review of Resident 1's Care Plan (CP) Report titled, Impaired neurological function related to complex central nervous system disorders and neuromuscular (relating to nerves and muscles) impairment., initiated on 12/30/2025, the CP indicated an intervention to administer phenobarbital and methocarbamol as ordered and to monitor the resident's (Resident 1) therapeutic response and observe for adverse effects (an undesired effect of a drug or other type of treatment). During an observation on 12/30/2025 at 8:31 a.m., with LVN 1, during the Medication Administration Facility Task, observed LVN 1 in front of Resident 1's room preparing for the morning (9 a.m.) medication pass. LVN 1 removed the following medications from the medication cart: 1. Acetaminophen 325 mg oral tablets.2. Methocarbamol 750 mg oral tablets. 3. Multiple Vitamins-Minerals one tablet. 4. Potassium Chloride oral solution 20 meq/15 ml (10%).5. Phenobarbital 30 mg oral tablet6. Miralax 17 gm packet. LVN 1 crushed two 325 mg Acetaminophen tablets and placed them into a medication cup. LVN 1 crushed two 750 mg Methocarbamol tablets and placed them into a medication cup. LVN 1 crushed one Multiple Vitamins-Minerals tablet and placed it into a medication cup. LVN 1 poured 15 ml of Potassium Chloride oral solution 20 meq/15 ml into a medication cup. LVN 1 crushed one 30 mg Phenobarbital tablet and placed it into a medication cup. LVN 1 mixed the Miralax packet with approximately four to eight oz. of water in a drinking cup. LVN 1 donned (put on) a gown, mask, and gloves and placed the prepared medications on the bedside (place next to a resident's bed) table. LVN 2 identified Resident 1 using the armband and Point Click Care (PCC- an electronic healthcare record system). LVN 1 checked the g-tube placement by checking for residuals and listening for gurgling sounds using a stethoscope (a medical tool that helps healthcare providers listen to internal body sounds, like heartbeats, breathing, and gut noises, by amplifying them through earpieces connected to a chest piece, allowing for diagnosis of heart, lung, and intestinal issues) on the abdomen while flushing air into the g-tube. LVN 1 confirmed Resident 1's g-tube placement. LVN 1 flushed the g-tube with 15 ml of water. LVN 1 then took the crushed acetaminophen tablets, poured 15 ml of water in the cup, mixed the medication using the piston syringe (a medical device with a hollow barrel and a movable plunger used to inject or withdraw fluids from the body, featuring a nozzle for attaching needles or tubing, offering precise control for applications like wound irrigation, medication delivery, or lab use) tip, aspirated (pulling back on the plunger on the piston syringe to draw up medication) the medication into the syringe and administered the medication via Resident 1's g-tube. LVN 1 repeated this process for the crushed Methocarbamol tablets and the crushed Multiple Vitamins-Minerals tablet, administering each medication via the g-tube without flushing the g-tube with at least 15 ml of purified water between each medications. LVN 1 took the crushed Methocarbamol tablets, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1's g-tube. LVN 1 took the crushed Multiple Vitamins-Minerals, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1's g-tube. LVN 1 aspirated the 15 ml of Potassium Chloride oral solution and administered the medication via piston syringe through the g-tube, LVN 1 then added 15 ml of water to the empty medication cup to wash off remaining medication, aspirated the water mixed with the remaining solution, and administered the medication via Resident 1's g-tube. LVN 1 did not follow the physician's order to administer the Potassium Chloride with at least 8 oz. of water. LVN 1 took the crushed Phenobarbital, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1's g-tube. LVN 1 took the Miralax solution and administered the medication via Resident 1's g-tube. Following medication administration, LVN 1 flushed Resident 1's g-tube with an additional 15 ml of water and re-connected the resident to the enteral feeding. LVN 1 removed her (LVN 1) gown and gloves, washed her hands, and documented the medication administration. During a concurrent interview and record review on 12/30/2025 at 9:15 a.m., with LVN 1, in front of Resident 1's room, Resident 1's OSR for December 2025 and Medication Administration Record (MAR- a document tracking every medication given to a resident, detailing the drug, dose, time, route) for 12/30/2025 were reviewed. LVN 1 stated she (LVN 1) had been working in the facility since July 2025 and could not recall being observed or evaluated for medication administration via g-tube. LVN 1 stated that when she (LVN 1) administers medication via g-tube, each medication should be prepared in a separate medication cup and should not be mixed with other medications. LVN 1 further stated that g-tube medications should be administered one at a time and that the tubing should be flushed with 15 to 30 ml of water, depending on the physician's order. LVN 1 stated that prior to medication administration, she (LVN 1) checks g-tube placement by instilling air into the tubing and listening for gurgling sounds. LVN 1 stated that if a medication is in powdered or crushed form, she (LVN 1) reconstitutes (to add liquid to a dry or powdered medication to make a solution) it by adding 15 ml of water to dissolve the medication for g-tube administration. LVN 1 stated she was supposed to pour the medication one at a time slowly through the barrel of the piston syringe by gravity for medication administration via g-tube, however, with Resident 1 she (LVN 1) decided to push the medication using the piston syringe because on a prior occasion, when she (LVN 1) was administering medications by gravity, the resident coughed and the medication spilled. LVN 1 stated each medication administration should be followed by flushing the g-tube with 10 to 15 ml of water in between. LVN 1 stated she (LVN 1) failed to flush the g-tube with 10 to 15 ml of water between medication administrations for Resident 1 and stated she forgot to perform the flushes. LVN 1 further stated that failure to flush the g-tube in between medication administration could result in clogging of the g-tube and might cause chemical and or drug interactions to Resident 1. LVN 1 stated there was a physician order within the enteral feeding orders to flush Resident 1's feeding tube with at least 15 ml of purified water between each medication. LVN 1 also stated there was a physician to give the 15 ml Potassium Chloride oral solution with at least eight oz. of water. LVN 1 stated she (LVN 1) did not administer the additional eight oz. of water when she gave the Potassium Chloride solution via g-tube. LVN 1 stated her (LVN 1) failure could result in gastric irritation for the resident. LVN 1 stated she (LVN 1) considered not flushing in between medication administration and not giving 8 oz of water with Potassium Chloride as ordered by Resident 1's physician, to be medication errors. During an interview on 12/30/2025 at 12:13 p.m., with the PC, the PC stated that when administering medications via g-tube, the licensed staff should flush the tubing between medications to ensure each medication fully passes through the tubing. The PC further stated that failure to flush the g-tube with water between medication administrations may result in potential medication interactions and potential clogging of the g-tube. The PC stated LVN 1 should have followed the physician's order to administer Potassium Chloride solution with at least eight oz. of water to prevent gastric irritation. The PC stated not following the physician's order to administer potassium chloride solution with the required amount (at least eight oz.) of water via g-tube and not flushing the g-tube with 15 ml of water in between medications constituted medication errors. During a concurrent interview and record review on 12/30/2025 at 1:07 p.m., with the DSD, LVN 1's Employee File was reviewed. The DSD stated there was no medication pass skills check list in LVN 1's file specifically for g-tube medication administration. The DSD stated he (DSD) observes licensed staff during medication passes via g-tube; however, he (DSD) has not observed LVN 1 performing g-tube medication administration at all. The DSD further stated that when he (LVN 1) observes licensed staff, he (LVN 1) does not complete any formal competency checklist. The DSD stated that during in-services, he instructs licensed staff that medications administered via g-tube should be flushed between each medication and should be given by gravity. The DSD stated the purpose of flushing the g-tube is to ensure that the medication is fully delivered and to prevent g-tube clogging. The DSD stated that not flushing the g-tube in between medication administration has the potential to result in chemical interactions between medications, which could harm the resident. The DSD also stated LVN 1 did not follow the physician's order to administer at least eight oz. of water with the Potassium Chloride solution for Resident 1, which could result in gastric irritation. The DSD stated that while new employees shadow experienced staff to ensure they are ready to care for residents in the facility, there is no formal nursing competency checklist for special procedures such as g-tube medication administration. The DSD further stated there should be a physician's order to crush medications for g-tube administration. The DSD stated there was no order on Resident 1's OSR indicating to crush medications for g-tube administration. The DSD stated it was important to obtain an order to crush medications for g-tube administration for the provider to be aware that certain medications needed to be converted to another form prior to administration. The DSD stated failure to follow the physician's order to flush the g-tube with at least 15 ml of water between medications, and failure to administer Potassium Chloride solution with at least eight oz. of water via the g-tube, constitutes a medication error. During a concurrent interview and record review on 12/30/2025 at 2:14 p.m., with the DON, Resident 1's OSR for December 2025, MAR for 12/30/2025, and CP Report titled, Impaired neurological function related to complex central nervous system disorders and neuromuscular impairment., initiated on 12/30/2025 were reviewed. The DON stated medications administered via g-tube should be flushed with 10 to 15 ml of water in between each medication to prevent g-tube clogging and potential medication interactions that could be harmful to residents. The DON stated LVN 1 failed to flush Resident 1's g-tube between medication administrations placing Resident 1 at risk for g-tube clogging and potential medication interactions. The DON further stated Potassium Chloride solution, Methocarbamol, and Phenobarbital are significant medications associated with serious potential adverse reactions (any unwanted, unpleasant, or harmful effect that happens while you are using a medicine or having another medical treatment). The DON stated LVN 1 did not administer at least eight oz. of water with Potassium Chloride solution for Resident 1, placing Resident 1 at risk for gastric distress (uncomfortable digestive issues such as bloating, abdominal pain, cramping often signaling an upset stomach). The DON stated not following the physician's order to flush the g-tube with 15 ml of water in between medication administration and not giving at least eight oz. of water with potassium chloride solution are considered medication errors that could potentially lead to hospitalization. The DON stated Resident 1's OSR did not indicate an order to crush Resident 1's medications for administration via gastrostomy tube. The DON stated that obtaining a physician's order to crush medications is essential to ensure provider awareness that certain medications require conversion to an alternative form prior to administration. During a concurrent interview and record review on 12/30/2025 at 3:10 p.m. with LVN 1, LVN 1's Medication Pass Observation Form, dated 8/5/2025 and 12/17/2025, were reviewed. LVN 1 stated she (LVN 1) barely remembers being observed during medication passes. LVN 1 authenticated her signature on 8/5/2025, however the medication pass observation dated 12/17/2025 did not include a signature line, and LVN 1 stated she (LVN 1) does not recall being observed on that date. During an interview on 12/30/2025 at 4:42 p.m., with the Medical Director (MD), the MD stated LVN 1's clinical practice was deficient, with the potential to clog Resident 1's tubing and cause possible medication interactions. The MD further stated that his (MD) order for Potassium Chloride solution should have been followed and administered with at least eight oz. to prevent gastric irritation. During a review of the PC's Drug Interaction Screening (DIS) for Resident 1, undated, the DIS identified the following medications as having potential drug interactions with corresponding Drug Interaction Risk Ratings: 1. Monitor therapy - Multivitamins/Minerals and Phenobarbital (Barbiturates – CNS depressant [medications that slow brain activity causing relaxation and drowsiness] used for seizure control)* Summary: Multivitamins/Minerals may decrease serum (clear liquid part of blood where drug levels are measured to guide dosing) concentrations of Barbiturates. * Severity: Moderate * Reliability Rating Intermediate-Low* Patient Management: Monitor for decreased serum concentrations and reduced therapeutic effects of barbiturates in patients receiving concomitant (same time) multivitamins. 2. Monitor therapy - Phenobarbital and Acetaminophen* Summary: Phenobarbital may increase the metabolism (the body's way of breaking down medications into smaller, more dissolvable in water compounds that are easier to remove) of Acetaminophen. Specifically, increasing the formation of the hepatotoxic (a condition characterized by damage to the liver caused by exposure to harmful substances, such as certain medications, toxins, or chemicals) metabolite (any substance that is produced or used during your body's natural chemical processes) may be increased. * Severity Moderate * Reliability Rating Intermediate.* Patient Management: Monitor for increased hepatotoxicity if acetaminophen is combined with phenobarbital, as liver toxicity may occur at lower acetaminophen doses when used with phenobarbital. Additionally, consider monitoring for reduced acetaminophen effectiveness. 3. Monitor therapy - Phenobarbital (CNS Depressants) and MethocarbamolSummary: CNS Depressants may increase CNS depressant effects of Methocarbamol. * Severity Moderate * Reliability Rating: Intermediate-Low* Patient Management: Caution patients that concomitant use of other CNS depressants may potentiate the CNS depressant effects of methocarbamol. During a concurrent interview and record review on 12/31/2025 at 10:06 a.m., with the DON, facility Drug References (date not specified) and Resident 1's CP Report titled, Impaired neurological function related to complex central nervous system disorders and neuromuscular impairment., initiated on 12/30/2025 were reviewed. The DON stated the pharmacy representatives who conducted medication pass observations for LVN 1 were Contracted Licensed Vocational Nurse 1 (CLVN 1) and Contracted Licensed Vocational Nurse 2 (CLVN 2). The DON stated that facility staff contact the PC for medication-related questions and that the facility does not maintain a specific drug handbook or reference resource for reviewing potential drug interactions. The DON further stated there was no care plan developed and implemented on medication administration via g-tube in Resident 1's electronic health record. The DON stated the purpose of a care plan is to ensure staff understand the proper procedures for medication administration via g-tube, however, the DON stated that the physician's order to flush the g-tube between medications should have been sufficient to guide LVN 1. The DON stated she (DON) did not believe the absence of a g-tube medication administration care plan would have altered the outcome. The DON stated LVN 1's failure to flush the g-tube between medication administration could result in g-tube clogging and increase the risk for potential drug interactions. During a concurrent interview and record review on 12/31/2025 at 12:25 p.m., with CLVN 1, LVN 1's Medication Pass Observation Form, dated 8/5/2025, was reviewed. CLVN 1 stated she (CLVN 1) conducted the Medication Pass Observation for LVN 1 on 8/5/2025. CLVN 1 stated during the observation period, there were no residents with a g-tube that LVN 1 was caring for. CLVN 1 further stated she (CLVN 1) discussed the P&P titled, General Guidelines for Administering Medication Via Enteral Tube, with LVN 1 however, no actual return demonstration of g-tube medication administration was observed. CLVN 1 stated she (CLVN 1) discussed the importance of flushing the g-tube in between medication administrations to promote drug absorption of the medication, to prevent clogging the g-tube, and reduce the risk of medication interaction with LVN 1. During a concurrent interview and record review on 12/31/2025 at 1:43 p.m. with CLVN 2, LVN 1's Medication Pass Observation Form, dated 12/17/2025 was reviewed. CLVN 2 stated she (CLVN 2) conducted the Med

Based on observation, interview, and record review the facility failed to enforce its policy of storing food brought in by family or visitors in a way that it was either separate or easily distinguishable from facility food when there was no designated refrigerator space for residents with leftover foods from home or outside sources. This failure had the potential to result in a decrease in the residents' food intake leading to unintentional (without trying) weight loss and frustrations among 33 of 35 facility residents. Findings: During a concurrent observation and interview during a brief kitchen tour on 12/29/2025 at 7:57 a.m. with the Dietary Supervisor (DS), observed a transparent bin with lid inside Refrigerator 2 labeled Resident Food. The DS stated the bin was for residents` food items that required refrigeration and the food item must be in a sealed container in its original packaging. During another follow up interview on 12/29/2025 at 12 p.m. inside the kitchen with DS, the DS stated that opened items or leftover food from outside sources brought in by family or visitors are not allowed for storage in the kitchen refrigerator due to possible cross contamination (transfer of harmful bacteria from one person, object or place to another). The DS stated that if family members bring in food for the resident, the food must be consumed within two (2) hours and if not consumed, the food will be discarded because there was no designated refrigerator for residents for leftover foods in the kitchen and at the nurses' station. The DS stated the residents could feel frustrated if they are not able to store food from outside sources or home and eat it if there is no refrigerator to store. During an interview on 12/31/2025 at 12:34 p.m. with the Director of Nursing (DON), the DON stated the facility policy regarding food brought by family or visitors indicated that the family or visitors can bring food items requested by the resident and must be in a sealed container and in its original packaging and stored in the kitchen refrigerator. The DON stated there is a bin with lid inside the kitchen refrigerator labeled Resident Food. The DON stated if the family or visitor brings food, the resident must consume the food within two hours, or it will be discarded as the facility does not have a refrigerator in the nurses' station and leftovers cannot be stored in the kitchen refrigerator which can cause cross contamination. The DON stated that food requiring refrigeration cannot be left out as it could spoil and cause illnesses. The DON stated residents may or may not be frustrated as a potential outcome if they are not able to store their food items that were from their family or friends. The DON stated it was important to encourage food from home or outside sources for residents who have low intake, or with food preferences such as cultural preferences other than what the facility can provide. During a review of the facility's policy and procedure (P&P) titled Food Brought by Family or Visitor, last reviewed 12/18/2025, the P&P stated: - Food brought to a resident by family/visitors must be accepted by the resident; inspected before facility storage; and stored and served in accordance with food safety professional standards. - The use of outside food is a possible intervention for residents with low intake, distinct food preferences, cultural/ethnic preferences. This intervention preserves the residents' right to self-determination to the greatest extent possible. - The facility kitchen will only store food that is sealed in manufacturer packaging. Food [NAME] from home in an already opened, non-sealed container will not be allowed to be stored in the facility kitchen. - Perishable prepared foods will be discarded in the morning of the next day by the designated dietary staff. - Prepared food is best consumed within 1 to 2 hours after removal from temperature control to minimize foodborne illness risk. It is recommended that the prepared food not be held over if it requires a second reheat. Prepared foods will be discarded after 2 hours.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure a bottle of salad dressing labeled with open date of 12/23/2025 was labeled with a best by date of 2/23/2026. 2. Failing to discard a bunch of parsley leaves inside a sealed plastic bag had brownish discoloration. 3. Failing to ensure a can of applesauce with dent was not placed in the shelf for dented cans. 4. Failing to ensure one (1) round shaped and 1 square shaped clean food containers were still wet and stacked in the clean and dried dishes/utensils section of the kitchen. 5. Failing to ensure eight (8) meal trays were stacked wet on the drying rack in the dishwashing room. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 33 out of 35 medically compromised residents who received food from the kitchen. Findings: During an initial kitchen tour on 12/29/2025 at 7:50 a.m. with the Dietary Supervisor (DS), observed inside Refrigerator two (2) and the dry storage room the following: 1. A bottle of salad dressing labeled with open date of 12/23/2025 was labeled with a best by date of 2/23/2026. 2. A bunch of parsley leaves inside a sealed plastic bag and the leaves had brownish discoloration. 3. A can of applesauce with dent was placed in the shelf for non-dented cans. a. During a concurrent interview and record review on 12/29/2025 at 8:10 a.m., reviewed with the DS, the facility provided Dry Good Storage Guidelines dated 2023. The DS stated the kitchen staff follow the Dry Good Storage Guidelines when labeling with the best by date. The DS stated the Dry Good Storage Guidelines indicated bottled salad dressings should be refrigerated when opened and must be used within 1 month after opening. The stated the Dry Good Storage Guidelines was not followed. The DS stated the bottled salad dressing should have been labeled with the best by date of 1/23/2026 instead of 2/23/2026 and had the potential to cause illnesses such as upset stomach, nausea, vomiting or diarrhea to the residents if the salad dressing was past the date indicated in the Dry Good Storage Guidelines. b. During a concurrent observation and interview on 12/29/2025 at 8:20 a.m. inside the dry storage room with the DS, the DS stated the bunch of parsley leaves inside the plastic bag had moisture and some of the leaves had brownish discoloration and could be spoiled. The DS stated she usually checks all the food items in the kitchen every day and discard or throws away whatever is past the best by dates, spoiled, or with discolorations. The DS stated the parsley leaves could be spoiled and when served to the residents can cause illness and give them upset stomach, nausea, vomiting, or diarrhea. The DS stated the bag of parsley leaves with brownish discoloration should have been discarded timely. c. During a concurrent observation and interview on 12/29/2025 at 8:23 a.m. inside the dry storage room with the DS, the DS stated 1 can of applesauce with a dent was not removed from the shelf with the non-dented. The DS stated she usually checks the shelf for canned products for dents daily and place them in a separate shelf for the dented cans to return to the food supply company. The DS stated the seal on the dented cannot be used anymore as the seal was already compromised and can possibly cause food poisoning if used or served to the residents. d. During a concurrent follow up observation and interview on 12/29/2025 at 2 p.m., inside the kitchen with the DS, observed 1 round shaped and 1 square shaped clean food containers stacked were still wet in the clean and dried dishes/utensils shelf of the kitchen. The DS stated the round and square shaped food containers were stacked and not completely dried. The DS state food containers were still wet. The DS stated that prior to placing the food containers in the dried dishes/utensils shelf of the kitchen, the kitchen staff have to ensure that the equipment are completely dry. The DS stated bacteria can form when the food containers were stacked together and can cause foodborne illnesses in the residents. During a concurrent interview and record review on 1/16/2026 at 1:03 p.m., the facility provided Dry Goods Labeling Guideline was reviewed with Director of Nursing (DON). The DON stated the dry goods storage guideline should be followed by the kitchen staff such as proper labeling of the salad dressing. The DON stated the Dry Goods Labeling Guideline indicated refrigerated salad dressing should be consumed within 1 month. The DON stated if consumed past the guideline, it placed the residents at risk for foodborne illnesses such as nausea, vomiting, and diarrhea. The DON stated kitchen equipment, utensils, food trays and containers should be completely dried before stacking together as bacteria can harbor or form in the between and may lead to foodborne illnesses. The DON stated any food items that have discoloration should be discarded to prevent serving to the residents and can cause illnesses such as nausea, vomiting, and diarrhea. During a review of the facility's policy and procedure titled, Labeling and Dating of Food, last reviewed 12/18/2025, the P&P indicated all food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for wither food safety or product rotation. The P&P further indicated the individual opening or preparing food shall be responsible for date marking at the time of processing. During a review of the facility's P&P titled, Dishwashing, last reviewed 12/18/2025, the P&P indicated all dishes will be properly sanitized through the dishwasher. The P&P further indicated: - Dishes are to be racked loosely without overlapping. - Dishes are to be air dried in racks before stacking and storing.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident during an inspection of one (1) out of two (2) medication carts, Medication Cart 1 (MC 1) reviewed under the Medication Storage and Labeling Task by: 1. Failing to accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Resident 23 in one (1) of two (2) inspected medication carts, Medication Cart (MC) 1. This deficient practice increased the risk of diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use) of controlled medications and the risk that Resident 23 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. 2. Failing to ensure Resident 23 received the 5 p.m. dose of pregabalin per physician's order on 12/13/2025 and 12/17/2025. This deficient practice placed Resident 23 at risk for complications and delay in the necessary care and services needed related to not receiving medications as prescribed by the physician such as worsening of pain. 3. Failing to ensure licensed nurses completed the incoming and outgoing Shift Change Narcotic Count Sheet (a form signed by the incoming and outgoing licensed nurse after reconciling narcotic medications) on 12/30/2025 For MC 1. This deficient practice had the potential to result in increased opportunity for medication diversion. Findings: a. During a review of Resident 23's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 23 on 12/12/2025 with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (nerve damage caused by high blood sugar from diabetes characterized by numbness, tingling, and burning pain), polyarthritis (a joint disease that involves at least five joints causing pain, stiffness, and swelling), and generalized muscle weakness. During a review of Resident 23's History and Physical (H&P) dated 12/16/2025, the H&P indicated Resident 23 had the capacity to understand and make decisions. During a review of Resident 23's Minimum Data Set (MDS, a resident assessment tool), dated 12/18/2025, the MDS indicated Resident 23 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was able to understand and make her needs known. The MDS further indicated Resident 23 required setup or clean-up assistance with eating and oral hygiene, personal hygiene, totally dependent with toileting, bathing, lower body dressing, partial/moderate assistance with all other activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 23 received scheduled pain medication regimen. During a review of Resident 23's Order Summary Report dated 12/31/2025, the Order Summary Report indicated the following physician's orders dated 12/12/2025: - Hydrocodone-acetaminophen (also known as Norco, a strong prescription pain reliever medicine for moderate to severe pain) oral tablet five (5)-325 milligram (mg - a unit of measurement) give one tablet by mouth every four (4) as needed for pain level of four (4) to ten (10) out of 10 not to exceed three (3) grams (gm - a unit of measurement) of APAP (chemical name for acetaminophen) in 24 hours. Do not give if respiratory rate (RR) is less than (< - a unit of measurement) or drowsy then notify the physician (MD). - Pregabalin (also known as Lyrica, a prescription medication that treats nerve pain by calming overactive nerves in your body) oral capsule 75 mg give one capsule by mouth two times a day for neuropathic pain. Hold if RR is <12 or drowsy then notify the MD. During an observation of MC 1 on 2/25/25 at 2:07 PM with the Assistant Director of Nursing (ADON), the following discrepancies were found between the Controlled Medication Count Sheet (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) or physical inventory: 1. Resident 23's Controlled Medication Count Sheet for hydrocodone-acetaminophen 5-325 mg indicated 52 tablets were dispensed on 12/18/2025 and the physical inventory contained 41 tablets remaining. 2. Resident 23's Controlled Medication Count Sheet for Lyrica 75 mg indicated 28 capsules were dispensed on 12/19/2025 and the physical inventory contained seven (7) doses. During a concurrent interview and record review with the ADON, reviewed and compared Resident 23's medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 12/2025, medication cards and the Controlled Medication Count Sheets for Norco and Lyrica, and the Shift Change Narcotic Count Sheet for Cart 1. The ADON stated: 1. Two tablets of Norco 5-325 mg oral tablets were removed on 12/21/2025 at 10:18 a.m. and one tablet on 12/25/2025 at 9:25 a.m. by Licensed Vocational Nurse (LVN) 2 but were not documented in the MAR. 2. Lyrica 75 mg oral capsules were documented in the MAR by LVN 4 as administered on 12/24/2025 and 12/25/2025 at 5 p.m. but the medication was not signed out in the Controlled Medication Count Sheet, and the expected inventory was supposed to be five capsules remaining instead of seven. 3. The Shift Change Narcotic Count Sheet Cart 1 was not signed off by the outgoing and incoming shift for 12/30/2025. The ADON stated that when administering controlled medications, the nurses are supposed to open the MAR, compare the bubble pack with the physician's order, and the Controlled Medication Count Sheet, remove the medication from the medication card, sign the Controlled Medication Count Sheet immediately and sign the MAR immediately after administration of the controlled medication. The ADON stated LVN 2 and LVN 4 should have signed Resident 23's MAR and Controlled Medication Count Sheet that the Norco and Lyrica were received by the resident. The ADON stated it is important to maintain accountability of controlled substances in order to prevent diversion or accidental overdose or underdosing to Resident 23. The ADON stated if Resident 23 received more often than prescribed, it could cause medical complications possibly leading to hospitalization or if Resident 23 did not receive the medications as prescribed, the resident could experience increased pain. The ADON stated incoming and outgoing licensed nurses (LNs) would count the narcotics and both licensed nurses would sign the Shift Change Narcotic Count Sheet form accepting the actual number on their shift for all residents that are receiving controlled medications. The ADON stated when the LNs do not sign the Shift Change Narcotic Count Sheet form on their shift it means the LNs did not do the counting. The ADON stated not counting the narcotics and not signing the Shift Change Narcotic Count Sheet, it had the potential for an opportunity for diversion of controlled medications. During an interview on 12/31/2025 at 10 a.m. with LVN 2, LVN 2 stated that she needs to sign out the doses of controlled medications on the Controlled Medication Count Sheet immediately after the medication is removed from the bubble pack. LVN 2 stated she (LVN 2 was unable to recall why she (LVN 2) did not sign the MAR and Controlled Medication Count Sheet. 2 further stated she (LVN 2) should have signed for the controlled medications she (LVN 2) removed for Resident 23 in the Controlled Medication Count Sheet and MAR immediately. LVN 2 stated it is important to maintain accountability of controlled substances in order to prevent diversion, accidental overdose to the resident. LVN 2 stated if Resident 23 received Norco more often than prescribed or not received as prescribed, it could cause medical complications such as increased pain and drowsiness possibly leading to hospitalization. During an interview on 12/31/2025 at 12:15 p.m. with the Director of Nursing (DON), the DON stated the outgoing and incoming LNs are supposed to count the narcotics and sign the Shift Change Narcotic Count Sheet form accepting the actual number of medications on their shift for all residents that are receiving controlled medications. The DON stated if the LNs did not sign the Shift Change Narcotic Count Sheet form on their shift it could mean that the LNs did not count the controlled medications and had the potential for an opportunity for diversion of controlled medications. The DON stated the LNs are supposed to open the MAR, compare the bubble pack with the physician's order, and the Controlled Medication Count Sheet, remove the medication from the medication card, sign the Controlled Medication Count Sheet immediately and sign the MAR immediately after administration of the controlled medication. The DON stated LVN 2 and LVN 4 should have signed Resident 23's MAR and Controlled Medication Count Sheet that the Norco and Lyrica were received by the resident. The DON stated it is important to maintain accountability of controlled substances in order to prevent diversion or accidental overdose or underdosing to Resident 23. During a review of the facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, last reviewed on 12/18/2025, the P&P indicated: - Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). - Medications are administered in accordance with written orders of the prescriber. - The individual who administers the medication dose records the administration on the resident's MAR/eMAR (electronic MAR) after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. - The resident's MAR/eMAR is initialed by the person administering the medication, in the space provided under the dare, and on the line for that specific medication dose administration - When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral). b. Signature or initials of person recording administration. During a review of the facility's P&P titled, Controlled Substances, last reviewed on 12/18/2025, the P&P indicated: - Medications included in the Drug Enforcement Administration (DEA - a United States government agency tasked with enforcing laws that cover illegal distribution of controlled substances) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. - Medications supplied by the provider pharmacy shall identify medications as controlled drugs, either as of the label or by sending a controlled drug count sheet with the medication or both. - Accurate accountability of all controlled drugs is maintained at all times. When a controlled substance is administered, the license nurse administering the medication immediately enters the following information on the accountability records and the MAR. 1. Date and time of administration (MAR, Accountability Record). 2. Amount administered (Accountability Record). 3. Remaining quantity (Accountability Record). 4. Initials of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record).

Based on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for two of two sampled residents (Resident 44 and 21) reviewed under the Pain Management care area by failing to: 1. Ensure the Licensed Nurse (LN) administered as needed (PRN) hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication) per the physician's order and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) for Resident 44. 2. Ensure the LNs followed the physician's order to administer the pain medication according to the resident's pain level for Resident 21. These deficient practices had the potential to result in side effects from unnecessary administration of narcotics including constipation and mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs-activities such as bathing, dressing and toileting a person performs daily), general activities, and mobility. Findings: a. During a review of Resident 44's admission Record (AR), the AR indicated the facility admitted the resident on 11/14/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body), metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), polyneuropathy (a disorder of the peripheral nervous system that may result in pain, discomfort, and mobility issues), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 44's Minimum Data Set (MDS – resident assessment tool) dated 11/20/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident required substantial / maximal assistance from staff for toileting, bathing, upper and lower body dressing, and mobility. The MDS indicated the resident was taking opioids, a high-risk drug class of medications (drugs that have a heightened risk of causing significant patient harm when they are used in error). During a review of Resident 44's Physician Order Summary, the Physician Order Summary indicated the following orders: - Hydrocodone - acetaminophen oral tablet five (5) - 325 milligrams (mg, a unit of measurement), give one (1) tablet by mouth every four (4) hours PRN for pain one (1)- six (6) out of 10, dated 11/14/2025. - Hydrocodone - acetaminophen oral tablet five 5 - 325 mg, give two (2) tablets by mouth every 4 hours PRN for pain seven (7) to 10 out of 10, dated 11/14/2025. During a review of Resident 44's Care Plan (CP) titled, Has acute / chronic pain, initiated 11/15/2025, the CP indicated a goal that the resident would not have an interruption in normal activities of daily living During a concurrent observation and interview on 12/29/2025 at 9:25 a.m., Resident 44 lay in bed and stated he (Resident 44) often had pain and is given pain medication. Resident 44 stated the pain medication causes constipation. During a concurrent interview and record review on 12/31/2025 at 8:22 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 reviewed Resident 44's physician orders, Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 12/2025, and Progress Notes for 12/2025. LVN 3 stated the facility process for administering PRN pain medication is the licensed nurse (LN) will first assess the resident for the location of pain, and the LN offers non-pharmacologic interventions. LVN 3 stated when non-pharmacologic interventions do not work, then the LN administers pain medication based on the numeric pain scale. LVN 3 stated the numeric pain level determines the amount of PRN pain medication administered to the resident. LVN 3 stated Resident 44 was able to verbalize the numeric pain scale level and received hydrocodone – acetaminophen 5/325 mg one tablet for pain level 1-6 and two tablets for pain level seven (7)-10. LVN 3 stated the LN documents the number of pain reported and the amount of medication administered in the MAR. LVN 3 stated if the LN documented the pain level in the MAR, then it was considered to be the resident's pain level at the time of administration. LVN 3 reviewed Resident 44's MAR and progress notes and noted the following regarding the PRN administration of one tablet of hydrocodone – acetaminophen 3/525 mg for pain one (1)- six (6): - On 12/1/2025 at 10:54 a.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was eight (8). - On 12/2/2025 at 1 a.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was 10. - On 12/2/2025 at 6 a.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was 10. - On 12/5/2025 at 6:20 a.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was seven (7). - On 12/6/2025 at 1 p.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was seven (7). - On 12/7/2025 at 2 a.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was seven (7). - On 12/7/2025 at 9 p.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was eight (8). - On 12/9/2025 at 6 a.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was eight (8). - On 12/14/2025 at 9:42 a.m., hydrocodone – acetaminophen one tablet was not administered per the physician's order when Resident 44's pain level was eight (8). LVN 3 stated there was no documented evidence that Resident 44 requested a lower dosage of pain medication when the one tablet of PRN hydrocodone – acetaminophen was administered. LVN 3 stated when a lower dose of pain medication is administered for a higher level of pain there is the potential that the pain medication would not be effective. LVN 3 stated there was also a missed opportunity for the physician to re-evaluate the resident's actual need for a higher dose, if one tablet was effectively treating Resident 44's higher level of pain. LVN 3 stated administering a lower dose of narcotics can reduce the risk of side effects like gastrointestinal upset and constipation. LVN 3 then reviewed Resident 44's MAR and progress notes and noted the following regarding the PRN administration of two tablets of hydrocodone – acetaminophen 3/525 mg for pain seven (7)-10: - On 12/9/2025 at 4:59 p.m., hydrocodone – acetaminophen two tablets were not administered per the physician's order when Resident 44's pain level was four (4). - On 12/17/2025 at 11 a.m., hydrocodone – acetaminophen two tablets were not administered per the physician's order when Resident 44's pain level was 0. LVN 3 stated when the higher dose of hydrocodone – acetaminophen was not administered per the physician's orders, then it was more likely to result in side effects of narcotics like constipation in Resident 44. During a concurrent interview and record review on 12/31/2025 at 10:55 a.m. with LVN 4, LVN 4 reviewed Resident 44's physician orders and MAR for 12/2025 and noted the following: - On 12/6/2025 at 1 p.m., LVN 4 stated he administered hydrocodone – acetaminophen one tablet for a pain level of seven (7). LVN 4 stated he (LVN 4) did not remember what happened and did not know why only one tablet was administered when the resident's pain level indicated to administer 2 tablets. LVN 4 stated if it was documented then that is what happened. - On 12/9/2025 at 4:59 p.m., LVN 4 stated he administered hydrocodone – acetaminophen two tablet for a pain level of four (4). LVN 4 stated he did not remember what happened and did not know why two tablets were administered when the resident's pain level indicated to administer only 1 tablet. - On 12/17/2025 at 11 a.m., LVN 4 stated he administered hydrocodone – acetaminophen two tablets for a pain level of 0. LVN 4 stated it was a documentation error when the MAR indicated a pain level of 0 because the resident reported a pain level of seven (7). During a concurrent interview and record review on 12/31/2025 at 2:05 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedures (P&P) regarding medication administration and pain management. The DON stated the facility process for PRN pain medication administration is to use the numeric pain scale and follow the physician's orders for pain medication administration. The DON stated the facility P&P was not followed when Resident 44 was not administered narcotic pain medication per the physician's orders when the resident was administered the incorrect dose for the reported numeric pain level. The DON stated when the incorrect dose of narcotics was administered there was the potential to result in ineffective pain management leading to more frequent administration of pain medication and side effects like constipation in Resident 44. During a review of the facility P&P titled, Pain Management, last reviewed 12/18/2025, the P&P indicated, Policy. It is the policy. to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences. Procedure. 2. To the extent possible, staff will: . b. Evaluate existing pain and the causes. c. Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 3. Pain will be identified and documented in the electronic health record (EHR). a. Using a scale of 1-10 is most common. Opioid treatment for pain is appropriately assessed and individualized for each resident. b. Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record (e-MAR). During a review of the facility P&P titled, Specific Medication Administration Procedures, last reviewed 12/18/2025, the P&P indicated, Policy. To administer medications in a safe and effective manner. Procedures. C. Review 5 Rights (3) times: . l.) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR for order.d. Check for vital signs, other tests to be done during/prior to medication administration. I. Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration. J. After administration, return to cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR or TAR, and controlled substance sign out record, if indicated .M. When administering an as needed (PRN) medication, document reason for giving. b. During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 12/10/2025, with diagnoses including sepsis (a life-threatening blood infection), malignant neoplasm (abnormal growth of tissues that spread to other parts of the body) of ovaries (female reproductive glands that make eggs and female hormones), and generalized muscle weakness. During a review of Resident 21's History and Physical (H&P) dated 12/10/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 had an intact cognition (mental action or process of acquiring knowledge and understanding) was able to understand others and make needs known. The MDS further indicated Resident 21 was independent with eating; required supervision or touching assistance with oral hygiene and personal hygiene; substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, sit-to-stand, and toilet transfers; partial/moderate assistance from staff with all other ADLs. The MDS indicated Resident 21 was on opioids. During a review of Resident 21's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 12/10/2025: Oxycodone hydrochloride oral tablet ten (10) milligrams (mg – a unit of measurement) give one tablet by mouth every six (6) hours as needed for pain four (4) to six (6) out of 10. Do not give if respiratory rate (RR) is less than (< - a unit of measurement) 12 or drowsy then notify the physician (MD). Oxycodone hydrochloride oral tablet 15 mg give one tablet by mouth every six (6) hours as needed for pain seven (7) to 10 out of 10. Do not give if RR is < 12 or drowsy then notify the MD. During a review of Resident 21's CP on generalized chronic pain related to malignant neoplasm of ovaries initiated on 12/11/2025, the CP indicated to follow pain scale to medicate as ordered as one of the interventions to prevent interruption on normal activities due to pain. During a review of the MAR for 12/2025, the MAR indicated Resident 21 received the following: Oxycodone hydrochloride 10 mg tablet: 12/13/2025 at 3:54 a.m. for pain level of nine (9) out of 10 12/20/2025 at 8:09 p.m. for pain level of nine (9) out of 10 12/24/2025 at 11:54 p.m. for pain level seven (7) out of 10 Oxycodone hydrochloride 15 mg tablet: 12/18/2025 at 9:26 a.m. for pain level of zero (0) out of 10 12/25/2025 at 8:23 a.m. for pain level of 0 out of 10 12/26/2025 at 9:27 a.m. for pain level of out of 10 During a concurrent observation and interview on 12/29/2025 at 9:06 a.m., inside Resident 21's room, observed Resident 21 lying in bed, alert and verbally responsive. Resident 21 stated often had pain and is given pain medication as needed. During a concurrent interview and record review on 12/31/2025 at 8:45 a.m., reviewed Resident 21's physician's orders, CP, MAR for 12/2025, and progress notes with Assistant Director of Nursing (ADON). The ADON stated prior to administration of pain medications, the LN asks the residents for their pain level and location and administers the pain medication according to the resident's pain level and physician's order. ADON stated Resident 21 had a physician's order to administered oxycodone hydrochloride 10 mg tablet one tablet every six (6) hours as needed for pain level of four (4) to six (6) out of 10 and oxycodone 15 mg tablet one tablet every six (6) hours as needed for pain level of seven (7) to 10 out of 10. The ADON stated the CP on chronic pain indicated to follow pain scale to medicate as ordered. The ADON stated Resident 21 received oxycodone hydrochloride 10 mg tablet on 12/13/2025 at 3:54 a.m. and 12/20/2025 at 8:09 p.m. for pain level of nine (9) out of 10, 12/24/2025 at 11:54 p.m. for pain level of seven (7) out of 10. The ADON stated Resident 21 received oxycodone hydrochloride 15 mg tablet on 12/18/2025 at 9:26 a.m., 12/25/2025 at 8:23 a.m. and 12/26/2025 at 9:27 a.m. pain level of 0 out of 10. The ADON stated the oxycodone was not administered to Resident 21 according to MD order. The ADON stated the MD order should have been followed to properly address Resident 21's pain. The ADON stated there was no documentation in the progress notes that Resident 21 requested a lower dosage of the pain medication for pain level of seven (7) or nine (9) out of 10 or higher dose for pain level of 0 out of 10. The ADON stated when a lower dose of pain medication is administered to Resident 21 for a higher level of pain there is the potential that the pain medication would not be effective and can affect Resident 21's participation with ADLs and mobility. The ADON stated when the higher than needed dose of oxycodone hydrochloride was administered for pain level of 0 out of 10, then it was more likely to result in side effects of narcotics like constipation, gastric irritation, or drowsiness in Resident 21. During a concurrent interview and record review on 12/31/2025 at 9:22 a.m. reviewed Resident 21's physician's order and MAR for 12/2025 with LVN 3. LVN 3 stated the facility process for administering as needed pain medication is the LN will first assess the resident for the location of pain, and the LN offers non-pharmacologic interventions. LVN 3 stated when non-pharmacologic interventions do not work, then the LN administers pain medication based on the numeric pain scale. LVN 3 stated the numeric pain level determines the amount of as needed pain medication administered to the resident. LVN 3 stated Resident 21 had a physician's order for oxycodone 10 mg tablet for pain level of four (4) to six (6) out of 10 and oxycodone15 mg tablet for pain level of seven (7) to 10 out of 10. LVN 3 stated the MAR indicated she administered oxycodone hydrochloride 15 mg to Resident 21 on 12/18/2025 at 9:26 a.m. and she indicated that the pain level was 0 out 10. LVN 3 stated she did not know why the pain level was documented as 0 out of 10. LVN 3 stated it was a documentation error when the MAR indicated a pain level of 0 because she will not administer the oxycodone hydrochloride if Resident 21's pain level was not between seven (7) to 10 out of 10. During a concurrent interview and record review on 12/31/2025 at 2:05 p.m. with the DON, the DON reviewed the facility P&P regarding medication administration and pain management. The DON stated the facility process for as needed pain medication administration is to use the numeric pain scale and follow the physician's orders for pain medication administration. The DON stated the facility P&P was not followed when Resident 21 was not administered narcotic pain medication per the physician's orders when the resident was administered the incorrect dose for the reported numeric pain level. The DON stated when the incorrect dose of narcotics was administered there was the potential to result in ineffective pain management leading to more frequent administration of pain medication and side effects like constipation in Resident 21. During a review of the facility P&P titled, Pain Management, last reviewed 12/18/2025, the P&P indicated: It is the policy of the facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences. To the extent possible, staff will Evaluate existing pain and the causes Manage or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Pain will be identified and documented in the electronic health record (EHR) Using a scale of 1-10 is most common. Opioid treatment for pain is appropriately assessed and individualized for each resident. Medication(s) received, refused and response to medication will be documented on the Electronic Medication Administration Record (e-MAR). During a review of the facility P&P titled, Specific Medication Administration Procedures, last reviewed 12/18/2025, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). Medications are administered in accordance with written orders of the prescriber. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral). b. Complaints or symptoms for which the medication was given.

Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Residents 1 and 33) reviewed for subcutaneous (sq - under the skin) anticoagulant (medicine that slows down the blood's clotting process, preventing dangerous clots from forming in the heart or blood vessels) use and for one of one sampled resident (Resident 12) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) sq heparin (a type of anticoagulant), enoxaparin (a type pf anticoagulant), and insulin.These deficient practices had the potential for adverse effects (unwanted, unintended result) of the same site subcutaneous administration of anticoagulants and insulin such as excessive bruising and bleeding, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F760.Findings: 1. During a review of Resident 1's admission Record (AR), the AR indicated the facility admitted the resident on 12/2/2025, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), and disorders of circulatory system (problems with the heart, blood vessels, or blood that stop oxygen and nutrients from getting to the body effectively). During a review of Resident 1's History and Physical (H&P), dated 12/5/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/8/2025, the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has significant problems with their mental abilities—such as thinking, remembering, and making decisions—to the extent that they can no longer live independently and require substantial help with everyday activities). The MDS indicated the resident was dependent to needing maximal assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) and was on a high-risk drug class anticoagulant. During a review of Resident 1's Order Summary Report (OSR), dated 12/2/2025, the OSR indicated an order for Heparin Sodium (Porcine) Injection Solution 5000 units per milliliters (unit/ml, refers to the concentration or the strength of the medication) (Heparin Sodium (Porcine)). Inject 1 milliliter (ml - a unit of volume) subcutaneously every 12 hours for cerebrovascular accident (CVA - stroke, loss of blood flow to a part of the brain) prophylaxis (taking steps to prevent a disease or problem before it happens). Rotate injection sites. During a review of Resident 1's Location of Administration Report (LAR) of Heparin for 12/2025, the LAR indicated Heparin Sodium (Porcine) Injection Solution 500 unit/ml was administered on: 12/10/2025 at 9:26 a.m. on the Abdomen- Right Lower Quadrant (RLQ) 12/10/2025 at 8:22 p.m. on the Abdomen- RLQ 12/15/2025 at 9:46 a.m. on the Abdomen- Left Upper Quadrant (LUQ) 12/16/2025 at 9 a.m. on the Abdomen- LUQ During a review of Resident 1's Care Plan (CP) Report titled, Anticoagulant therapy: Heparin Sodium (Porcine) Injection Solution for CVA prophylaxis, last revised on 12/28/2025, the CP indicated a goal of the resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date and an intervention to administer medication per physician orders. During a concurrent interview and record review on 12/30/2025 at 3:38 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Medical Diagnosis, OSR, LAR, and CP were reviewed. The ADON stated there was a physician's order for Heparin Sodium (Porcine) Injection Solution 5000 unit/ml (Heparin Sodium (Porcine)). Inject 1 ml subcutaneously every 12 hours for CVA prophylaxis. Rotate injection sites. The ADON stated the LAR indicated there were multiple instances where the licensed nurses did not rotate the Heparin administration sites to Resident 1. The ADON stated not following the physician's order to rotate insulin administration sites predisposes Resident 1 to severe bruising and bleeding at the frequented sites of administration. The ADON stated there was a care plan for anticoagulation therapy indicating a goal of the resident will be free from discomfort or adverse reactions related to anticoagulant use and an intervention to administer medication per physician's order was not followed. The ADON stated not following the physician's order and not rotating administration sites of Heparin as a professional nurse is considered a medication error. During a review of the facility's recent policy and procedure (P&P) titled, Injectable Medication Administration, last reviewed on 12/28/2025, the P&P indicated to administer medication via subcutaneous, intradermal and intramuscular routes in a safe, accurate, and effective manner. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Heparin Sodium Injection, for intravenous or subcutaneous use, with initial U.S. approval on 1939, the HPI indicated a different site should be used for each injection to prevent the development of massive hematoma. 2. During a review of Resident 33's AR, the AR indicated the facility admitted the resident on 12/3/2025, with diagnoses including closed fracture (a broken bone where the skin stays intact), difficulty walking and pulmonary fibrosis (scarred and thickened tissue around and between the air sacs called alveoli in the lungs). During a review of Resident 33's H&P, dated 12/4/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had an intact cognition (having a clear, sharp, and sound mind). The MDS indicated the resident was on a high-risk drug class anticoagulant medication. During a review of Resident 33's OSR, dated 12/3/2025, the OSR indicated an order for Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml (Enoxaparin Sodium). Inject 40 mg subcutaneously one time a day for DVT PPX for 30 Days. Rotate injection sites. During a review of Resident 33's Location of Administration Report (LAR) of Enoxaparin Sodium for 12/2025, the LAR indicated Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml was administered on: 12/20/2025 at 8:12 a.m. on the Abdomen-LUQ 12/21/2025 at 10:53 a.m. on the Abdomen- LUQ 12/23/2025 at 9:02 a.m. on the Abdomen- Left Lower Quadrant (LLQ) 12/24/2025 at 9:33 a.m. on the Abdomen- LLQ 12/27/2025 at 9:07 a.m. on the Abdomen- LLQ 12/28/2025 at 9:38 a.m. on the Abdomen- LLQ During a review of Resident 33's CP Report titled, Anticoagulant therapy: Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/ 0.4 ml (Enoxaparin Sodium) for DVT PPX, initiated on 12/8/2025, the CP indicated a goal of the resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date and an intervention to administer medication per physician orders. During a concurrent interview and record review on 12/30/2025 at 3:55 p.m. with the ADON, Resident 33's Medical Diagnosis, OSR, LAR, and CP were reviewed. The ADON stated there was a physician's order for Enoxaparin Sodium Injection Solution Prefilled Syringe 40 mg/0.4 ml (Enoxaparin Sodium). Inject 40 mg subcutaneously one time a day for DVT PPX for 30 Days. Rotate injection sites. The ADON stated the LAR indicated there were multiple instances where the licensed nurses did not rotate the Enoxaparin Sodium administration sites to Resident 33. The ADON stated not following the physician's order to rotate Enoxaparin Sodium administration sites predisposes Resident 33 to severe bruising and bleeding at the frequented sites of administration. The ADON stated there was a care plan for anticoagulation therapy indicating a goal of the resident will be free from discomfort or adverse reactions related to anticoagulant use and an intervention to administer medication per physician's order was not followed. The ADON stated not following the physician's order and not rotating administration sites of Heparin as a professional nurse is considered a medication error. During a review of the facility's recent P&P titled, Injectable Medication Administration, last reviewed on 12/28/2025, the P&P indicated to administer medication via subcutaneous, intradermal and intramuscular routes in a safe, accurate, and effective manner. During a review of facility-provided HPI on the use of Enoxaparin sodium injection. USP for subcutaneous use, with initial U.S. approval on 1993, the HPI indicated to alternate injection sites between the left and right anterolateral and left and right posterolateral abdominal wall. 3. During a review of Resident 12's AR, the AR indicated the facility admitted Resident 12 on 12/15/2025 with diagnoses including type two diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, and difficulty walking. During a review of Resident 12's H&P, dated 12/16/2025, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had severely impaired cognition and was sometimes able to understand and make her needs known. The MDS further indicated Resident 12 required substantial or maximal assistance to total assistance from staff with all ADLs. The MDS indicated Resident 12 had a diagnosis of DM 2 and received insulin. During a review of Resident 12's CP titled, Diabetes, initiated on 12/28/2025, the CP indicated to administer Humalog kwikpen as ordered and monitor response and adverse symptoms as one of the interventions to maintain stable glycemic control to support healing and functional participation. During a review of Resident 12's OSR, dated 12/31/2025, the OSR indicated a physician's order dated 12/15/2025: - Humalog (a fast-acting insulin) kwikpen 100 unit per milliliter (unit/ml – a unit of measurement) solution pen injector. Inject as per sliding scale (the amount of insulin to be administered changes or slides up or down based on the person's blood sugar): if blood sugar (BS) is 70-15- = 0 unit, if BS is less than (< - a unit of measurement) 70 give orange juice (OJ) if awake and able to swallow then notify the physician (MD); 151-200 = two(2) units; 201- 250 = four (4) units; 251-300 = six (6) units; 301-350 = eight (8) units; 351-400 = ten (10) units; above 400 = 12 units then notify the MD, subcutaneously before meals and at bedtime for DM 2. Rotate injection sites. During a concurrent interview and record review on 12/31/2025 at 10:05 a.m. with the ADON, Resident 12's physician's orders, care plan, and location of administration sites for Humalog kwikpen for 12/2025 were reviewed. The ADON stated that Resident 12 had a physician's order for Humalog kwikpen per sliding scale as were administered as follows: - 12/16/2025 6:24 a.m. – left arm - 12/16/2025 11:30 a.m. - left arm - 12/22/2025 12:25 p.m. – RLQ - 12/22/2025 5:04 p.m. – RLQ - 12/23/2025 12:27 p.m. – RLQ - 12/24/2025 2:43 p.m. – RLQ - 12/24/2025 10:03 p.m. – RLQ - 12/25/2025 5:36 a.m. – RLQ The ADON stated that the administration sites for insulin should be rotated per standards of practice, manufacturer's guidelines, and per physician's order to prevent hardening or lumps in the skin. The ADON stated the location of administration sites for Resident 12's Humalog were not rotated. The ADON stated there was a physician's order to rotate administration sites and was not followed. The ADON stated Resident 12's administration sites should have been rotated to prevent pain, redness, irritation, and lumps on the resident's skin which can affect the absorption of the insulin. The ADON stated that not rotating Resident 12's insulin administration sites can be considered a medication error by not following physician's orders, manufacturer's guidelines, and professional standards of care. During a concurrent interview and record review on 12/31/2025 at 1:45 p.m. with the Director of Nursing (DON), Resident 12's physician's order, Humalog administration sites, Humalog manufacturer's specifications, and P&P on Medication errors and Adverse Actions were reviewed. The DON stated the licensed nurses are supposed to rotate insulin administration sites according to the physician's order, manufacturer's specifications, and accepted professional standards of practice per facility P&P. The DON stated Resident 12 had a physician's order for Humalog and the physician's order also indicated to rotate the injection sites. The DON stated Resident 12's Humalog injection sites were not rotated. The DON stated the manufacturer's specification for Humalog listed injection site reactions, and lipodystrophy as a few of the adverse reactions and injection sites should be rotated within the same region from one injection to the next to reduce the risk of lipodystrophy. The DON stated facility P&P and manufacturer's specifications were not followed and not rotating the injection sites placed Resident 21 at risk for injection site reactions and formation of lipodystrophy. During a review of the facility's P&P titled, Medication errors and Adverse Actions, last reviewed on 12/18/2025, the P&P indicated that: - Medication errors and adverse drug reactions must be reported to the resident's attending physician. - Medication Error means the observed or identified preparation of administration of medications or biologicals which is not in accordance with: a. The prescriber's order; b. Manufacturer's specifications regarding the preparation and administration of the medication or biological; c. Accepted professional standards and principles which apply to professionals providing services. Accepted professional standards and principles include the various practice regulations in each State, and current commonly accepted health standards established by national organizations, boards, and councils. - Significant medication error means one which causes the resident discomfort or jeopardizes hir or her health and safety. Significance may be subjective depending on the individual situations and duration. During a review of the facility provided manufacturer's specifications on Humalog dated 3/2013, the manufacturer's specifications indicated that adverse reactions associated with Humalog include hypoglycemia (low blood sugar), injection site reactions, lipodystrophy, pruritus (itching), and rash. The manufacturer's specification further indicated that Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy.

Based on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in long-term care facilities to ensure that antibiotics are used only when necessary and appropriate [means prescribing the right drug at the right dose at the right time for the right duration]) program and infection prevention and control program for four of four sampled residents (Residents 12, 1, 33, and 41) reviewed for antibiotic use by failing to ensure:1. Failing to ensure Resident 12 meets the criteria for the use of sulfamethoxazole and trimethoprim double strength (also known as Bactrim DS, a combination of two antibiotics used to treat bacterial infections in the ear, sinus, throat, lungs, and skin) for urinary tract infection (UTI - an infection in the bladder/urinary tract). 2. Failing to ensure Resident 12 was monitored for adverse side effects (an unintended, negative health outcome or unwanted event that occurs as a result of a treatment, medication, or exposure to a substance) for the use of Bactrim DS while receiving the medication. 3. Resident 1's Amoxicillin (an antibiotic used to treat infections caused by bacteria) had a specific indication for its use and had monitoring for its adverse effects. 4. Resident 1's Diflucan (a prescription antifungal medication used to treat infections caused by fungus or yeast) had a monitoring for its adverse effects. 5. Resident 33's Methenamine Hippurate (a urinary antiseptic used as preventive treatment for recurrent urinary tract infections (UTIs, occur when bacteria enter the urinary tract through the urethra and begin to spread in the bladder) indicated an end date and had monitoring for its adverse effects. 6. Resident 41's Bactrim had monitoring for its adverse effects. These failures had the potential to increase antibiotic resistance (when bacteria develop the ability to withstand the effects of antibiotics, making it difficult or impossible to treat infections) from unnecessary or inappropriate antibiotic use and had the potential for the residents to experience an unmonitored adverse reaction. Findings: 1. During a review of Resident 12's admission Record (AR - front page of the chart that contains a summary of basic information about the resident), the AR indicated the facility admitted Resident 12 on 12/15/2025 with diagnoses including type two diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, and difficulty walking. During a review of Resident 12's History and Physical (H&P), dated 12/16/2025, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 12/21/2025, the MDS indicated Resident 12 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was sometimes able to understand and make her needs known. The MDS further indicated Resident 12 required substantial or maximal assistance to total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 12's Order Summary Report (OSR), dated 12/31/2025, the OSR indicated a physician's order dated 12/28/2025 for Bactrim DS (sulfamethoxazole-trimethoprim) oral tablet 800-160 milligrams (mg – a unit of measurement) give one (1) tablet by mouth two (2) times a day for UTI for seven (7) days. During a review of Resident 12's SBAR (situation, background, assessment, recommendation - a communication tool used by healthcare workers when there is a change of condition among the residents) Communication Form, dated 12/26/2025, the SBAR Communication Form indicated Resident 12 had increased confusion or disorientation and was trying to get out of bed and temperature of 98.3 degrees Fahrenheit (F – a unit of measurement) but did not have any other symptoms of UTI such as, but not limited to, dysuria (difficulty in urinating), urgency, frequency, and gross hematuria (blood in the urine that is visible in the naked eye). The SBAR Communication Form further indicated, the physician ordered a urinalysis (UA - a test that examines the urine to check for various health issues) with culture and sensitivity (a test that checks the urine for bacteria that may be causing an infection and determine effective treatment. During a review of Resident 12's SBAR Communication Form, dated 12/28/2025, the SBAR Communication Form indicated Resident 12 had increased confusion and temperature of 98F. The SBAR Communication Form further indicated the UA result was relayed to the physician with new order to start Resident 12 on Bactrim DS oral tablet 800-160 mg give 1 tablet by mouth 2 times a day for UTI for 7 days. During a review of Resident 12's Loeb's Minimum Criteria for Initiating Antibiotic Therapy (a set of guidelines that helps healthcare providers decide when to start antibiotics for residents in long-term care facilities) form, dated 12/29/2025, the Loeb's Minimum Criteria for Initiating Antibiotic Therapy form indicated under the criteria for suspected UTI without catheter, Resident 12 did not meet any of the criteria such as dysuria, urgency, frequency, and gross hematuria. The Loeb's Minimum Criteria for Initiating Antibiotic Therapy form further indicated under the criteria for fever where the focus of infection is unknown, Resident 12 did not meet both criteria required as Resident 12 only had increased confusion but did not have a temperature of more than 100F. During a review pf Resident 12's care plan (CP) on infection of the urinary tract initiated on 12/28/2025, the CP indicated to administer antibiotic as ordered by the physician for the resident to have minimal to no complications related to infection. During a review of Resident 12's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 12/29/2025, the MAR indicated Resident 12 received the first dose of Bactrim DS on 12/28/2025 at 5 p.m. During a review of Resident 12's UA result, dated 12/27/2025, the UA result indicated Resident 12 had 2 plus blood in the urine and the normal range should be negative (did not find the substance), many bacteria in the urine and the normal range is none, and the white blood cells (WBC, a type of cell in the urine) that helps the body fight infections and other diseases) were more than 50 HPF (high power field – a unit of measurement for volume) and the normal range should zero (0) to four (4). During a review of Resident 12's Change in Condition (CIC) Follow Up Nurses Notes form, dated 12/28/2025 to 12/30/2025, the CIC Follow Up Nurses Notes form did not indicate Resident 12 was monitored for adverse side effects of antibiotic use on 12/29/2025 and 12/30/2025 7 a.m. to 7 p.m. shift. During a concurrent interview and record review on 12/31/2025 at 8:14 a.m. with the Infection Preventionist (IP), Resident 12's physician's orders, UA results, SBAR Communication form, dated 12/26/2025 and 12/28/2025, MAR, for 12/2025, CIC Follow Up Nurses Notes form, dated 12/28/2025 to 12/30/2025, and Loeb's Minimum Criteria for Initiating Antibiotic Therapy form, dated 12/29/2025, were reviewed. The IP stated if a resident had an order for antibiotics, she (IP) utilizes Loeb's Minimum Criteria for Initiating Antibiotic Therapy form by checking if the resident meets the minimum criteria and the use of the antibiotic is appropriate. The IP stated the nurses are supposed to monitor the residents on antibiotics for adverse side effects every shift for the duration of the antibiotics and notify the physician immediately. The IP stated Resident 12 had a physician's order for Bactrim DS 2 times a day for 7 days on 12/28/2025 but did not have any fever and signs and symptoms of UTI, therefore Resident 12 did not meet any of the minimum criteria required according to the Loeb's Minimum Criteria for Initiating Antibiotic Therapy form. The IP stated an abnormal UA result was not one of the criteria in the Loeb's Minimum Criteria for Initiating Antibiotic Therapy form. The IP stated Resident 12 did not have any monitoring for adverse side effects for the use of Bactrim DS on 12/29/2025 and 12/30/2025 7a.m. to 7 p.m. shift. The IP stated Resident 12 should have been monitored for adverse side effects every shift. The IP stated if Resident 12 was not monitored for the adverse effects of antibiotics, Resident 12 could have adverse reactions, which could result in delay in physician notification and delay in resident care. The IP stated she should have notified the physician that Resident 12 did not meet the minimum criteria required for the use of antibiotics for UTI as it placed Resident 12 at risk for development of resistance to most antibiotics which makes infections harder to treat. During a concurrent interview and record review on 12/31/2025 at 1:30 p.m. with the Assistant Director of Nursing (ADON), Resident 12's physician's orders, UA results, SBAR Communication form, dated 12/26/2025 and 12/28/2025, MAR, for 12/2025, CIC Follow Up Nurses Notes form, dated 12/28/2025 to 12/30/2025, were reviewed. The ADON stated Resident 12 had an abnormal UA result, the SBAR Communication form indicated increased confusion and temperatures of 98.3F and 98F and a physician's order for Bactrim D 800-160 mg 1 tablet 2 times a day for 7 days for UTI. The ADON stated nurses are supposed to monitor the residents for adverse side effects of antibiotic use every shift and document in the CIC Follow Up Nurses Notes. The ADON stated Resident 12 did not have monitoring documented for adverse side effects of antibiotic on 12/29/2025 and 12/30/2025 7 a.m. to 7 p.m. shift. The ADON stated Resident 12 should have been monitored for adverse side effects of antibiotic use which placed Resident 12 at risk for notifying the physician and a delay in care the resident needed. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, last reviewed on 12/18/2025, the P&P indicated: It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection and Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting improving treatment efficacy and resident safety. Antibiotic Stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse effects associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. Action: a. Facility may consider a time-out (TO) practice. A time-out can be considered a stop order of an antibiotic when a diagnostic test or symptoms of resident do not support the diagnosis of infection. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing, and implementing an antibiotic review process for all antibiotics prescribed in the facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available. Tracking: a. IP or designee will be responsible for infection surveillance and MDRO (multidrug resistant organism – a germ or bacteria that is resistant to many organisms) tracking. b. IP or designee will collect and review data. 2. During a review of Resident 1's AR, the AR indicated the facility admitted the resident on 12/2/2025, with diagnoses including sepsis (a life-threatening blood infection), presence of cerebrospinal fluid drainage device (often called a shunt, is a thin tube system surgically placed to drain excess fluid from around the brain or spine, redirecting it to another body area (like the abdomen or heart) where it can be reabsorbed), and acute respiratory failure (a life-threatening condition that occurs when fluid leaks from small blood vessels in the lungs and builds up in the air sacs). During a review of Resident 1's H&P, dated 12/5/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 1's MDS, dated [DATE], the MDS indicated the resident rarely to never had the ability to make self-understood and understand others and had severely impaired cognition (a person has significant problems with their mental abilities—such as thinking, remembering, and making decisions—to the extent that it majorly interferes with their daily life and they can no longer live independently). The MDS indicated the resident was on a high-risk drug class antibiotic. During a review of Resident 1's Order Summary Report (OSR), the OSR indicated an order for: - 12/4/2025 Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give 1 tablet via gastrostomy tube (g-tube - a soft tube placed through the belly wall directly into the stomach, acting as a shortcut for delivering food, fluids, and medicine when someone cannot eat enough or safely by mouth, ensuring they get essential nutrition and hydration) every 12 hours for bacterial infection for 7 days and give 1 tablet via g-tube one time only for bacterial infection until 12/04/2025. - 12/10/2025 Diflucan Oral Tablet 200 mg (Fluconazole). Give 1 tablet via g-tube one time a day for oral thrush (a type of fungal infection) for 7 days. The OSR dated 12/30/2025 did not indicate any orders for monitoring for adverse effect on the use of Amoxicillin and Diflucan. During a review of Resident 1's CP Report titled, Is at risk for adverse reaction related to Amoxicillin-Pot Clavulanate Tablet 875-125 mg for g-tube insertion, last revised on 12/12/2025, the CP indicated a goal of the resident will be free of adverse drug reactions through the review date and an intervention to discuss with resident and family the number and type of medications resident is taking and the potential for drug interactions and side effects from over-medication. During a review of Resident 1's CP Report titled, Is at risk for adverse reaction related to Diflucan Oral Tablet 200 mg (Fluconazole)., last revised on 12/23/2025, the CP indicated a goal of the resident will be free of adverse drug reactions through the review date and an intervention to monitor for possible signs and symptoms of adverse drug reaction: falls, weight loss, fatigue, incontinence, agitation, lethargy, confusion, agitation, depression, poor appetite, constipation, and gastric upset. During a concurrent interview and record review on 12/30/2025 at 3:43 p.m. with the Assistant Director of Nursing (ADON), Resident 1's Medical Diagnosis, OSR, MAR, and CP. The ADON stated there was an order for two antibiotics that were completed in 12/2025, they were Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give 1 tablet via g-tube every 12 hours for bacterial infection for 7 Days and give 1 tablet via g-tube one time only for bacterial infection until 12/4/2025 and Diflucan Oral Tablet 200 mg (Fluconazole). Give 1 tablet via g-tube one time a day for oral thrush for 7 days. The ADON stated the order for Amoxicillin-Pot Clavulanate Tablet 875-125 mg. Give 1 tablet via g-tube every 12 hours for bacterial infection for 7 days should have been clarified with the attending physician by the licensed nurses because the indication was not specific. The ADON stated the indication bacterial infection is not enough justification for the use of the antibiotic and there were multiple missing monitoring for adverse effect on the use of Amoxicillin in the resident's electronic healthcare record. The ADON also stated there was an order for Diflucan Oral Tablet 200 mg (Fluconazole). Give 1 tablet via g-tube one time a day for oral thrush for 7 days and the licensed staff did not do a every shift monitoring for adverse effect on the use of Diflucan. The ADON stated antibiotics should have a valid specific indication for their use, an end date, and should be monitored for adverse effects on its use every shift. The ADON stated the failure of the licensed staff to clarify the indication of the Amoxicillin's use and to monitor the adverse effects of Amoxicillin and Diflucan had predisposed the resident to antibiotic resistance and they failed to monitor if the antibiotic is working and to intervene if the resident had been experiencing adverse effects. During a concurrent interview and record review on 12/31/2025, at 1:11 p.m., with the Infection Preventionist (IP), Resident 1's Diagnosis, OSR, MAR, and CP were reviewed. The IP stated the order for Resident 1's Amoxicillin should have been clarified with the attending physician as the indication was not specific, indicating bacterial infection is not enough to justify its use. The IP stated she screens the resident for appropriate antibiotic use and the antibiotic orders should have a specific indication, an end date, and should have monitoring for its adverse effects. The IP stated the Amoxicillin and Diflucan orders of Resident 1 did not have an order for monitoring for adverse effects of its use. The IP stated the staff failed to monitor for adverse effects of the two antibiotics that predisposed the resident to its adverse effects and antibiotic resistance. During a review of the facility's recent P&P titled, Antibiotic Stewardship, last reviewed on 12/18/2025, the P&P indicated it is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection and Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. During a review of the facility-provided Highlights of Prescribing Information (HPI) on the use of Amoxil (amoxicillin) capsules, tablets, or powder for oral suspension, with initial U.S. approval in 1974, the HPI indicated warnings and precautions of: -Anaphylactic reactions: Serious and occasional fatal anaphylactic reactions have been reported in patients on penicillin therapy. Serious anaphylactic reactions require immediate emergency treatment with supportive measures. -Clostridium difficile diarrhea (ranging from mild diarrhea to fatal colitis. Evaluate if diarrhea occurs. During a review of the facility-provided Information on the use of Diflucan (Fluconazole Tablets) (Fluconazole Injection- for intravenous infusion only) (Fluconazole for Oral Suspension), revised 5/2011, the Information indicated warnings: 1. Hepatic (relating to the liver - body part that filters toxins from the blood, help digest food, and store energy) Injury. 2. Anaphylaxis (a severe, sudden, potentially fatal allergic reaction). 3. Dermatologic (relating to the skin, hair, nails, and mucous membranes) . Etc. 3. During a review of Resident 33's AR, the AR indicated the facility admitted the resident on 12/3/2025, with diagnoses including closed fracture (a broken bone where the skin stays intact), retention of urine (when a person is unable to empty the urine from the bladder and the urine may back up into the kidneys [part of the body that filters blood]), gastro-esophageal reflux disease (GERD - a chronic condition where stomach acid frequently flows back up into the esophagus [food pipe] because the muscle at the end of the esophagus does not close properly, causing irritation and symptoms like heartburn, regurgitation, and difficulty swallowing). During a review of Resident 33's H&P, dated 12/4/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 33's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having a clear, sharp, and sound mind). During a review of Resident 33's OSR, dated 12/15/2025, the OSR indicated an order for Methenamine Hippurate Oral Tablet 1 gram (gm - a unit of weight) (Methenamine Hippurate). Give 1 tablet by mouth two times a day for prophylaxis (PPX - taking action to prevent something bad from happening, usually a disease or infection, before it starts) for UTI. During a review of Resident 33's CP Report titled, Is at risk for adverse reaction related to Methenamine Hippurate Oral Tablet 1 gm. Give 1 tablet by mouth two times a day for supplement, initiated on 12/4/2025, the CP indicated a goal of the resident will be free of adverse drug reactions through the review date and an intervention to discuss with resident and family the number and type of medications the resident is taking and the potential for drug interactions and side effects from over-medication. During a concurrent interview and record review on 12/30/2025, at 3:59 p.m., with the ADON, Resident 33's Medical Diagnosis, OSR, MAR, and CP were reviewed. The ADON stated the licensed staff should have clarified the order with the attending physician because there was no end date on the use of Methenamine Hippurate and there was no order to monitor for its adverse effects. The ADON stated the medication was for UTI prophylaxis but somehow it needs a certain date to reevaluate its use because the antibiotic tends to be resistant to infection if used for a longer period of time. The ADON also stated he did not find any monitoring for its adverse effects on the resident's electronic chart. The ADON stated it was important to monitor for its adverse effects to know if the medication needed to be adjusted or discontinued. During a concurrent interview and record review on 12/31/2025, at 1:18 p.m., with the IP, Resident 33's Medical Diagnosis, OSR, MAR, and CP were reviewed. The IP stated there was no end date for the drug due to the resident was having recurrent UTIs. The IP stated there should be monitoring for adverse effects on the use of Methenamine Hippurate to determine if the medication is working and if it needed to be adjusted. The IP stated it was important to monitor for its adverse effect for the healthcare team to intervene right away and relieve the resident from unnecessary discomforts the drug may bring. During a review of the facility's recent P&P titled, Antibiotic Stewardship, last reviewed on 12/18/2025, the P&P indicated it is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection and Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. During a review of the facility-provided Information on the use of Hiprex (methenamine Hippurate tablets USP), revised 12/2017, the Information indicated to reduce the development of drug-resistant bacteria and maintain the effectiveness of Hiprex (methenamine Hippurate tablets USP) and other antibacterial drugs, Hiprex should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. Precautions Prescribing Hiprex in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria. 4. During a review of Resident 41's AR, the AR indicated the facility admitted the resident on 12/2/2024, with diagnoses including traumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain as a direct result of a head injury), acute kidney failure (the rapid (less than 2 days) loss of the kidneys' ability to remove waste and help balance fluids and electrolytes in the body), and dysphagia (difficulty swallowing). During a review of Resident 41's H&P, dated 12/29/2025, the H&P indicated the resident does not have the capacity to understand and make decisions. During a review of Resident 41's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. During a review of Resident 41's OSR, dated 12/28/2025, the OSR indicated an order for Bactrim DS Oral Tablet 800-160 mg (Sulfamethoxazole-Trimethoprim). Give 1 tablet by mouth every 12 hours for UTI for 5 days. During a review of Resident 41's CP Report titled, Resident has infection of the UTI, initiated on 12/28/2025, the CP indicated a goal of the resident will have minimal to no complications related to infection through the course of treatment. During a concurrent interview and record review on 12/30/2025, at 4:28 p.m., with the ADON, Resident 41's Medical Diagnosis, OSR, MAR, and CP were reviewed. The ADON stated there was an order for Bactrim on Resident 41 however, there was no monitoring for adverse reaction on the use of the antibiotic by the licensed staff done. The ADON stated there should be monitoring for adverse effects of the drug so that they could adjust the medication and intervene if the resident exhibits signs and symptoms of adverse effect caused by the antibiotic. During a concurrent interview and record review on 12/31/2025 at 1:20 p.m. with the IP, Resident 41's Medical Diagnosis, OSR, MAR, and CP were reviewed. The IP stated there was no monitoring for adverse effect on the use of Bactrim on Resident 41. The IP stated the licensed staff should have monitored for the adverse effect of the medication to help the attending physician adjust or discontinue the dose of the medication. During a review of the facility's recent P&P titled Antibiotic Stewardship, last reviewed on 12/18/2025, the P&P indicated it is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection and Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. During a review of the facility provided Information on the use of Bactrim Sulfamethoxazole and trimethoprim DS (double strength) tablets and tablets USP, revised 6/2013, the Information indicated precautions: - Development of drug-resistant bacteria - Folate (a type of vitamin) deficiency - Hemolysis (the breakdown or destruction of red blood cells)- Hypoglycemia (low blood sugar)- Phenylalanine (a protein building block the body needs, but cannot make) metabolism (the body's internal process of turning food and drinks into the energy it needs to function) Etc.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure Resident 73's personal bag was not stored on the ground during a tour of the Laundry Facilities on 12/30/2025. This deficient practice had the potential to spread communicable diseases among residents, staff, and visitors. 2. Ensure the Enhanced Barrier Precaution (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) sign was posted by the door leading into the room of one (1) of one (1) sampled resident (Resident 21) reviewed under infection control. This deficient practice had the potential to spread infections and illnesses to residents, visitors, and staff. 3. Ensure the ice scooper was not left open to air and exposed to environmental contaminants. The deficient practice had the potential to cause adverse effects (the undesired, unwanted, or harmful things that happen as a result, even if you follow the instructions correctly) on residents such as food-borne illnesses. Findings: a) During a review of Resident 73's admission Record (AR), the AR indicated the facility admitted the resident on 12/30/2025, with diagnosis that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), acute on chronic respiratory failure (serious condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (low oxygen in the tissues), pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred), and malignant neoplasm of breast (breast cancer). During a review of Resident 73's History and Physical (H&P) dated 12/31/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a Facility`s Laundry Tour on 12/30/2025 at 3:35 p.m., with Laundry Attendant (LA) 1 and the Maintenance Supervisor (MS), observed a green bag placed directly on the ground and behind the door in the clean linen area. LA 1 stated he (LA 1) was temporarily storing a new resident's green bag on the floor behind the door until LA 1 was able to label the resident's clothing located inside the bag. LA 1 then stated nothing should be placed on the floor in the laundry area. LA 1 stated all items should be elevated off the floor. The MS exited the laundry area and stated all resident personal belongings, including the resident's green bag, should be kept off the floor because of the potential of transferring something dirty from the floor to the resident by cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 12/31/2025 at 9:45 a.m. with the Infection Preventionist (IP), the IP stated the green bag belonged to Resident 73 and should not have been stored on the floor in the laundry area because the floor is dirty. The IP stated when Resident 73's bag was stored on the floor it created a cross-contamination issue with the potential that the dirty bag could be placed on a clean surface resulting in the surface becoming contaminated with bacteria that could spread to a resident. During a concurrent interview and record review on 12/31/2025 at 2:05 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedures (P&P) regarding infection prevention. The DON stated resident personal items should be kept off the floor for infection control practices to ensure the bag does not become dirty from the floor and then unknowingly the bag is used in a way that causes cross contamination. The DON stated the facility P&P was not followed. During a review of the facility P&P titled, Laundry Services, last reviewed 12/18/2025, the P&P indicated, POLICY: It is the policy of this facility that careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious diseases to other staff members, residents and visitors PROCEDURES: . General: . 2. The supervisor of laundry services will work closely with the infection control designee to establish and maintain consistent high standards. 6. All laundry employees will be expected to attend in-service programs pertaining to infection control. During a review of the facility P&P titled, Storing Personal Belongings in Laundry Room, last reviewed 12/18/2025, the P&P indicated, Purpose. To maintain a safe, clean, and sanitary environment for residents, staff, and visitors by preventing personal belongings from being stored directly on the floor. Policy Statement. Personal belongings shall not be placed or stored on the floor in resident rooms, laundry room or common areas. All personal items must be kept in designated storage areas to reduce infection risk, prevent falls, and maintain compliance with safety and housekeeping standards. Procedure. .1. Resident Personal Belongings. Personal items (e.g., clothing, shoes, bags, .) must be stored in: - Closets - Drawers - Cabinets - Shelving units -Over-bed tables or designated hooks. Items may not be placed directly on the floor. 2. Staff Responsibilities . Staff should routinely monitor resident rooms, laundry and common areas for items placed on the floor. 3. Infection Control. Items found on the floor are considered contaminated. Compliance. Failure to follow this policy may result in: . Increased infection risk. b) During a review of Resident 21's admission Record, the admission Record indicated the facility admitted the resident on 12/10/2025, with diagnoses including sepsis (a life-threatening blood infection), malignant neoplasm (abnormal growth of tissues that spread to other parts of the body) of ovaries (female reproductive glands that make eggs and female hormones), and generalized muscle weakness. During a review of Resident 21's History and Physical (H&P) dated 12/10/2025, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool), dated 12/16/2025, the MDS indicated Resident 21 had an intact cognition (mental action or process of acquiring knowledge and understanding) was able to understand others and make needs known. The MDS further indicated Resident 21 was independent with eating; required supervision or touching assistance with oral hygiene and personal hygiene; substantial/maximal assistance with toileting hygiene, bathing, lower body dressing, sit-to-stand, and toilet transfers; partial/moderate assistance from staff with all other ADLs. During a review of Resident 21's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 12/10/2025: - Enhanced Barrier Precautions: PPE (personal protective equipment - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) required for high resident contact care activities. Indication: peripherally inserted central catheter (PICC - a long, thin tube inserted through a vein in the arm and passed through to the larger veins near the heart used for long-term intravenous access) line every shift. - Flush PICC line catheter on right upper arm (RUA) every day shift as maintenance. - Change injection cap when visibly soiled, if removed, or disconnected as needed. During a review of Resident 12 care plan (CP) for PICC line in RUA, initiated on 12/11/2025, the CP indicated to use EBP to keep the resident free of complications. During a concurrent observation and interview on 12/29/2025 at 9:06 a.m. inside Resident 21's room, observed Resident 21 lying in bed, awake, alert, and verbally responsive. Resident 21 stated she (Resident 21) was transferred from an acute hospital due to severe infection in her blood and had a PICC line placed in the RUA sometime in October. Observed Resident 21 with two (2) lumens (refers to the cavity or channel within a tube or tubing) PICC line catheter on the RUA dated 12/28/2025. Observed disposable gowns and gloves on a rack attached to the wall inside Resident 21's room. During an observation on 12/29/2025 at 9:29 a.m., outside Resident 21's room, observed there was no EBP sign posted by the wall. During a concurrent observation and interview on 12/29/2025 at 9:45 a.m. outside Resident 21's room with the Infection Preventionist (IP). The IP stated she just placed the EBP sign by the door as she was just notified that Resident 21 had a PICC line on the RUA. The IP stated Resident 21 had a PICC line since admission date of 12/10/2025. The IP stated the nurse who admitted Resident 21 and received the order from the physician should have implemented the EBP and placed the EBP sign by the door outside the room. During an interview on 12/29/2025 at 9:49 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated staff were reminded during huddle at the start of the shift regarding proper hand hygiene and wearing of PPEs during high contact resident care activities for residents on EBP. CNA 2 stated if there was a sign for EBP by the door outside a resident's room, staff are supposed to perform hand hygiene prior to putting on gown and gloves and entering the room for showers and ADLs. CNA 2 stated she did not remember seeing the EBP sign outside Resident 21's room until the IP placed the sign today. CNA 2 stated the EBP sign should have been placed as soon as possible. CNA 2 stated if the EBP sign was not placed timely, it placed Resident 21 at risk to get infection and potentially spread the infection to other residents and staff. During a concurrent record review and follow up interview on 12/31/2025 at 10:06 a.m. with the IP, Resident 21's physician's orders, photograph of the wall without the EBP sign, and CP were reviewed. The IP stated Resident 21 had orders to place on EBP due to PICC line use, and PICC line care. The IP stated the CP indicated to use EBP to keep the resident free of complications. The IP stated the photograph of the wall by the door entrance dated 12/29/2025 at 9:29 a.m. showed that the EBP sign was not in place. The IP stated the EBP sign should have been placed by the door entrance on the day Resident 21was admitted to the facility as it placed Resident 21at risk for acquiring infection from staff who provided care to a resident with infection and to prevent the spread of infection in the facility to other staff and residents. During an interview on 12/29/2025 at 2:30 p.m. with the Director of Nursing (DON), the DON stated Resident 21 had a PICC line when admitted on [DATE] and a physician order was received to place Resident 21 on EBP due to presence of PICC line. The DON stated whoever the nurse was during admission should have placed the EBP sign and the IP is in charge of monitoring who are the residents with indwelling medical devices such as PICC line to ensure the proper precautions are being implemented. The DON stated Resident 21 did not have an EBP sign placed outside the door to remind staff to don (put on) and doff (take off) PPE during high contact resident activity. The DON stated the EBP sign should have been placed outside Resident 21's room as it had the potential for the spread of infection between residents and staff and placed Resident 21 at risk for getting infection. During a review of the facility's policy and procedure (P&P) titled IPCP Standard and Transmission-Based Precautions, last reviewed on 12/18/2025, the P&P indicated: - It is the policy of the facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Procedure: 3. Enhanced Barrier Precautions (EBP): used on conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing when indirectly transferred to residents or from resident-to-resident. a. PPE: the use of gown and gloves for high contact resident care activities is indicated for nursing home residents with wounds and/or indwelling medical devices During a review of the facility's P&P titled Infection Prevention and Control Program, last reviewed on 12/18/2025, the P&P indicated: - The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program is carried out by the facility infection preventionist. - It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. c) During an observation on 12/29/2025 at 8:38 a.m., while doing resident screening, near the kitchen door hallway of the facility, observed a blue ice chest on wheels with the ice scooper placed inside an open container beside the ice chest. During a concurrent observation and interview on 12/29/2025 at 8:40 a.m., with the Infection Preventionist (IP), near the kitchen door entrance, observed a blue ice chest on wheels with the ice scooper placed inside an open container beside the ice chest. The IP stated the ice scooper should be covered because leaving them open to air exposes the ice scooper to environmental contaminants such as bacteria and viruses that when ingested by the resident can cause gastric infections. During a concurrent interview and record review on 12/31/2025 at 4:10 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the ice scoopers should be protected inside a plastic container to prevent them from environmental contaminants such as bacteria, dust, and viruses. The ADON stated the ice scoopers are used to scoop ice for resident's drinks and when the ice scooper is contaminated and used to scoop for ice on a resident drinking their favorite drinks it can cause gastric infection that can make them ill. The ADON stated the staff did not follow their policy on ice procedures. During a review of the facility's recent policy and procedure (P&P) titled Ice Procedures, last reviewed on 12/18/2025, the P&P indicated ice is to be handled properly to prevent infection. Procedure: 2. A covered plastic or stainless-steel container will be used to hold the scoop. The PM dishwasher will run this container through the dish machine daily. During a review of the facility's recent P&P titled Infection Prevention and Control Program, last reviewed on 12/18/2025, the P&P indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program is carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goals -Identify and correct problems relating to infection control.

Based on observation, interview, and record review, the facility failed to maintain the residents' right to privacy and confidentiality by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 did not leave an unattended computer screen in a public area displaying a resident`s personal clinical information and Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for one randomly sampled resident (Resident 23). 2. Provide privacy when LVN 2 administered Resident 6's scheduled morning medications in the activity room. This deficient practice had resulted in unauthorized exposure of the resident's medical care and treatment resulting in violation of the resident's right to privacy with the potential to cause psychosocial harm. Findings: a. During a review of Resident 23's admission Record (AR), the AR indicated the facility admitted the resident on 12/12/2025, with diagnoses that included morbid obesity (a serious health condition that results from an abnormally high body mass), pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred), and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 23's Minimum Data Set (MDS – resident assessment tool) dated 12/18/2025, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated that the resident was dependent on staff for toileting, bathing, and lower body dressing. During a review of Resident 23's History and Physical (H&P), the H&P indicated the resident had the capacity to understand and make decisions. During an observation on 12/29/2025 at 12:20 p.m., observed Medication Cart 1 unattended by staff in the hallway outside Room A with the monitor screen turned on. While standing in the hallway, the surveyor was able to view the monitor screen displaying Resident 23's full name, photo, date of birth , age, allergies, code status, most recent vital signs, weight, and MAR. Observed LVN 2 was inside Room A attending to a resident while standing behind a closed curtain that separated the computer from LVN 2. During a concurrent observation and interview on 12/29/2025 at 12:23 p.m., observed LVN 2 exit Room A and stated that she (LVN 2) left the monitor screen on with Resident 23's MAR visible from the hallway while she (LVN 2) was inside another resident's room. LVN 2 stated she (LVN 2) should not have left the monitor on and open to Resident 23's MAR because of the Health Insurance Portability and Accountability Act (HIPAA, a federal law that sets standards protecting sensitive health information from disclosure). LVN 2 stated she (LVN 2) was sorry and should have closed the monitor screen prior to leaving Medication Cart 1 in the hallway to attend to another resident. During a concurrent interview and record review on 12/31/2025 at 2:05 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedures (P&P) regarding resident privacy of medical records. The DON stated the facility P&P is that resident personal information is protected. The DON stated the computers on the medication carts have privacy screens that can be turned on when the licensed nurse is not near the computer to protect personal information, like resident medications, from being seen by others. The DON stated LVN 2 could also have just turned off the monitor screen, but she did not. The DON stated the facility P&P was not followed when LVN 2 left the computer unattended with the screen open to Resident 23's personal clinical information and MAR potentially affecting the resident psychosocially resulting in the resident to have distrust of the facility staff. During a review of the facility P&P titled, Medication Administration-General Guidelines, last reviewed 12/18/2025, the P&P indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). privacy is maintained always for all resident information (e.g., MAR) [by closing the MAR book/covering the MAR sheet or computer screen] when not in use. During a review of the facility P&P titled, Resident / Patient Confidentiality, last reviewed 12/18/2025, the P&P indicated, POLICY: All resident Health Information is confidential and protected by HIPPA Law. HIPAA DEFINITION-The Health Insurance Portability and Accountability Act. HIPAA is a federal law that is designed to protect the privacy and security of patient health information. Privacy Rule-The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization.All staff, volunteers, and vendors must not disclose any medical information about a resident, either, verbally, written, or electronically. During a review of the facility P&P titled, Dignity and Privacy, last reviewed 12/18/2025, the P&P indicated, POLICY. It is the policy of this facility that all residents be treated with kindness, dignity and respect. PROCEDURES: 1. The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings. b. During a review of Resident 6's admission Record (AR), the AR indicated that the facility admitted the resident on 11/4/2025 with diagnoses including wedge compression fracture (the front side of the bone collapses, resulting in wedge-shaped vertebra [backbones supporting the body and protecting the spinal cord (a bundle of nerves that extends from the base of the brain to the lower back)]) of first lumbar vertebra, dysphagia (difficulty swallowing), and immunodeficiency (a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent) due to conditions. During a review of Resident 6's History and Physical (H&P), dated 11/6/2025, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 6's Minimum Data Set (MDS-a resident assessment tool), dated 11/10/2025, the MDS indicated the resident usually understand others and usually make himself understood. The MDS indicated that the resident required assistance with eating, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene. During a review of Resident 6's Care Plan (CP) Report focused on Cognitive Loss, dated 11/6/2025, the CP Report indicated the resident with goals of maintaining current level of cognitive function with interventions which included to maintain consistent daily routines for waking, meals, therapies, and bedtime to reduce confusion, and support orientation. During an observation on 12/29/2025 at 9:58 a.m., in the activity room, LVN 2 administered medications to Resident 6. Resident 6 was observed sitting on a wheelchair and sharing a table facing two other residents. During a concurrent interview and record review on 12/29/2025 at 10:10 a.m. with LVN 2, reviewed Resident 6's Medication Administration Record for 12/29/2025. LVN 2 stated she (LVN 2) gave Resident 6 his morning medications. LVN 2 stated she (LVN 2) went to the resident's room and he (Resident 6) was not there and found him in the activity room and administered the medications there. LVN 2 stated she (LVN 2) gave Resident 6`s morning medications including blood pressure medications: amlodipine, metoprolol, and other medications including Cymbalta (an antidepressant medication), clopidogrel (an antiplatelet medication used to prevent blood clots), methocarbamol (muscle relaxant), tamsulosin (an alpha blocker used to relax he muscles in the prostate and bladder and improves urine flow), Zenpep (an enzyme replacement medication), aspirin (an anti-inflammatory medication and in low doses prevent blood clots), senna (stimulant laxative), and Percocet (medication used for the relief of moderate to moderately severe pain). During an interview on 12/29/2025 at 2:07 p.m. with Resident 6, Resident 6 stated he (Resident 6) always takes his medications in his room and takes his pain medication before his therapy. Resident 6 stated he (Resident 6) takes his medications, including his pain medication, every day. Resident 6 stated today the nurse gave his medications in the dining room (activity room). Resident 6 stated he (Resident 6) needed to take his pain medication before his therapy, but that was the first time he (Resident 6) was taking his medications in the dining room. Resident 6 stated he (Resident 6) prefers to take his medications in his room. During an interview on 12/31/2025 at 4:25 p.m. with Assistant Director of Nursing (ADON), the ADON stated the medications should be provided at the bedside for privacy and confidentiality of the resident. The ADON stated the licensed nurse should have asked the resident what his preferences are when taking his medications and follow the resident's preferences. During a review of the facility's policy and procedure (P&P), titled, Resident / Patient Confidentiality, last reviewed 12/18/2025, the P&P indicated, POLICY: All resident Health Information is confidential and protected by HIPPA Law. HIPAA DEFINITION-The Health Insurance Portability and Accountability Act. HIPAA is a federal law that is designed to protect the privacy and security of patient health information. Privacy Rule-The HIPAA Privacy Rule establishes national standards to protect individuals' medical records and other personal health information and applies to health plans, health care clearinghouses, and those health care providers that conduct certain health care transactions electronically. The Rule requires appropriate safeguards to protect the privacy of personal health information, and sets limits and conditions on the uses and disclosures that may be made of such information without patient authorization. All staff, volunteers, and vendors must not disclose any medical information about a resident, either, verbally, written, or electronically. During a review of the facility's P&P titled, Dignity and Privacy, last reviewed 12/18/2025, the P&P indicated, that it is the policy of this facility that all residents be treated with kindness, dignity and respect. The P&P indicated its procedures including: 1. The staff shall display respect for Resident's when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings.

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one (1) of one (1) sampled resident (Resident 12) reviewed for physical restraints by failing to obtain a physician's order, informed consent, and complete a restraint assessment prior to placement of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). These deficient practices had the potential to result in the restriction of the resident's freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents. Findings: During a review of Resident 12's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 12 on 12/15/2025, with diagnoses including type two (2) diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing), generalized muscle weakness, and difficulty walking. During a review of Resident 12's History and Physical (H&P) dated 12/16/2025, the H&P indicated Resident 12 did not have the capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS, a resident assessment tool), dated 12/21/2025, the MDS indicated Resident 12 had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and was sometimes able to understand and make her needs known. The MDS further indicated Resident 12 required substantial or maximal assistance to total assistance from staff with all activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 12's Order Summary Report dated 12/31/2025, the Order Summary Report did not indicate a physician's order for the use of bed pad alarm. During a review of Resident 12's paper and electronic health records, the paper and electronic health records did not indicate a consent that was obtained from the Resident 12`s responsible party for the use of the bed pad alarm. During a review of Resident 12's fall risk evaluation dated 12/15/2025, the fall risk evaluation indicated that Resident 12 was at high risk for falls. During a review of Resident 12's care plan (CP) on risk for falls initiated on 12/15/2025 last revised on 12/28/2025, the CP indicated bed alarm to remind the resident or staff of unassisted transfers from bed as one of the interventions so the resident will remain free from falls. During a concurrent observation and interview on 12/29/2025 at 10:25 a.m. inside Resident 12's room with the Infection Preventionist (IP), the IP stated Resident 12 had a bed alarm and the bed alarm was functioning well as evidenced by the presence of a green. The bed alarm made a loud beeping sound when the two (2) buttons were pressed. During a concurrent interview and record review on 12/31/2025 at 11:20 a.m. with the Assistant Director of Nursing (ADON), Resident 12's physician's orders, informed consents, CP, and restraint assessment were reviewed. The ADON stated a device used in any form that the resident is unable to remove freely can be considered a restraint and should have a physician's order, informed consent, and restraint assessment prior to application of the restraint. The ADON stated Resident 12 did not have a physician's order, informed consent obtained from the responsible party, and restraint assessment completed prior to application of bed pad alarm. The ADON stated there should have been a physician's order, informed consent, and a completed restraint assessment prior to applying the bed pad alarm to Resident 12 even if the bed pad alarm was a family preference. The ADON stated that when the bed pad alarm activates during movement, the sound startles Resident 12 and restricts movement. During an interview on 12/31/2025 at 11:45 a.m. with the DON, the DON stated prior to application of restraints, the staff are supposed to try the least restrictive measures first. The DON stated if the least restrictive measures did not work, the LN is supposed to obtain an order from the physician for the type of restraint needed, the reason for the restraint is required, confirm informed consent from the family with explanation of risks and benefits to give them a chance to decline or agree with the plan, and complete a restraint assessment to ensure the type of restraint to be used is appropriate. The DON stated Resident 12 had a previous order for a bed pad alarm and was discontinued on 12/28/2025. The DON stated the previous physician's order did not indicate that the physician obtained informed consent from the family to explain the risks and benefits of the restraint use. The DON stated if the family insisted on not removing the bed pad alarm, it should have been care planned, obtain a new physician's order, obtain informed consent from the family, and complete a restraint assessment prior to reapplying the bed pad alarm. The DON stated applying the restraint without a physician's order, informed consent, and restraint assessment is not honoring Resident 12's right to be restraint free which can result in a decline in physical functioning. During a review of the facility's policy and procedure (P&P) titled, Restraint, Physical, last reviewed on 12/18/2025, the P&P indicated that it is the facility's policy to only use restraints as a last resort in the least restrictive manner when it is considered medically necessary. - Physical Restraint - any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. - All resident will be assessed on admission, quarterly, annually, and with significant change of status for the use and appropriateness of physical restraints. - If it is determined that a resident requires the use of a restraint, then further assessment will be done. - Any resident using a restraint will have a current order with the following components: the exact type of restraint, circumstances for usage, the medical reason for usage, a release/exercise statement. - Any resident using a physical restraint must have a current signed consent in the clinical chart that identifies the risks/benefits of the restraint, the medical symptom for the restraint usage, and alternatives to the restraint - The facility may not use restraints in violation of the regulation solely based on a legal surrogate or representative's request or approval.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan for one of two sampled resident (Resident 44) reviewed for Pain Management by failing to develop a care plan that identified resident-centered interventions per facility policy and procedure (P&P) regarding Resident 44's use of as needed (PRN) hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication). This deficient practice had the potential to result in miscommunication among facility staff and a delay in care or lack of delivery of care and services for the resident. Findings: During a review of Resident 44's admission Record (AR), the AR indicated the facility admitted the resident on 11/14/2025 with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body), metabolic encephalopathy a (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), polyneuropathy (a disorder of the peripheral nervous system that may result in pain, discomfort, and mobility issues), and peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 44's Minimum Data Set (MDS - resident assessment tool), dated 11/20/2025, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated that the resident required substantial / maximal assistance from staff for toileting, bathing, upper and lower body dressing, and mobility. The MDS indicated the resident was taking opioids, a high-risk drug class of medication (drugs that have a heightened risk of causing significant patient harm when they are used in error). During a review of Resident 44's Physician Order Summary, the Physician Order Summary indicated the following orders: - Hydrocodone - acetaminophen oral tablet five (5) - 325 milligrams (mg - a unit of measurement), give one (1) tablet by mouth every four (4) hours PRN for pain 1- six (6) out of 10, dated 11/14/2025 and discontinued and re-ordered on 12/26/2025. - Hydrocodone - acetaminophen oral tablet 5 - 325 mg, give two (2) tablets by mouth every 4 hours PRN for pain seven (7) to 10 out of 10, dated 11/14/2025 and discontinued and re-ordered on 12/26/2025. During a review of Resident 44's Care Plan (CP) titled, Has acute / chronic pain, initiated 11/15/2025, the CP indicated a goal that the resident would not have an interruption in normal activities of daily living. The CP listed the following interventions: anticipate need for pain relief and respond immediately to any complaint of pain; identify, record and treat resident's existing conditions which may increase pain and or discomfort; observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care; pain assessment every shift; and report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs or symptoms or complaints of pain or discomfort. During a review of Resident 44's Hospital Discharge summary, dated [DATE], the Hospital Discharge Summary indicated the resident was hospitalized from [DATE] to 12/26/2025. During a concurrent observation and interview on 12/29/2025 at 9:25 a.m., Resident 44 lay in bed and stated he (Resident 44) often had pain and is given pain medication. Resident 44 stated the pain medication causes constipation. During a concurrent interview and record review on 12/31/2025 at 8:22 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 44's physician orders, Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 12/2025, and CPs were reviewed. LVN 3 stated baseline CPs are completed when a resident is readmitted . LVN 3 stated the baseline CP indicates the main focuses of each resident's care with specific goals and interventions for each discipline to provide the care to meet those goals. LVN 3 stated that when a resident has acute or chronic pain it is important to include the use of opioid medication in the CP because it is a resident specific intervention used to achieve the goal for acute or chronic pain relief. LVN 3 stated Resident 44 was readmitted on [DATE], verbalized pain, and receives hydrocodone - acetaminophen pain management. LVN 3 stated Resident 44's CP regarding acute / chronic pain should include an intervention for the administration of opioid pain medication, but it did not. LVN 3 stated when Resident 44's did not have a baseline CP that included the use of opioids there was the potential for ineffective care and poor pain management resulting in a decline in the resident's functional mobility, an increase in depression, or unrecognized side effects of opioids like constipation. During a concurrent interview and record review on 12/31/2025 at 2:05 p.m. with the Director of Nursing (DON), the facility policy and procedures (P&P) regarding CPs and pain management were reviewed. The DON stated baseline CPs include the minimum healthcare information to provide basic care to a resident upon admission or readmission. The DON stated the facility P&P indicates physician's orders are included in the baseline CP. The DON stated Resident 44's physician order for the use of PRN hydrocodone - acetaminophen tablets to treat pain should have been included in the baseline CP because the medication was an important intervention for pain management, but it was not included. The DON stated the facility P&P was not followed with the potential to result in staff not knowing how to provide care for pain management to Resident 44. During a review of the facility's P&P titled, Pain Management, last reviewed 12/18/2025, the P&P indicated, Policy. It is the policy. to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, comprehensive and routine assessments, person-centered care plan, and the residents' goals and preferences. Procedure. 2. To the extent possible, staff will: . b. Evaluate existing pain and the causes. c. Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. 4. Management: a. The care plan will include preventative or care interventions (pharmacological and non pharmacological) to manage and/or prevent pain and consider the resident needs, preferences and goals. During a review of the facility's P&P titled, Comprehensive Person - Centered Care Planning, last reviewed 12/18/2025, the P&P indicated, Policy. It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care. Definitions. Resident's Goal - refers to the resident's desired outcomes and preferences for admission, which guide decision-making during care planning.Interventions - are actions, treatments, procedures, or activities designed to meet an objective. Objective - is a statement describing the results to be achieved to meet the resident's goals. Person-centered care - means to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. Procedure: 1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. 2. The baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to:. a) Initial goals based on admission orders,.b) Physician orders.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate below five (5) percent (% - unit of measure) by having seven (7) medication errors out of 26 medication administration opportunities contributing to an overall error rate of 26.92% affecting two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. The medication errors were as follows: 1. Resident 5 did not receive the following medications as ordered by Resident 5's physician: - two (2) doses on [DATE] at 9 a.m. and 5 p.m. of metoprolol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) - one (1) dose on [DATE] at 8 a.m. of bumetanide (a medication used for edema [swelling of feet, ankles, legs, and other parts of the body, such as the face, hands, and abdomen caused by fluid retention]) 2. Resident 31 did not receive the following medications, as ordered by Resident 31's physician: - two (2) doses on [DATE] at 9 a.m. and 5 p.m. of Eliquis (a medication used for cerebrovascular accidents [CVA, also known as stroke] - an interruption in the flow of blood to cells in the brain caused by blood clots and high blood pressure]), - two (2) doses on [DATE] at 9 a.m. and 5 p.m. of brimonidine (a medication used for glaucoma [a condition of increased pressure in the eyeball]), - one (1) dose on [DATE] at 9 a.m. of finasteride (a medication used for benign prostatic hyperplasia ([BPH] - a condition in men where the prostate gland - a small gland located inside the groin - is enlarged), - one (1) dose on [DATE] at 9 a.m. of folic acid (a medication used for anemia [a condition with lower-than-normal number of red blood cells]), - one (1) dose on [DATE] at 9 a.m. of tamsulosin (a medication used for BPH) On [DATE] at 3:36 p.m. the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADMIN) and the Director of Nursing (DON) under 42 Code of Federal Regulations (CFR) S483.45(f)(1) Medication error rates are not 5 percent or greater. The facility had seven (7) medication errors out of 26 medication administration opportunities contributing to an overall error rate of 26.92 %. These deficient practices had the potential to cause Resident 5 serious harm, serious impairment, and serious complications, potentially resulting in elevated blood pressure, hospitalization , and/or death; and had the potential to cause Resident 31 serious harm, serious impairment, and serious complications, potentially resulting in blood clots, blindness, stroke, hospitalization , and/or death. On [DATE] at 3:47 p.m., the IJ was removed in the presence of the ADMIN and the DON while onsite, after verifying through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan which included the following summarized actions: 1. Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered on [DATE]. 2. Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR - a communication framework used to share information about a resident that needs attention tool) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1). 3. LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1). 4. P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31. 5. Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT - a team of health care professionals from different disciplines who work together to provide personalized care for residents) and MD 1 of the medication omissions, lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions. 6. The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31. 7. The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 on [DATE] to reconcile (the process of identifying the most accurate list of all medications that the resident is taking) medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand. 8. MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31 on [DATE]. As of [DATE], no untoward (unexpected) findings or side effects related to medication omission have been noted for either Resident 5 or 31. 9. The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications. 10. The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered. 11. A Root Cause Analysis (RCA - a structured process for identifying the underlying cause of a problem and developing solutions to prevent it from happening again) was initiated on [DATE] by the ADMIN and the DON to determine causative factors for the systemic breakdown. 12. The DON conducted in-service (a type of training that takes place while an employee is on the job, and is designed to improve their skills and knowledge to enhance their performance) for the licensed nursing staff on [DATE] regarding the following: - Daily review of resident medication supply for availability, - Ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, Ensuring all licensed nurses are following facility policy and procedures (P&P) on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, - Following through daily with the dispensing pharmacy for timely delivery of all ordered medications, - How to utilize the Medication Refill Audit Tool. 13. The DON or designee will track the following during the Daily Nursing Huddles (short, regular meeting where a healthcare team discusses resident safety and care, and plans for the day ahead) Monday through Sunday: - Timely (5 days) Ordering of Medications - Timely Delivery of Medication - Timely Administration of Medication 14. The DON or designee will present findings at the Daily Stand-Up Meeting (short, daily meeting where healthcare team members share updates on their work and discuss progress) Monday through Friday for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved. 15. The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy weekly or as often as necessary to support process improvement until 100% compliance is achieved. 16. The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at monthly Quality Assurance Performance Improvement (QAPI - a systematic, comprehensive, and data-driven approach conducted by the facility to improve the quality of care and services provided to the residents) meetings for three months with modifications to the process as warranted. Cross references: F755 and F760 Findings: a. During a review of Resident 5's Admission Record (a document containing demographic and diagnostic information), the Admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die,) atrial fibrillation (irregular heartbeat,) essential hypertension (high blood pressure that develops over time), and heart disease (a general term for conditions that affect the heart or blood vessels, and how they function which can lead to edema.) During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, and lying to sitting on side of bed. The MDS also indicated Resident 5 needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds the trunk or limbs and provides more than half the effort) with chair/bed-to-chair transfers. During a review of Resident 5's IDT Care Plan Conference Summary dated [DATE], the IDT Care Plan Conference Summary indicated Resident 5 is forgetful, able to express (make self understood), and able to understand others. During a review of Resident 5's Physician Orders (a report listing the physician order for the resident) from [DATE] to [DATE], the Physician Orders indicated Resident 5 was prescribed the following: 1. bumetanide 0.5 milligrams (mg - a measure of unit of mass) tablet by mouth once a day at 8 a.m. for fluid retention, starting [DATE], 2. metoprolol 25 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for hypertension, starting [DATE]. During a review of Resident 5's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered bumetanide 0.5 mg at 8 a.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered metoprolol 25 mg at 9 a.m. and 5 p.m. During a medication administration observation on [DATE] at 9:18 a.m. by Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 5: 1. metoprolol 25 mg 2. bumetanide 0.5 mg LVN 1 informed Resident 5 that the metoprolol and bumetanide were not available that morning (9:18 a.m.) and that Resident 5 would have to wait for the pharmacy to deliver the medication to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer metoprolol 25 mg on [DATE] at 9 a.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. to Resident 5, since the medications were not available in the medication carts or in the facility. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated that by missing doses of those critical medications (such as metoprolol) it increased the risk that Residents 5 could experience high blood pressure and stroke possibly resulting in hospitalization and/or death. During an interview on [DATE] at 1:35 p.m. with the DON, the DON stated that licensed nurses should ensure physician orders are followed and medications are administered at the scheduled times by following the five (5) rights of medication administration, which includes: right patient, right drug, right dose, right time, right route. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated that Resident 5 was not administered metoprolol 25 mg on [DATE] at 9 a.m. and 5 p.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. due to the medications not being available. The DON stated those (metoprolol and bumetanide) medications were not available in the medication carts and not available in the emergency kits ([eKIT] - a kit with limited supply of medications needed during emergent situations). The DON stated Resident 5 was prescribed metoprolol for high blood pressure and bumetanide for edema. The DON stated missing the administrations of those critical medications (such as metoprolol) can cause elevated blood pressure by not maintaining normal pressures leading to potential stroke resulting in hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 5. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 3:19 p.m. with LVN 1, LVN 1 stated that he (LVN 1) was not able to administer the 5 p.m. dose of metoprolol 25 mg for Resident 5 on [DATE] since the medication was not available. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like metoprolol can potentially increase the risk of elevated heart rate and elevated blood pressure resulting in hospitalization . During a review of the facility's pharmacy delivery manifests (detailed statement or invoice for shipment of medications) faxed to the facility on [DATE], the pharmacy delivery manifest indicated the facility received a 30-day supply of Resident 5's bumetanide 0.5 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy Consolidated Delivery Sheets (record that includes the medications delivered to the facility from the dispensing pharmacy) faxed to the facility on [DATE], the Consolidated Delivery Sheets indicated the facility received a 30-day supply of Resident 5's metoprolol 25 mg tablets on [DATE] and did not receive an additional supply until [DATE]. b. During a review of Resident 31's Admission Record, the Admission Record indicated Resident 31 was originally admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack,) atrial fibrillation (irregular heartbeat,) BPH, hypertensive heart disease (heart disease caused by constant high blood pressure). During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 31 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers. During a review of Resident 31's Physician Orders, from [DATE] to [DATE], the Physician Orders indicated Resident 31 was prescribed the following: 1. Eliquis 2.5 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for CVA prophylaxis (the prevention of disease or the measures taken to maintain health), starting [DATE], 2. brimonidine 0.2% one (1) drop each eye twice a day at 9 a.m. and 5 p.m. for glaucoma, starting [DATE], 3. finasteride five (5) mg tablet by mouth once a day at 9 a.m. for BPH, starting [DATE], 4. folic acid one (1) mg tablet by mouth once a day at 9 a.m. for anemia, starting [DATE], 5. tamsulosin 0.4 mg capsule by mouth once a day at 9 a.m. for BPH, starting [DATE]. During a review of Resident 31's MAR for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered Eliquis 2.5 mg at 9 a.m. and 5 p.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered brimonidine 0.2% at 9 a.m. and 5 p.m. 3. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered finasteride five (5) mg at 9 a.m. 4. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered folic acid one (1) mg at 9 a.m. 5. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered tamsulosin 0.4 mg at 9 a.m. During a medication administration observation on [DATE] at 8:49 a.m., with LVN 1 by Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 31: 1. Eliquis 2.5 mg tablet 2. brimonidine 0.2% eye drops 3. finasteride five (5) mg tablet 4. folic acid one (1) mg tablet 5. tamsulosin 0.4 mg tablet LVN 1 informed Resident 31 that the Eliquis, brimonidine, finasteride, folic acid and tamsulosin were not available and that Resident 31 would have to wait for pharmacy to deliver the medications to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer Eliquis 2.5 mg and brimonidine 0.2%, finasteride five (5 mg), folic acid one (1) mg and tamsulosin 0.4 mg on [DATE] at 9 a.m. to Resident 31, since the medications were not available in the medication carts or in the facility. LVN 1 stated that those medications were not available in the eKIT either. LVN 1 stated that he (LVN 1) will follow-up with the pharmacy for the refill of those (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) medications and inform the physicians that the morning doses on [DATE] were not administered to Resident 31. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated missing doses of those critical medications (such as Eliquis, brimonidine,) can harm Resident 31 by causing increased eye pressures, another CVA, and stroke resulting in hospitalization and/or death. During an interview, on [DATE] at 1:35 p.m. with the DON, the DON stated per facility policy, medication refills should be re-ordered from the pharmacy three (3) to five (5) days before the last dose to prevent medications from not being available to the residents at their scheduled times. The DON stated licensed nurses are expected to re-order residents' medications timely (5 days) and follow-up on the refills to ensure medications are available to residents. The DON also stated that licensed nurses should ensure physician orders are followed and medications are administered at the scheduled times. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated Eliquis, brimonidine, finasteride, folic acid, and tamsulosin were not available in the medication carts and not available in the eKITS. The DON stated Resident 31 was prescribed Eliquis for CVA prophylaxis, finasteride and Tamsulosin for BPH, Brimonidine for glaucoma, and folic acid for anemia management. The DON stated missing the administrations of those critical medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) can cause clotting (sticky lump that forms when blood dries up or becomes thick) of blood due to the blood not being properly thinned, the clot traveling the heart and brain forming an embolism (obstruction caused by clots) potentially causing a heart attack and stroke, elevated eye pressure by not maintaining normal pressures leading to potential stroke and vision impairment such as blindness, all resulting in potential hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 31. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 2:10 p.m. with LVN 3, LVN 3 stated that medications should be re-ordered from the pharmacy five (5) to six (6) days in advance of using the last available dose to ensure timely delivery by pharmacy. LVN 3 stated that she (LVN 3) informed the DON that the Eliquis 2.5 mg for Resident 31 was not available (unable to recall the date). LVN 3 stated it was important for Resident 31 to receive Eliquis to prevent blood clots, heart attack, stroke, hospitalization , and/or death. During an interview on [DATE] at 2:25 p.m. with the DON, in the presence of LVN 3, the DON stated that on [DATE] was the first day the DON followed up with pharmacy regarding the refill and delivery of Eliquis 2.5 mg for Resident 31. The DON stated she (DON) had not called or communicated with pharmacy personnel prior to [DATE] and only faxed Eliquis refill requests to the pharmacy on [DATE] and [DATE] and assumed the medication was delivered. The DON stated she (DON) failed to follow-up with the requests and that going forward there needs to be a system put in place for following up on medication refills. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like Eliquis and brimonidine for Resident 31 can potentially increase the risk of blood clotting, CVA, and elevated internal pressure of the eye resulting in hospitalization and/or death. During a review of the facility's pharmacy delivery manifests to the facility on [DATE], the pharmacy delivery manifests indicated the facility received a 30-day supply of Resident 31's brimonidine 0.2% drops on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy delivery manifests faxed to the facility on [DATE], indicated the facility received 14-day supply (28 tablets) of Resident 31's Eliquis 2.5 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy Consolidated Delivery Sheets faxed to the facility on [DATE], the Consolidated Delivery Sheets indicated the facility received a 30-day supply of Resident 31's finasteride five (5) mg tablets, folic acid one (1) mg tablets, and tamsulosin 0.4 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's P&P, titled Medication Administration - General Guidelines, dated [DATE], the P&P indicated: B. Administration 2) Medications are administered in accordance with written orders of the attending physician. 10) Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) . routine medications are administered according to the established medication administration schedule for the facility. During a review of the facility's P&P, titled Ordering and Receiving Medications from The Dispensing Pharmacy, dated [DATE], the P&P indicated that Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications five days in advance of need to assure adequate supply is on hand. c. The refill is called in, faxed, or otherwise transmitted to the pharmacy. 3.a. If needed before the next regular delivery, inform pharmacy of the need for prompt delivery. During a review of the facility's P&P, titled Emergency Pharmacy Service and Emergency Kits, dated [DATE], the P&P indicated: D. The ordered medication is obtained either from the emergency supply or from the provider pharmacy. During a review of the facility's P&P, titled Medication Error Reporting, dated ,d+[DATE], the P&P indicated: Medication errors will include but not be limited to: d. dose skipped.

Based on observation, interview, and record review, the facility failed to: 1. Reorder medications five (5) days in advance of need to assure an adequate supply was on hand (current availability) as per facility policy for two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. 2. Follow-up for delivery and availability of medications for two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. 3. Remove and destroy and not use another resident's medication (Resident 18, a discharged resident) to provide Eliquis (a medication used for cerebrovascular accidents [CVA, also known as stroke, a loss of blood flow to part of the brain, which damages brain tissue]) to Resident 31 from [DATE] to [DATE]. These deficient practices resulted in: 1. Resident 5 not receiving two (2) doses on [DATE] at 9 a.m. and 5 p.m. of metoprolol (a medication used to treat hypertension [a condition in which the blood vessels have persistently raised pressure]) and one (1) dose on [DATE] at 8 a.m. of bumetanide (a medication used to treat edema [swelling of feet, ankles, legs, and other parts of the body, such as the face, hands, and abdomen caused by fluid retention]) on [DATE], increasing the potential to cause Resident 5 serious harm, serious impairment, and serious complications, potentially resulting in elevated blood pressure, hospitalization , and/or death. 2. Resident 31 not receiving two (2) doses on [DATE] at 9 a.m. and 5 p.m. of Eliquis, two (2) doses on [DATE] at 9 a.m. and 5 p.m. of brimonidine (a medication used for glaucoma [a condition of increased pressure in the eyeball]), one (1) dose on [DATE] at 9 a.m. of finasteride (a medication used for benign prostatic hyperplasia [BPH] - a condition in men where the prostate gland - a small gland located inside the groin - is enlarged]), one (1) dose on [DATE] at 9 a.m. of folic acid (a medication used for anemia [a condition with lower-than-normal number of red blood cells]), and one (1) dose on [DATE] at 9 a.m. of tamsulosin (a medication used for BPH) increasing the potential to cause Resident 31 serious harm, serious impairment, and serious complications, potentially resulting in blood clots, blindness, stroke, hospitalization , and/or death. 3. Resident 31 receiving 60 doses of Eliquis between [DATE] and [DATE] from Resident 18's medication supply. On [DATE] at 3:36 p.m. the State Survey Agency (SSA) called an Immediate Jeopardy (IJ - a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for the facility's failure to provide routine and emergency medications to its residents, and the facility's failure to acquire medications to meet the needs of the residents. The Administrator (ADMIN) and the Director of Nursing (DON) were notified of the IJ from the failure to ensure Residents 5 and 31 had medication available for administration at the scheduled times per physician orders. On [DATE] at 3:47 p.m., the IJ was removed in the presence of the ADMIN and the DON while onsite, after verifying through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan which included the following summarized actions: 1. Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered on [DATE]. 2. Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR - a communication framework used to share information about a resident that needs attention tool) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1). 3. LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1). 4. P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31. 5. Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT - a team of health care professionals from different disciplines who work together to provide personalized care for residents) and MD 1 of the medication omissions (not giving/skipping), lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions. 6. The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31. 7. The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 on [DATE] to reconcile (the process of identifying the most accurate list of all medications that the resident is taking) medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand. 8. MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31 on [DATE]. As of [DATE], no untoward (unexpected) findings or side effects related to medication omission have been noted for either Resident 5 or 31. 9. The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications. 10. The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 on [DATE] to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered. 11. A Root Cause Analysis (RCA - a structured process for identifying the underlying cause of a problem and developing solutions to prevent it from happening again) was initiated on [DATE] by the ADMIN and the DON to determine causative factors for the systemic breakdown. 12. The DON conducted in-service (a type of training that takes place while an employee is on the job, and is designed to improve their skills and knowledge to enhance their performance) for the licensed nursing staff on [DATE] regarding the following: - Daily review of resident medication supply for availability, - Ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, - Ensuring all licensed nurses are following facility policy and procedures (P&P) on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, - Following through daily with the dispensing pharmacy for timely delivery of all ordered medications, - How to utilize the Medication Refill Audit Tool. 13. The DON or designee will track the following during the Daily Nursing Huddles (short, regular meeting where a healthcare team discusses resident safety and care, and plans for the day ahead) Monday through Sunday: - Timely (5 days) Ordering of Medications - Timely Delivery of Medication - Timely Administration of Medication 14. The DON or designee will present findings at the Daily Stand-Up Meeting (short, daily meeting where healthcare team members share updates on their work and discuss progress) Monday through Friday for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved. 15. The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy weekly or as often as necessary to support process improvement until 100% compliance is achieved. 16. The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at monthly Quality Assurance Performance Improvement (QAPI - a systematic, comprehensive, and data-driven approach conducted by the facility to improve the quality of care and services provided to the residents) meetings for three months with modifications to the process as warranted. Cross references: F759 and F760 Findings: a. During a review of Resident 5's Admission Record (a document containing demographic and diagnostic information), the Admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die,) atrial fibrillation (irregular heartbeat,) essential hypertension (high blood pressure that develops over time), and heart disease (a general term for conditions that affect the heart or blood vessels, and how they function which can lead to edema.) During a review of Resident 5's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated [DATE], the MDS indicated Resident 5 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 5 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, and lying to sitting on side of bed. The MDS also indicated Resident 5 needed substantial/maximal assistance (helper does more than half the effort; helper lifts or holds the trunk or limbs and provides more than half the effort) with chair/bed-to-chair transfers. During a review of Resident 5's IDT Care Plan Conference Summary dated [DATE], the IDT Care Plan Conference Summary indicated Resident 5 is forgetful, able to express (make self understood), and able to understand others. During a review of Resident 5's Physician Orders (a report listing the physician order for the resident) from [DATE] to [DATE], the Physician Orders indicated Resident 5 was prescribed the following: 1. bumetanide 0.5 milligrams (mg - a measure of unit of mass) tablet by mouth once a day at 8 a.m. for fluid retention, starting [DATE], 2. metoprolol 25 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for hypertension, starting [DATE]. During a review of Resident 5's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered bumetanide 0.5 mg at 8 a.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 5 was administered metoprolol 25 mg at 9 a.m. and 5 p.m. During a medication administration observation on [DATE] at 9:18 a.m. by Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 5: 1. metoprolol 25 mg 2. bumetanide 0.5 mg LVN 1 informed Resident 5 that the metoprolol and bumetanide were not available that morning (9:18 a.m.) and that Resident 5 would have to wait for the pharmacy to deliver the medication to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer metoprolol 25 mg on [DATE] at 9 a.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. to Resident 5, since the medications were not available in the medication carts, in the facility or in the emergency kits ([eKIT] - a kit with limited supply of medications needed during emergent situations). LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated that by missing doses of those critical medications (such as metoprolol) it increased the risk that Residents 5 could experience high blood pressure and stroke possibly resulting in hospitalization and/or death. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated that Resident 5 was not administered metoprolol 25 mg on [DATE] at 9 a.m. and 5 p.m. and bumetanide 0.5 mg on [DATE] at 8 a.m. due to the medications not being available. The DON stated those (metoprolol and bumetanide) medications were not available in the medication carts and not available in the eKIT. The DON stated Resident 5 was prescribed metoprolol for high blood pressure and bumetanide for edema. The DON stated missing the administrations of those critical medications (such as metoprolol) can cause elevated blood pressure by not maintaining normal pressures leading to potential stroke resulting in hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 5. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 3:19 p.m. with LVN 1, LVN 1 stated that he (LVN 1) was not able to administer the 5 p.m. dose of metoprolol 25 mg for Resident 5 on [DATE] since the medication was not available. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like metoprolol can potentially increase the risk of elevated heart rate and elevated blood pressure resulting in hospitalization . During a review of the facility's pharmacy delivery manifests (detailed statement or invoice for shipment of medications) faxed to the facility on [DATE], the pharmacy delivery manifest indicated the facility received a 30-day supply of Resident 5's bumetanide 0.5 mg tablets on [DATE] and did not receive an additional supply until [DATE]. During a review of the facility's pharmacy Consolidated Delivery Sheets (record that includes the medications delivered to the facility from the dispensing pharmacy) faxed to the facility on [DATE], the Consolidated Delivery Sheets indicated the facility received a 30-day supply of Resident 5's metoprolol 25 mg tablets on [DATE] and did not receive an additional supply until [DATE]. b. During a review of Resident 31's Admission Record, the Admission Record indicated Resident 31 was originally admitted to the facility on [DATE] with diagnoses including myocardial infarction (heart attack,) atrial fibrillation (irregular heartbeat,) BPH, hypertensive heart disease (heart disease caused by constant high blood pressure). During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 31 needed partial/moderate assistance (helper does less than half the effort; helper lifts, holds, or supports the trunk or limbs, but provides less than half the effort) with rolling from left and right, sitting to lying, lying to sitting on side of bed, sitting to standing, and chair/bed-to-chair transfers. During a review of Resident 31's Physician Orders, from [DATE] to [DATE], the Physician Orders indicated Resident 31 was prescribed the following: 1. Eliquis 2.5 mg tablet by mouth twice a day at 9 a.m. and 5 p.m. for CVA prophylaxis (the prevention of disease or the measures taken to maintain health), starting [DATE], 2. brimonidine 0.2% one (1) drop each eye twice a day at 9 a.m. and 5 p.m. for glaucoma, starting [DATE], 3. finasteride five (5) mg tablet by mouth once a day at 9 a.m. for BPH, starting [DATE], 4. folic acid one (1) mg tablet by mouth once a day at 9 a.m. for anemia, starting [DATE], 5. tamsulosin 0.4 mg capsule by mouth once a day at 9 a.m. for BPH, starting [DATE]. During a review of Resident 31's MAR for [DATE], the MAR indicated the following: 1. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered Eliquis 2.5 mg at 9 a.m. and 5 p.m. 2. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered brimonidine 0.2% at 9 a.m. and 5 p.m. 3. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered finasteride five (5) mg at 9 a.m. 4. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered folic acid one (1) mg at 9 a.m. 5. For [DATE], there was no documentation noted in the MAR that Resident 31 was administered tamsulosin 0.4 mg at 9 a.m. During a medication administration observation on [DATE] at 8:49 a.m. with LVN 1 at Medication Cart 1, LVN 1 was observed not administering the following medications to Resident 31: 1. Eliquis 2.5 mg tablet 2. Brimonidine 0.2% eye drops 3. finasteride five (5) mg tablet 4. folic acid one (1) mg tablet 5. Tamsulosin 0.4 mg tablet LVN 1 informed Resident 31 that the Eliquis, Brimonidine, finasteride, folic acid, and Tamsulosin were not available and that Resident 31 would have to wait for pharmacy to deliver the medications to administer later that day. During an interview on [DATE] at 9:20 a.m. with LVN 1, LVN 1 stated that he (LVN 1) did not administer Eliquis 2.5 mg and brimonidine 0.2%, finasteride five (5 mg), folic acid one (1) mg, and tamsulosin 0.4 mg on [DATE] at 9 a.m. to Resident 31, since the medications were not available in the medication carts or in the facility. LVN 1 stated that those medications were not available in the eKIT either. LVN 1 stated that he (LVN 1) will follow-up with the pharmacy for the refill of those (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) medications and inform the physicians that the morning doses on [DATE] were not administered to Resident 31. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated missing doses of those critical medications (such as Eliquis, brimonidine,) can harm Resident 31 by causing increased eye pressures, another CVA, and stroke resulting in hospitalization and/or death. During a concurrent observation and interview on [DATE] at 1:35 p.m. by Medication Cart 1 with LVN 1 and the DON, LVN 1 stated that due to the unavailability of Eliquis 2.5 mg from [DATE] to [DATE], LVN 1 used Resident 18's supply of Eliquis 2.5 mg to ensure that Resident 31 did not miss any doses of the critical medication. LVN 1 stated that he (LVN 1) should not have used another resident's medication supply. LVN 1 stated that according to facility policy, discharged resident's medications should be destroyed. LVN 1 stated that he (LVN 1) did not administer Eliquis 2.5 mg and brimonidine 0.2%, finasteride five (5 mg), folic acid one (1) mg and tamsulosin 0.4 mg on [DATE] at 9 a.m. to Resident 31, since the medications were not available in the medication carts or in the facility. LVN 1 stated that those medications were not available in the eKIT either, and LVN 1 pulled out Resident 18's medication bubble pack (medication packaging system that contains individual doses of medication per bubble) from the bottom drawer of Medication Cart 1. The medication bubble pack indicated Resident 18 was prescribed Eliquis 2.5 mg tablet to be given by mouth twice a day. LVN 1 stated that he (LVN 1) will follow-up with the pharmacy for the refill of those (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) medications and inform the physicians that the morning doses on [DATE] were not administered to Resident 31. LVN 1 stated that medications should be re-ordered from the pharmacy three (3) to five (5) days prior to the last available dose and followed up as needed, to ensure timely availability of medications to all residents. LVN 1 stated missing doses of those critical medications (such as Eliquis, brimonidine,) can harm Resident 31 by causing increased eye pressures, another CVA, and stroke resulting in hospitalization and/or death. The DON stated per facility policy, medication refills should be re-ordered from the pharmacy about three (3) to five (5) days before the last dose to prevent medications from not being available to the residents at their scheduled times. The DON stated licensed nurses were expected to re-order medications timely (5 days) and follow-up on the refills to ensure medications were available to residents. The DON also stated that licensed nurses should ensure physician orders are followed and medications are administered at the scheduled times. The DON stated per facility policy, medications supplied for one resident should not be used for another resident, and when a resident was discharged the medications should have been destroyed or returned to the resident. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated that Resident 31 was not administered Eliquis 2.5 mg, brimonidine 0.2% drops, finasteride five (5) mg, folic acid one (1) mg, and tamsulosin 0.4 mg for the 9 a.m. and 5 p.m. doses on [DATE] due to the medications not being available. The DON stated those medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) were not available in the medication carts and not available in the eKITS. The DON stated Resident 31 was prescribed Eliquis for CVA prophylaxis, finasteride and Tamsulosin for BPH, Brimonidine for glaucoma, and folic acid for anemia management. The DON stated missing the administrations of those critical medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) can cause clotting (sticky lump that forms when blood dries up or becomes thick) of blood due to the blood not being properly thinned, the clot traveling the heart and brain forming an embolism (obstruction caused by clots) potentially causing a heart attack and stroke, elevated eye pressure by not maintaining normal pressures leading to potential stroke and vision impairment such as blindness, all resulting in potential hospitalization and/or death. The DON stated that several licensed nurses failed to reorder those medications (Eliquis, brimonidine, finasteride, folic acid, tamsulosin) within the three (3) to five (5) day timeframe and that the DON failed to follow-up on the status of the re-ordered medications from pharmacy to prevent the unavailability of medications and interruption of medication therapy and continuity of care for Residents 31. The DON stated there was no consistent system in place to ensure timely reordering and follow-up of medications. The DON stated there needed to be a more proactive approach and better communications put in place to prevent those system failures from affecting other residents in the future. The DON stated she (DON) sees the immediacy of those deficient practices and why the facility needed to have immediate actions taken to prevent further harm to its residents. During an interview on [DATE] at 2:10 p.m. with LVN 3, LVN 3 stated that medications should be re-ordered from the pharmacy five (5) to six (6) days in advance of using the last available dose to ensure timely delivery by pharmacy. LVN 3 stated that she (LVN 3) informed the DON that the Eliquis 2.5 mg for Resident 31 was not available (unable to recall the date). LVN 3 stated it was important for Resident 31 to receive Eliquis to prevent blood clots, heart attack, stroke, hospitalization , and/or death. LVN 3 stated she (LVN 3) used Resident 18's supply of Eliquis 2.5 mg from [DATE] to [DATE] nsure that Resident 31 did not miss any doses. LVN 3 stated that she (LVN 3) knew not to use another resident's medication supply but used it in desperation, and that it was wrong to do so. LVN 3 stated that she (LVN 3) did not inform anyone that she (LVN 3) was using another resident's Eliquis supply, and that discharged resident's medications should be destroyed according to facility policy. During an interview on [DATE] at 2:25 p.m. with the DON, in the presence of LVN 3, the DON stated that on [DATE] was the first day the DON followed up with pharmacy regarding the refill and delivery of Eliquis 2.5 mg for Resident 31. The DON stated she (DON) had not called or communicated with pharmacy personnel prior to [DATE] and only faxed Eliquis refill requests to the pharmacy on [DATE] and [DATE] and assumed the medication was delivered. The DON stated she (DON) failed to follow-up with the requests and that going forward there needs to be a system put in place for following up on medication refills. During an interview on [DATE] at 3:19 p.m. with LVN 1, LVN 1 stated that he (LVN 1) was not able to administer the 5 p.m. doses of Eliquis 2.5 mg and brimonidine 0.2% for Resident 31 on [DATE] since the medications were not available. During an interview on [DATE] at 8:44 a.m. with the CP, the CP stated that medications supplied for one resident should not be used for another resident. The CP stated that the physician should be informed when medications are skipped and not administered to a resident as alternate medications and assessments may need to be ordered to prevent resident harm. The CP stated not administering critical medications like Eliquis and brimonidine for Resident 31 can potentially increase the risk of blood clotting, CVA, and elevated internal pressure of the eye resulting in hospitalization and/or death. During a review of the facility's P&P, titled Medication Administration - General Guidelines, dated [DATE], the P&P indicated: B. Administration 2) Medications are administered in accordance with written orders of the attending physician. 10) Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after) . routine medications are administered according to the established medication administration schedule for the facility. 12) Medications supplied for one resident are never administered to another resident. During a review of the facility's P&P, titled Ordering and Receiving Medications from The Dispensing Pharmacy, dated [DATE], the P&P indicated that Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications five days in advance of need to assure adequate supply is on hand. c. The refill is called in, faxed, or otherwise transmitted to the pharmacy. 3.a. If needed before the next regular delivery, inform pharmacy of the need for prompt delivery. During a review of the facility's P&P, titled Emergency Pharmacy Service and Emergency Kits, dated [DATE], the P&P indicated: D. Medications are not borrowed from other residents. The ordered medication is obtained either from the emergency supply or from the provider pharmacy. During a review of the facility's P&P, titled Medication Error Reporting, dated ,d+[DATE], the P&P indicated: Medication errors will include but not be limited to: d. dose skipped t. wrong Resident's card used to give medication. During a review of facility's P&P titled, Discontinued Medications, dated [DATE], the P&P indicated that When medications are expired, discontinued by a prescriber, a resident is transferred or discharged and does not take medications with him/her, or in the event of a resident's death, the medications are marked as discontinued or stored in a separate location and later destroyed. A. If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified or shall be stored in a separate location designated solely for this purpose. The date the medication was discontinued shall be indicated on the medication container. B. Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed. Medications are removed from the medication cart or storage area prior to expiration, and immediately upon receipt of an order to discontinue. During a review of facility's P&P titled, Medication Destruction, dated [DATE], the P&P indicated that Discontinued medications and medications left in the facility after a resident's discharge .are destroyed. A. All medications are placed in the proper waste container per facility policy.