Every finding on record at Wadesboro Health & Rehab Center

Based on record reviews, observation, and interviews with the Registered Dietician and staff, the facility failed to accurately code the Minimum Data Set (MDS) assessment for weight loss or gain (Residents #6, # 62, #1, #14, and #2) and for alarm usage (Resident #6) for 5 of 20 residents reviewed. The findings included: 1) Resident #6 was admitted to the facility on [DATE] with diagnoses that included mild protein-calorie malnutrition, diabetes type 2, anxiety disorder and dementia. a) Review of Resident #6's weight data revealed the following weights during the MDS assessment look back period of February 2026 to August 2026, which showed stable weights. 8/3/26 172 pounds (lbs.) 7/2/26 175 lbs. 6/24/26 175 lbs. 6/2/26 174 lbs. 5/5/26 177 lbs. 4/1/26 173 lbs. 3/3/26 177 lbs. 2/4/26 179 lbs. Review of a Nutritional Observation Assessment completed by the Registered Dietician (RD) on 8/5/26 revealed Resident #6's weight was entered as 172 lbs. The assessment was marked yes for weight gain of 5% or more in the last month or 10% or more in the last 6 months. The assessment further read that there had been no significant weight change in the past 30, 90 or 180 days. A Significant Change in Status MDS assessment dated [DATE] indicated Resident #6 had moderately impaired cognition and was coded for weight gain of 5% or more in the last month or a gain of 10% or more in the last 6 months. On 8/19/26 at 11:31 AM, an interview was conducted with the RD. The RD explained that completing the Nutritional Observation Assessment automatically populated the corresponding fields in the nutritional section of the MDS assessment. After reviewing Resident #6's medical record and the MDS assessment dated [DATE], the RD stated she had mistakenly marked the weight gain field and explained that Resident #6's weight had remained stable over both the past month and the past six months. An interview occurred with MDS Nurse #1 and #2 on 8/19/26 at 1:08 PM, who explained that the Nutritional Observation Assessment completed by the RD on 8/5/26 populated the nutritional section of the Significant Change in Status MDS assessment dated [DATE]. According to MDS Nurse #1, she did not verify the RD's coding because she relied on the RD's information to be correct. Both MDS Nurse #1 and #2 stated they did not calculate Resident #6's weights independently. b) Review of Resident #6's active physician orders included an order dated 7/2/26 for a wander guard due to wandering behaviors, check placement and operation every shift. Inspect skin for alterations in skin integrity. A quarterly MDS assessment dated [DATE] indicated Resident #6 had moderately impaired cognition and was not coded for a wander/elopement alarm. A Significant Change in Status MDS assessment dated [DATE] indicated Resident #6 had moderately impaired cognition and was not coded for a wander/elopement alarm. Resident #6's active care plan, last reviewed 8/7/26 included a problem area for risk of injury related to wandering. The interventions included a wander guard that was initiated on 7/2/26. On 8/18/26 at 11:45 AM, Resident #6 was observed lying in bed watching television, with a wander guard attached to the back of his wheelchair. An interview was conducted with MDS Nurse #2 on 8/19/26 at 12:40 PM. He stated that he had coded both MDS assessments dated 7/28/26 and 8/5/26. After reviewing the assessments, he confirmed that the wander/elopement alarm had not been coded and acknowledged that this was an oversight. During an interview with the Administrator and the Director of Nursing on 8/19/26 at 1:13 PM, they stated that it was their expectation for MDS assessments to be coded accurately in the areas of weight loss or gain and alarm usage. 2) Resident #62 was admitted to the facility on [DATE] with diagnoses that included mild protein-calorie malnutrition, and diabetes type 2. Resident #62's weight data revealed the following weights during the MDS assessment look back period of September 2025 to March 2026. 3/3/26 143 lbs. 2/4/26 146 lbs. 1/6/26 146.6 lbs. 12/4/25 147 lbs. 12/2/25 171.3 lbs. 11/11/25 169 lbs. 11/3/25 145 lbs. 10/16/25 146 lbs. 10/15/25 146 lbs. 10/6/25 146 lbs. 10/2/25 146 lbs. 10/1/25 146 lbs. There were no weights showing for September 2025. Review of a Nutritional Observation Assessment completed by the Registered Dietician (RD) on 3/18/26 revealed Resident #62's weight was entered as 143 lbs. The assessment was marked yes for weight loss of 5% or more in the last month or 10% or more in the last 6 months. The assessment further read that weights had remained stable for 180 days and questioned accuracy of weight dated 12/2/25. A quarterly MDS assessment dated [DATE] indicated Resident #62 was cognitively intact and was coded for weight loss of 5% or more in the last month or 10% or more in the last 6 months. On 8/19/26 at 11:31 AM, an interview was conducted with the Registered Dietician (RD). The RD explained that completing the Nutritional Observation Assessment automatically populates the nutritional section of the MDS assessment. After reviewing Resident #62's medical record and the MDS assessment dated [DATE], the RD stated she had mistakenly marked the weight loss field, noting that Resident #62's weight had remained stable over both the past month and the past six months. An interview occurred with MDS Nurse #1 and #2 on 8/19/26 at 1:08 PM, who explained that the Nutritional Observation Assessment completed by the RD on 3/18/26 populated the nutritional section of the quarterly MDS assessment dated [DATE]. According to MDS Nurse #1, she did not verify the RD's coding because she relied on the RD's information to be correct. Both MDS Nurse #1 and #2 stated they did not calculate Resident #62's weights independently. During an interview with the Administrator and the Director of Nursing on 8/19/26 at 1:13 PM, they stated that it was their expectation for MDS assessments to be coded accurately in the areas of weight loss or gain. 3. Resident #1 was admitted to the facility on [DATE] with diagnoses that included mild protein-calorie malnutrition and dysphagia (difficulty swallowing) following a stroke. Review of Resident #1's weight data revealed the following weights during the MDS assessment look back period of February 2026 to July 2026, which showed a weight gain of 5.64% in a six-month period. 07/08/26 103 pounds (lbs.) 06/02/26 103 lbs 05/05/26 100.0 lbs 04/01/26 97.0 lbs 03/03/26 96.0 lbs 02/04/26 97.5 lbs Review of a Nutritional Observation Assessment completed by the Registered Dietician (RD) on 07/08/26 revealed Resident #1's weight was entered as 103.0 lbs. The assessment was marked yes for weight loss of 5% or more in the last month or 10% or more in the last 6 months. A quarterly MDS assessment dated [DATE] 26 indicated Resident #1 had severely impaired cognition and was coded for weight loss of 5% or more in the last month or a gain of 10% or more in the last 6 months. An interview was conducted on 8/19/26 at 11:42 AM with the RD. The RD explained that completing the Nutritional Observation Assessment automatically populated the corresponding fields in the nutritional section of the MDS assessment. After reviewing Resident #1's medical record and the MDS assessment dated [DATE], the RD stated she had mistakenly marked the weight loss field and explained that Resident 1 has had a gradual weight gain over the past six months. An interview occurred with MDS Nurse #1 in the presence of MDS Nurse #2 on 08/19/26 at 1:08 PM, who explained that the Nutritional Observation Assessment completed by the RD on 07/08/26 populated the nutritional section of the quarterly MDS assessment dated [DATE]. According to MDS Nurse #2, he did not verify the RD's coding because he relied on the RD's information to be correct. Both MDS Nurse #2 stated they did not calculate Resident #1's weights independently and indicated the assessment would be corrected. 4. Resident #14 was admitted to the facility on [DATE] with diagnoses that included mild protein-calorie malnutrition, Type 2 diabetes mellitus, and dysphagia (difficulty swallowing) following a stroke. Review of Resident #14's weight data revealed the following weights during the MDS assessment look back period of January 2026 to June 2026, which showed weights ranged from 127.0 pounds to 133.0 pounds. 06/02/26 129.0 pounds (lbs.) 05/05/26 127.0 lbs 04/01/26 131.0 lbs 03/03/26 130.0 lbs 02/25/26 130.0 lbs 02/18/26 130.0 lbs 02/11/26 133.0 lbs 01/07/26 130.0 lbs Review of a Nutritional Observation Assessment completed by the Registered Dietician (RD) on 06/18/26 revealed Resident #14's weight was entered as 129.0 lbs. The assessment was marked yes for weight loss of 5% or more in the last month or 10% or more in the last 6 months. Resident #14's annual Minimum Data Set assessment dated [DATE] indicated her cognition was intact and and was coded for weight loss of 5% or more in the last month or a gain of 10% or more in the last 6 months. An interview was conducted on 8/19/26 at 11:42 AM with the RD. The RD explained that completing the Nutritional Observation Assessment automatically populated the corresponding fields in the nutritional section of the MDS assessment. After reviewing Resident #14's medical record and the MDS assessment dated [DATE], the RD stated she had mistakenly marked the weight loss field and explained that Resident #14's weight had remained stable over both the past month and the past six months. An interview occurred with MDS Nurse #1 in the presence of MDS Nurse #2 on 08/19/26 at 1:08 PM, who explained that the Nutritional Observation Assessment completed by the RD on 07/08/26 populated the nutritional section of the quarterly MDS assessment dated [DATE]. According to MDS Nurse #2, he did not verify the RD's coding because he relied on the RD's information to be correct. Both MDS Nurse #2 stated they did not calculate Resident #1's weights independently and indicated the assessment would be corrected. During an interview with the Director of Nursing and the Administrator on 8/19/26 at 1:13 PM, they stated that it was their expectation for MDS assessments to be coded accurately in the areas of weight loss or gain and alarm usage. 5. Resident #2 was admitted to the facility on [DATE] with diagnoses of reflux disease, rheumatoid arthritis and chronic kidney disease. A review of Resident #2's weights for the past six months from 2/4/26 to 8/3/26 revealed on 2/4/26 Resident #2 weighed 102 pounds, on 7/2/26 she weighed 100 pounds, and on 8/3/26 she weighed 100 pounds which equaled a total weight loss of 1.96% in a six-month period. A review of the Registered Dietitian's (RD) Nutritional Observation assessment dated [DATE] read that Resident #2 had a significant weight loss of 18% for the past 6 months. A review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the area of nutrition was marked a weight loss of 5% or more in the last month or 10% or more in six months without being on a physician-prescribed weight loss regimen. The MDS transmission date was noted as 8/17/26. An interview was held with the RD on 8/19/26 at 11:26 AM who stated she had completed the nutritional section of the MDS assessment dated [DATE]. She explained that when she completed the Nutritional Observation Assessment on 8/5/26, the information automatically flowed over to the MDS assessment. She further explained that she calculated a resident's weight based on the date of the most recent weight then compared it to the weight from 30 days and 6-months prior to that date. According to the RD, she calculated the weights in her head. Upon review of Resident #2's electronic medical record, during the interview, the RD stated she accidentally put the decimal in the wrong place when calculating Resident #2's weight which coded Resident #2 with weight loss in error. An interview was conducted with MDS Nurse #1 and MDS Nurse #2 on 8/19/26 at 1:08 PM who explained the nutrition assessment completed by the RD on 8/5/26 populated the nutritional section of the quarterly MDS assessment dated [DATE]. According to MDS Nurse #1, she did not verify the RD's coding because she relied on the RD's information to be correct. Both MDS Nurse #1 and MDS Nurse #2 stated they did not calculate Resident #2's weights independently. On 8/19/26 at 1:45 PM the Director of Nursing was interviewed and stated she expected the MDS nurse verify that the MDS assessment was coded correctly before signing off on it.

Based on observations, record reviews, Medical Director, Pharmacist and staff interviews the facility failed to have a physician's order for water flushes via gastrostomy (G-tube- a soft plastic tube placed through the skin directly into the stomach to deliver food and/or medication) for medication administration and failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe which had the potential for bacterial growth and contamination. This deficient practice affected 3 of 3 residents reviewed for enteral feeding management (Residents #1, #14, and #59). The findings included: 1. Resident #1 was admitted to the facility with diagnoses that included presence of a G-tube, mild protein-calorie malnutrition, dysphagia (difficulty swallowing) following a stroke. Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated her cognition was severely impaired, and she received 51% or more of her total calories and more than 501 milliliters of fluids per day via the G-tube. a. A review of the active physician orders revealed Resident #1 had an order dated 07/06/26 for a tube feeding formula to be provided at 70ml/hr (milliliters/per hour) continuous over 16 hours from 6:00 PM until 10:00 AM with a water flush of 65ml/hr. On 8/16/26 at 10:55 AM, an observation revealed Resident #'1s G-tube syringe was noted in a plastic bag, dated 8/16/26, with the plunger in the barrel of the syringe located on top of the nightstand. Droplets of water and a cream white substance were noted in the tip of the syringe, and the interior of the plastic bag was noted to have droplets of water. An interview with Nurse #1 was conducted on 8/16/26 at 11:45 AM who stated Resident #1 received all medications and fluids by the G-tube and nothing by mouth. Nurse #1 explained that she typically flushed Resident #1's G-tube, rinsed the syringe and plunger and let them dry, then stored them separately in the plastic bag. Nurse #1 went on to say she had been busy that morning with a different resident and forgot to rinse the syringe and plunger for Resident #1. Nurse #1 then discarded the syringe and plunger from Resident #1's nightstand. An interview was conducted on 08/19/26 at 9:40 AM with the Director of Nursing who stated Nurse #1 should have cleaned the G-tube syringe after using it, then stored the syringe separately from the plunger in a bag labeled with the resident's information once the syringe had air dried. b. A review of the active physician orders for Resident #1 revealed no order for water flushes of the G-tube with medication administration. The active physician orders revealed that Resident #1 received all medications via G-tube. An interview was conducted on 08/18/26 at 12:30 PM with Nurse #2 who stated when administering each medication through a G-tube she first flushed the G-tube with 30ml of water, mixed the crushed individual medication with 5ml of water and then administered the medication, followed with 30 ml water flush. Nurse #2 explained she did not recall who told her but was always told to administer G-tube medications with the water flushes of 30ml, 5ml, then 30ml. An interview was conducted on 08/18/26 at 12:35 PM with Nurse #3 who stated she had worked at the facility for more than 10 years and there used to be a binder at the nurses' station that included the steps and water flush information. Nurse #3 explained that she had used water flushes of 30ml, 5ml, then 30ml when she administered each medication. An interview was conducted on 08/18/26 at 12:40 PM with Nurse #4. When asked how she knew what amount of water to use when administering G-tube medications she stated, I just know. Nurse #4 looked at Resident #1's Medication Administration Record and agreed there was no order in place for water flush during medication administration. An interview was conducted on 08/18/26 at 12:50 PM with the DON who indicated she was not aware there were no orders in place for the water flush during medication administration and the order should be present for all residents who receive medications via a G-tube. The DON stated the amount of water flush would be per the pharmacy recommendations. A phone interview was conducted on 08/19/26 at 11:54 AM with the Medical Director who stated the amount of fluid used to flush medications for a G-tube was not exactly a fixed number because it depended on the volume of medication being crushed to administer through the G-tube. He stated the nurse should use her knowledge and experience on the amount of fluid needed to flush medications through the G-tube. The Medical Director suggested the pharmacist would be able to give a more accurate answer. A phone interview was conducted on 08/19/26 at 1:23 PM with Pharmacist #1 who stated the water flush needed to flush medications given by G-tube varied by the provider and was based on any fluid restriction. Pharmacist #1 stated the typical policy was to flush a G-tube with 15 ml of water before, with, and after medication administration. 2. Resident #14 was admitted to the facility with diagnoses that included presence of a G-tube, mild protein-calorie malnutrition, dysphagia (difficulty swallowing) following a stroke. Resident #14's annual Minimum Data Set assessment dated [DATE] indicated her cognition was intact and she received 51% or more of her total calories and more than 501 milliliters of fluids per day via the G-tube. a. A review of the active physician orders revealed Resident #14 had an order dated 05/06/26 for a tube feeding formula to be provided at 40ml/hr. continuous over 22 hours from 8:00 PM until 6:00 PM with a water flush of 45ml/hr. On 8/16/26 at 10:59 AM, an observation revealed Resident #14's G-tube syringe was noted in a plastic bag located on the nightstand, dated 8/16/26, with the plunger in the barrel of the syringe. Droplets of water and a cream white substance were noted in the tip of the syringe, and the interior of the plastic bag was noted to have droplets of water. An interview with Nurse #1 was conducted on 8/16/26 at 11:59 AM who stated Resident #14 received all medications and fluids by the G-tube and nothing by mouth. Nurse #1 explained that she typically flushed Resident #14's G-tube, rinsed the syringe and plunger and let them dry then stored them separated in the plastic bag. Nurse #1 went on to say she had been busy that morning with a different resident and forgot to rinse the syringe and plunger for Resident #14. Nurse #1 then discarded the syringe and plunger from Resident #14's nightstand. An interview was conducted on 08/19/26 at 9:40 AM with the Director of Nursing who stated Nurse #1 should have cleaned the G-tube syringes after using it then stored the syringe separately from the plunger in a bag labeled with the resident's information once the syringe had air dried. b. A review of the active physician orders for Resident #14 revealed no order for water flushes of the G-tube with medication administration. The active physician orders revealed that Resident #14 received all medications via the G-tube. An interview was conducted on 08/18/26 at 12:30 PM with Nurse #2 who stated when administering each medication through a G-tube she first flushed the G-tube with 30ml of water, mixed the crushed individual medication with 5ml of water and then administered the medication, followed with 30 ml water flush. Nurse #2 explained she did not recall who told her but was always told to administer G-tube medications with the water flushes of 30ml, 5ml, then 30ml. An interview was conducted on 08/18/26 at 12:35 PM with Nurse #3 who stated she had worked at the facility for more than 10 years and there used to be a binder at the nurses' station that included the steps and water flush information. Nurse #3 explained that she had used water flushes of 30ml, 5ml, then 30ml when she administered each medication. An interview was conducted on 08/18/26 at 12:40 PM with Nurse #4. When asked how she knew what amount of water to use when administering G-tube medications she stated, I just know. Nurse #4 looked at Resident #14's Medication Administration Record and agreed there was no order in place for water flush during medication administration. An interview was conducted on 08/18/26 at 12:50 PM with the DON who indicated she was not aware there were no orders in place for the water flush during medication administration and the order should be present for all residents who receive medications via a G-tube. The DON stated the amount of water flush would be per the pharmacy recommendations. A phone interview was conducted on 08/19/26 at 11:54 AM with the Medical Director who stated the amount of fluid used to flush medications for a G-tube was not exactly a fixed number because it depended on the volume of medication being crushed to administer through the G-tube. He stated the nurse should use her knowledge and experience on the amount of fluid needed to flush medications through the G-tube. The Medical Director suggested the pharmacist would be able to give a more accurate answer. A phone interview was conducted on 08/19/26 at 1:23 PM with Pharmacist #1 who stated the water flush needed to flush medications given by G-tube varied by the provider and was based on any fluid restriction. Pharmacist #1 stated the typical policy was to flush a G-tube with 15 ml of water before, with, and after medication administration. 3. Resident #59 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) following a cerebral infarction (stroke), mild protein-calorie malnutrition, and presence of a gastrostomy tube (G-tube- a soft plastic tube placed through the skin directly into the stomach to deliver food and/or medication). A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #59 was cognitively intact and received 51% of more of her total calories and more than 501 milliliters of fluids per day via the G-tube. a. A review of the active physician orders revealed Resident #59 had an order dated 2/18/26 for a tube feeding formula to be provided at 62 ml/hr. (milliliters/per hour) continuous over 16 hours from 6:00 PM until 10:00 AM with a water flush of 40 ml/hr. She had an active order dated 10/15/25 for an additional 240 ml of water flush at 2:00 PM. On 8/16/26 at 11:17 AM, an observation revealed Resident #59's G-tube syringe was dated 8/16/26 and was stored with the plunger inside and placed in a plastic bag laying on the resident's nightstand. The base of the syringe had a white liquid pooled around the plunger. An interview with Nurse #1 was conducted on 8/16/26 at 12:02 PM who stated she typically flushed Resident #59's G-tube then washed the syringe and let it air dry. Nurse #1 explained she had been busy that morning with a different resident and forgot to rinse the syringe for Resident #59. Nurse #1 then discarded the syringe from Resident #59's nightstand. An interview was conducted with the Director of Nursing (DON) on 8/19/26 at 9:40 AM who stated Nurse #1 should have cleaned the G-tube syringe after using then stored the syringe separately from the plunger in a bag labeled with the resident's information once the syringe had air dried. b. A review of the active physician orders for Resident #59 did not reveal an order for water flushes of the G-tube with medication administration. The active physician orders revealed that Resident #59 received all medications via the G-tube. Nurse #2 was interviewed on 8/18/26 at 12:30 PM who stated she was unaware who told her, but she was told G-tubes were flushed with 30 milliliters (ml) of water before giving medications, then 5 ml of water was mixed with each crushed medication and administered, then a final flush of 30 ml of water was given with each medication pass. On 8/18/26 at 12:35 PM Nurse #3 was interviewed and stated there used to be a binder kept at the nurse's station that contained information regarding G-tube flushes. She was unable to locate the binder. According to Nurse #3, she flushed G-tubes with 30 ml of water before administering medications, 5 ml of water with each crushed medication, then 30 ml of water as a final flush of the G-tube after all medications were given. On 8/19/26 at 11:54 AM the Medical Director was interviewed by phone who stated the amount of fluid used to flush medication for a G-tube was not exactly a fixed number because it depended on the volume of medication being crushed to administer through the G-tube. He stated the nurse should use her knowledge and experience on the amount of fluid needed to flush medication through the G-tube. The Medical Director suggested the pharmacist would be able to give a more accurate answer. On 8/19/26 at 1:23 PM Pharmacist #1 was interviewed who stated the amount of water needed to flush medications given by G-tube varied by the provider and was based on any fluid restriction. Pharmacist #1 stated the typical policy was to flush a G-tube with 15 ml of water before, with, and after medication administration. An interview was conducted with the Director of Nursing on 8/19/26 at 1:48 PM who stated she was unaware Resident #2 did not have an order for flushing her G-tube with medication administration. The DON explained the amount of water flush would be according to the pharmacy's recommendation.

Based on observations, record reviews, interviews with staff and Medical Director, the facility failed to have a medication error rate of less than 5% as evidenced by a medication error rate of 11.11% when there were 3 medication administration errors out of 26 medication administration opportunities.The findings included:Resident #49 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF), gastro-esophageal reflux disease (GERD), epilepsy, and history of traumatic brain injury (TBI). A review of Resident #49's active Physician Orders included current orders for the following medications:-Calcium carbonate chewable (Tums) (antacid); 500 milligrams (mg); amount to administer: 2 tablets; orally once a day-Cholecalciferol (vitamin D3) (dietary supplement) tablet; 50 mcg (2,000 unit); amount to administer: 3 tablets; orally once a day.-Docusate sodium capsule (stool softener); 100 mg; amount to administer: 2 capsules; orally once a day.On 08/18/2026 at 9:02 AM, Nurse #4 was observed as she prepared and administered 15 medications to Resident #49. The administered medications included:-Calcium carbonate chewable; 500 mg; amount to administer: 2 tablets; orally once a day. Nurse #4 was observed administering 1 tablet.-Cholecalciferol tablet; 50 mcg (2,000 unit); amount to administer: 3 tablets; orally once a day. Nurse #4 was observed administering 1 tablet.-Docusate sodium capsule; 100 mg; amount to administer: 2 capsules; orally once a day. Nurse #4 was observed administering 1 capsule. An interview was conducted on 08/18/26 at 10:26 AM with Nurse #4 who stated she did not look at the directions for the medications on the Medication Administration Record (MAR) which included the amount of medication to be administered and other information about the medications. Nurse #4 went on to say, I know my patient's, I didn't need to look at that.An interview was conducted on 08/18/26 at 12:38 PM with the DON who stated nurses were to thoroughly read medication administration orders in the MAR and to administer the correct medication and amount of the medication per physician orders. A phone interview was conducted on 08/19/26 at 11:54 AM with the Medical Director (MD) who indicated the medication should have been administered per the order. The MD explained he did not feel a negative outcome would occur due to Nurse #4 not administering the correct amount of calcium carbonate chewable, vitamin D3, or docusate sodium, however he expected the medications to be administered per orders.

Based on observations and staff interviews the facility failed to discard leftover food stored past the use by date in 1 of 1 walk-in cooler. The facility also failed to label and date leftover frozen food removed from its original packaging in 1 of 1 reach-in freezer and 1 of 1 deep freezer. This practice had the potential to affect food served to residents. The findings included: Observations during the initial tour of the main kitchen with Dietary Aide #1 on 05/04/25 at 11:03 AM, revealed the following: a. In the reach-in freezer the following leftover frozen food removed from its original packaging were observed: -1/4 bag of beef riblets with no label or date. -1/2 of large bag of fish fillets with no label or date. An interview was conducted on 05/04/25 at 11:10 AM with Dietary Aide #1. She stated a date should have been written on the bags of leftover frozen foods when they were opened. She stated whoever opened the items were the ones responsible for writing the open date on it. She indicated the Dietary Manager checks the freezers and coolers daily. b. In the deep freezer the following leftover frozen food removed from its original packaging was observed on 05/04/25 at 11:15 AM with the Dietary Manager. -1/4 bag of mixed vegetables with no label or date. c. In the walk-in cooler the following items were observed on 05/04/25 at 11:25 AM with the Dietary Manager. - one gallon size bag of corn bread pieces with an open date of 04/24/25. - one gallon size bag with 20 precooked crescent rolls with an open date of 04/19/25. There were white and blue fuzzy spots present on 2 of the crescent rolls. - two 14 oz bags of mini bagels with an open date of 04/15/25. An interview was conducted on 05/04/25 at 11:25 AM with the Dietary Manager. She explained when an item was opened the date should be written on the item at that time. The Dietary Manager also stated items in the cooler should be discarded within 7 days. Items in the freezer should include date of delivery and an open date upon opening the item. An interview was conducted on 05/06/25 at 11:32 AM with Dietary [NAME] #2. She stated food items in the cooler should be discarded after 7 days and all food items should be dated when they were opened. The also stated the Dietary Manager checks the coolers and freezers daily for dated and/or expired food items. A follow-up interview was conducted on 05/06/25 at 11:42 AM with the Dietary Manager (DM). She stated she was responsible for monitoring the freezer and coolers for dated and labeled food items. She explained the cooks could also check for dated, expired, or labeled items but there was no one assigned to perform the tasks. She indicated staff turnover could have been a reason for food items not being dated upon opening in the freezers and items not being discarded after 7 days in the coolers. She then stated that the kitchen cooks and aides were to put the leftover food in an airtight container/baggy and write their initials and open date on the containers and store in the cooler. The DM indicated that all frozen foods must be dated to ensure proper rotation by expiration dates. An interview was conducted on 05/07/25 at 9:02 AM with the Administrator. She stated she was unaware that dietary staff were not labeling or dating opened food items and that they were not discarding opened food items within 7 days. She explained that she expected the Dietary Manager and kitchen staff to properly label, date, and discard prepared food items per regulations and for education to be provided during orientation and reeducation to current staff as needed.

Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of falls (Resident #32) for 1 of 3 residents reviewed for accidents. The findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses that included a history of a fracture to the right knee and muscle weakness. A review of Resident #32's medical record revealed she had a self-reported fall on 1/3/25 that resulted in a skin tear to her left hip since the admission MDS assessment on 12/2/24. A quarterly MDS assessment dated [DATE] indicated that Resident #32 was cognitively intact. She was not coded with any falls since the last assessment. On 5/6/25 at 10:19 AM, an interview occurred with the MDS Nurse #2 who reviewed the MDS assessment dated [DATE] as well as Resident #32's medical record. MDS Nurse #2 confirmed Resident #32 had a documented fall with a skin tear on 1/3/25 and should have been coded as a fall with minor injury. She stated it was an oversight. The Director of Nursing was interviewed on 5/6/25 at 1:42 PM and stated that it was her expectation for the MDS to be coded accurately in the area of falls.

Based on record review, observations and staff interviews, the facility failed to develop an individualized person-centered care plan in the area of smoking for 1 of 1 resident reviewed for smoking (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE] with diagnoses that included wedge compression fracture of first lumbar vertebra, hypertension, and pain. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #58's cognition was intact. The MDS indicated Resident #58 used tobacco. Review of Resident #58's active care plan, dated 04/30/25, revealed no care plan related to smoking. An observation and interview were conducted on 05/06/25 from 8:55 AM through 09:20 AM with Resident #58 in the smoking area. She safely lit, smoked, discarded ashes and disposed of cigarette safely. No concerns were observed with Resident #58 while she was smoking. She stated she had smoked since she was admitted to the facility. An interview was conducted on 05/07/25 at 8:32 AM with MDS Coordinator #2. She verified there were no areas on Resident #58's care plan to include smoking until 05/06/25. She stated it was an oversight that this was not added on Resident #58's care plan prior to 05/06/25. An interview was conducted on 05/07/25 at 8:52 AM with the Director of Nursing. She indicated Resident #58's care plan should have included a focus related to smoking. An interview was conducted on 05/07/25 at 9:02 AM with the Administrator. She stated Resident #58's care plan should have included a focus related to smoking.

Based on record review and staff interviews, the facility failed to transcribe the correct route of medication administration for 1 of 1 resident reviewed with gastric feeding tube (Resident #2). The findings included: Resident #2 was originally admitted to the facility on [DATE] with diagnoses that included cerebrovascular disease, and dysphagia (difficulty swallowing). Resident #2 had recently been hospitalized from [DATE] through 4/6/25. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had severely impaired cognition, had a feeding tube and received all nutrition and fluids via a feeding tube. Review of Resident #2's active care plan, last reviewed 4/25/25, included a focus area for being at risk for nutrition and dehydration due to nothing by mouth (NPO) status and tube feed. The active May 2025 physician orders included the following orders: - An order dated 4/6/25 read; NPO - An order dated 4/6/25 for Briviact (an antiseizure medication) 10 milligrams (mg) per milliliter (ml). Give 10 ml orally twice a day. - An order dated 4/7/25 for Hydrocodone-Acetaminophen 5-325 mg one tablet orally three times a day as needed. - An order dated 4/7/25 for Lacosamide (an antiseizure medication) 10 mg per ml. Give 15 ml orally twice a day. All other medications were written to be provided through the gastric feeding tube. On 5/6/25 at 9:26 AM, an interview occurred with Nurse #1 who had transcribed the order for Briviact on 4/6/25. She explained that she entered the medication, dose and frequency into the Electronic Medical Record (EMR) but failed to change the medication route to gastrostomy tube (G-tube). She stated the system default route was oral. On 5/6/25 at 9:39 AM, an interview was conducted with the Unit Manager who had transcribed the orders for Hydrocodone-Acetaminophen and Lacosamide on 4/7/25. He explained that he entered the medication, dose and frequency into the EMR but failed to change the medication route to via G-tube. He explained the EMR system default route was oral. An interview occurred with Nurse #2 on 5/6/25 at 11:00 AM. She was working the medication cart for Resident #2's hall and had administered Resident #2's medications earlier. Nurse #2 confirmed that Resident #2 did not receive any medications orally and she had not provided the morning doses of Briviact or Lacosamide by mouth. The Director of Nursing (DON) was interviewed on 5/6/25 at 1:42 PM. She reviewed Resident #2's physician orders and confirmed the route for the Briviact, Hydrocodone-Acetaminophen and Lacosamide were entered as oral instead of via G-tube. She further explained that when entering the medications into the EMR the default route was oral, and she felt it was an oversight that the nursing staff failed to change the route to G-tube. The DON stated it was her expectation for all medication administration routes to be entered correctly when the order was received.

Based on staff interviews and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessments in the areas of trach care (Resident #17), prognosis (Resident #47), discharge (Resident #63), and medication (Resident #41 and #55). This was for 5 of 17 residents reviewed for MDS accuracy. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included a tracheostomy. The quarterly MDS assessment dated [DATE] indicated Resident #17 ' s cognition was intact. The special treatments, procedures, and programs section for tracheostomy care while a resident was not coded. Review of Resident #17 ' s active orders revealed an order that read in part to change inner cannula of trach daily for infection control, the medication administration record (MAR) was signed daily as being completed. Another order read to change trach ties weekly on Tuesdays for infection control, the MAR was signed every Tuesday as being completed. An interview was conducted on 06/25/24 at 1:45 PM with MDS Coordinator #1. She verified Resident #17 had a tracheostomy and that she did not code the special treatments, procedures, and programs section. She stated it was an oversight that she did not code tracheostomy care on his MDS assessment. An Interview was conducted on 06/25/24 at 2:20 PM with the Administrator. She stated she expected the MDS assessments to be accurately coded. 2. Resident #47 was admitted to the facility on [DATE] with diagnoses that included Dementia Disorder. Record review revealed Resident #47 started receiving Hospice services on 08/17/22. Review of Resident #47 ' s orders revealed an order that read in part that resident was admitted to Hospice Services for significant decline in overall health and a decline in status was expected related to terminal illness. Resident #47's active care plan, last revised on 02/28/24, included a focus area that read Resident #47 was on Hospice services for significant decline in overall health. Has expected to decline in status related to terminal illness. The interventions included for staff to contact hospice for changes in resident condition and to keep resident comfortable. The quarterly MDS assessment dated [DATE] indicated Resident #47 ' s cognition was severely impaired. The health conditions section for Resident #47 under prognosis was coded as not having a condition or chronic disease that may result in a life expectancy of less than 6 months although she was coded as receiving Hospice services while being a resident. An interview was conducted on 06/25/24 at 1:45 PM with MDS Coordinator #1. She verified Resident #47's Health Conditions section for terminal prognosis was coded as No. She stated she was aware Resident #47 was being followed by Hospice and it was an oversight that she miscoded this question. She verified the resident was covered by Hospice and had a life expectancy of 6 months or less. An Interview was conducted on 06/25/24 at 2:20 PM with the Administrator. She stated she expected the MDS assessments to be accurately coded. 3. Resident #63 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus and closed fracture with routine healing. The discharge MDS assessment dated [DATE], identification information section under discharge status indicated Resident #63 was discharged to a short-term general hospital. Review of a Nursing Progress Note dated 04/15/24 revealed that Resident #63 was discharged home with son. Review of Discharge Summary, dated 04/15/24, revealed Resident #63 was discharged home with family. An interview was conducted on 06/25/24 at 1:45 PM with MDS Coordinator #1. She verified Resident #63's Identification Information section under discharge status was coded as being discharged to a short-term general hospital. She stated she was aware Resident #63 was discharged home and it was an oversight that she miscoded this question. An Interview was conducted on 06/25/24 at 2:20 PM with the Administrator. She stated she expected the MDS assessments to be accurately coded. 4. Resident #41 was admitted to the facility on [DATE] with diagnoses that included essential (primary) hypertension and primary pulmonary hypertension. Review of Resident #41 ' s active orders revealed an order for furosemide (used to treat high blood pressure (hypertension), heart failure and a buildup of fluid in the body) 40 milligram (mg) tablet once a day, 1 tablet, with a start date of 04/10/24. The admission MDS assessment dated [DATE] indicated Resident # 41 was not coded for diuretics. An Interview was conducted on 06/25/24 at 1:45 PM with MDS Coordinator #2. She verified she did not code that Resident #41 received diuretics during the look back period of his admission assessment. She stated she overlooked Resident #41's diuretic medication order when she was completing his assessment. It was an oversight that she did not code the diuretic on his MDS assessment. An Interview was conducted on 06/25/24 at 2:20 PM with the Administrator. She stated she expected the MDS assessments to be accurately coded and that care plans should be patient centered. 40197 5. Resident #55 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder and dementia with mood disorder. a. A review of Resident #55's physician orders included orders dated 3/26/24 for Trazodone (an antidepressant medication) 50 milligrams one tablet by mouth once a day and Duloxetine (an antidepressant medication) 30 milligrams three capsules by mouth one a day. A review of the May 2024 Medication Administration Record (MAR) showed that Resident #55 received the antidepressant medications during the 7-day look back period for the 5/9/24 MDS assessment (5/3/24 through 5/9/24). A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] did not have antidepressant medications coded. b. A review of Resident #55's physician orders included an order dated 5/1/24 for Macrobid (an antibiotic) 100 milligrams 1 capsule by mouth twice a day with a stop date of 5/8/24. A review of the May 2024 MAR showed that Resident #55 received the antibiotic medication during the 7-day look back period for the 5/9/24 MDS assessment (5/3/24 through 5/8/24). A review of the quarterly MDS assessment dated [DATE] did not have antibiotic medications coded. On 6/25/24 at 10:50 AM, an interview occurred with MDS Nurse #1 and #2, who reviewed the MDS assessment dated [DATE] as well as Resident #55's medical record. MDS Nurse #1 stated she failed to include the antidepressant and antibiotic medications on the assessment and felt it was an oversight. Both MDS Nurse #1 and #2 stated the MARs should be reviewed carefully to code the medication section of the MDS assessment accurately. The Administrator was interviewed on 6/25/24 at 1:30 PM and stated she would expect the MDS assessments to be accurately.

Based on observations, and staff interviews the facility failed to discard opened food items ready for use within 7 days of opening in 1 of 1 walk-in refrigerators and in 1 of 2 reach-in refrigerators. The facility also failed to label, and date opened food items in 1 of 1 walk-in refrigerators and in 1 of 2 reach-in refrigerators. This practice had the potential to affect food served to residents. The findings included: Observations during the initial tour of the main kitchen with Dietary Cook/Aide #1 on [DATE] at 10:55 AM, revealed the following: a. In the walk-in refrigerator the following items were observed. -32 oz pack (,d+[DATE] full) sliced Virginia baked ham-no open date. -21 hot dogs in a zip lock bag with an opening date of [DATE]. -Twelve 8 ounce (oz) bowls with a yellow pudding like substance in them that were not dated and were not covered. - Forty-eight 8 oz bowls with a yellow pudding like substance in them were not dated. b. In the reach-in refrigerator #1 the following items were observed. -2 pounds of sliced turkey with no open date. -,d+[DATE] of quart sized zip lock bag with sliced onions with an opening date of [DATE]. -,d+[DATE] of a gallon size zip-lock bag with sliced cheese with no open date. -3-pound container of Pimento cheese spread with an opening date of [DATE]. On [DATE] at 10:55 AM an interview was conducted with Dietary Cook/Aide #1. She stated the Dietary Manager (DM) checks the coolers and freezers for undated foods and expired food, use by dates. She also stated she was unaware how many days items could be stored in the coolers before discarding them. She verified staff were to label and date items after opening or preparing. Dietary Cook/Aide #1 discarded the above items at the end of the initial tour. On [DATE] at 10:59M an interview was conducted with Dietary [NAME] #2, and Dietary Aide #1. They both stated they were unaware how many days items could be stored in the coolers before discarding them. They verified staff were to label and date items after opening or preparing. On [DATE] at 12:10 PM an interview was conducted with the Dietary Manager (DM). She verified all items that were not dated or had not been removed within 7 days had been discarded. She stated she forgot to date the sliced lunch meat in the coolers and did not remove the dated food items that were unused after 7 days. A follow-up interview was conducted on [DATE] at 10:56 AM with the Dietary Manager (DM). She stated she was the only one responsible for monitoring the freezer and coolers for food dates and labels. She also stated she tries to check the opened items and discard dates daily or at least every other day. She indicated she had been having staffing issues lately and she had been covering shifts. She also indicated she had forgotten to check the coolers and freezers. She then stated, I dropped the ball on it, I just have to make it right now. She then stated that the kitchen cooks and aides are to put the food in an airtight container/baggy and write their initials and open date on the containers. She then stated she needed to reeducate staff.

Based on record reviews and staff interviews, the facility failed to complete an annual comprehensive assessment within the required time frame (Resident #29) for 1 of 15 sampled residents. The findings included: Resident #29 was admitted to the facility on [DATE]. A review of Resident #29's Minimum Data Set (MDS) assessments revealed an admission MDS completed on 5/4/24, and Quarterly MDS assessments completed on 8/4/23, 11/4/23, 2/4/24 and 5/6/24. The annual assessment was not completed. On 6/25/24 at 11:10 AM, an interview occurred with the MDS Nurse #1. She reviewed the MDS assessments that had been completed for Resident #29 and stated that the quarterly MDS assessment that was completed on 5/6/24 should have been an annual assessment. She further explained the facility had recently transitioned to a new Electronic Medical Record (EMR) system in April 2024 and felt it was an oversight due to the transition that another quarterly assessment was completed instead of an annual assessment. The Administrator was interviewed on 6/25/24 at 1;30 PM and stated that she would expect the annual MDS assessment to be completed in the required time frame for Resident #29.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan for the presence of a nephrostomy tube (a tube that let's urine drain from the kidney through an opening in the skin on the back-Resident #2), and a skin condition (Resident #34). This was for 2 of 15 resident care plans reviewed. The findings included: 1) Resident #2 was originally admitted to the facility on [DATE]. She was hospitalized from 2/19/24 to 2/29/24 and found to have a complex urinary tract infection due to a kidney stone. At that time a left sided nephrostomy tube was placed. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #2 had severe cognitive impairment. She was coded with an indwelling catheter. Review of the active care plan, last revised 6/14/24, did not include the presence of a nephrostomy tube. On 6/25/24 at 10:50 AM, an interview occurred with MDS Nurses #1 and #2 who reviewed Resident #2's active care plan. They confirmed a care plan was not developed for the presence of a nephrostomy tube but should have been and stated it was an oversight. The Administrator was interviewed on 6/25/24 at 1:30 PM and stated it was her expectation for the care plan to be person centered and should have included the presence of the nephrostomy tube for Resident #2. 2) Resident #34 was admitted to the facility on [DATE]. A physician progress note dated 4/25/24 indicated Resident #34 was seen for skin lesions to the scalp and left ear and had a history of skin cancers to his head in the past. A referral was made to dermatology. A review of Resident #34's medical record revealed he was seen by the dermatologist and had a procedure completed to remove skin cancer lesions to his scalp and left ear on 5/21/24. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #34 was cognitively intact and was coded for open lesions other than ulcers, rashes or cuts. A review of the May 2024 physician orders included an order dated 5/24/24 to cleanse the scalp and left ear gently with soap and water twice a day and apply a thin layer of Vaseline. Review of the active care plan, last revised 5/31/24, did not include the skin condition to Resident #34's scalp and left ear. On 6/25/24 at 10:50 AM, an interview occurred with MDS Nurse #1 and #2 who reviewed Resident #34's active care plan and MDS assessment dated [DATE]. They confirmed a care plan was not developed for the skin condition to Resident #34's scalp and left ear but should have been and stated it was an oversight. The Administrator was interviewed on 6/25/24 at 1:30 PM and stated it was her expectation for the care plan to be person centered and should have included the skin condition to Resident #34's scalp and left ear.

Based on record review, observations, and staff interviews, the facility failed to change a gastrostomy tube dressing site that was ordered to be completed daily for 1 of 2 residents reviewed for gastrostomy tubes (Resident #31). The findings included: Resident #31 was admitted to the facility 1/9/2024 with diagnoses including stroke and gastrostomy tube for feeding. Resident #31's medical record was reviewed, and a physician order dated 4/25/2024 ordered for daily gastrostomy site dressing to be completed by cleaning the site and applying clean gauze. The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #31 was severely cognitively impaired, and he received tube feeding nutrition daily. The treatment record for Resident #31 indicated the gastrostomy tube dressing change had been changed on 6/22/2024 and 6/23/2024. Resident #31 was observed on Monday 6/24/2024 at 2:05 PM. A gastrostomy tube with a dressing was noted and the dressing was dated Friday 6/21/2024. The gastrostomy dressing appeared to be wet with a clear, light yellow, odorless drainage. Nurse #1 was interviewed at the time of the observation, and she reported the gastrostomy dressing was ordered to be changed daily and she was going to change the dressing in a few minutes. The Director of Nursing (DON) was interviewed on 6/24/2024 at 2:17 PM. The DON explained that the weekend supervisor was responsible for completing all treatments in the facility during the weekend. The DON reported the dressing should have been changed by the weekend supervisor. MDS Nurse #1 was interviewed on 6/25/2024 at 9:03 AM. MDS Nurse #1 reported she was responsible for the treatments and wound care on the weekend as the weekend supervisor. MDS Nurse #1 ran a report of the treatments that were due for Resident #31 and the gastrostomy dressing change was not on the report. MDS Nurse #1 explained that she was not aware the gastrostomy dressing needed to be changed and she would have changed the dressing if it was on her report. The Administrator was interviewed on 6/25/2024 at 1:23 PM and she reported the gastrostomy dressing change was not entered into the electronic medical record as a treatment and the dressing change was not completed by the weekend supervisor. The Administrator reported she expected gastrostomy dressing changes to be added to the treatment plan so dressing changes were not missed.

Based on record review, observations, and staff interviews, the facility failed to implement the facility's policy for enhanced barrier precautions for 1 of 11 residents reviewed for infection control (Resident #31). The findings included: The facility infection control policy with a revision date of 4/15/2024 read, in part: Enhanced Barrier Precautions are intended to prevent the transmission of multi-drug resistant organisms via contaminated hand and clothing of healthcare workers to high-risk residents. Resident #31 was observed in bed on 6/23/2024 at 10:52 AM. There was no sign on the door indicating EBP were in place and no caddy with Personal Protective Equipment (PPE) outside of his door. Resident #31 was noted to have tube feeding (on hold) and a wound dressing was noted to his left lower leg. Incontinence care for Resident #31 was observed with Nursing Assistant (NA) #1 and NA #2 on 6/24/2024 at 2:03 PM. NA #1 and NA #2 performed hand hygiene and applied gloves but did not don gowns to provide incontinence care to Resident #31. When asked if providing incontinence care for Resident #31 required any additional PPE, NA #1 stated there was not a sign on the door, so there was no need for additional PPE. Nurse #1 was interviewed on 6/24/2024 at 2:05 PM. Nurse #1 explained because Resident #31 had a chronic wound and a gastrostomy tube, he should have EBP in place and the NAs should have worn appropriate PPE to provide care. Nurse #1 explained the signs on the door and the PPE carts outside the door communicated to staff and visitors that EBP were in place for residents. The Infection Control nurse was interviewed on 6/24/2024 at 2:10 PM and she reported that due to Resident #31's wound and gastrostomy tube, the NAs should have applied gowns and gloves to provide incontinence care. The Infection Control nurse explained that when Resident #31 was moved to his current room the sign for EBP was not moved with him. The Infection Control nurse reported the signs on the door and PPE carts communicated to staff and visitors that EBP were in place. An interview was conducted with the Director of Nursing (DON) on 6/24/2024 at 2:17 PM. The DON explained any resident with an indwelling device, such as a gastrostomy tube for feeding, and/or a chronic wound should have Enhanced Barrier Precautions implemented to prevent the transmission of pathogens or possible contamination of the indwelling device or wound. The DON reported Resident #31 was moved from a room and the signage for EBP was not moved with him. The DON reported she expected all residents with an indwelling device or chronic wound to have a physician order for EBP, a sign on their door, and a PPE caddy available for staff to use the appropriate PPE. The DON reported EBP were communicated in report to the staff, the signs on the door, and the PPE carts by the resident rooms. The Administrator was interviewed on 6/25/2024 at 1:23 PM and she reported that staff had received infection control education and should be able to recognize when a resident required EBP.

Based on record review, staff, Nurse Practitioner, and physician interviews, the facility failed to follow an order for warfarin (a blood thinner used to prevent stroke in a patient with atrial fibrillation [an abnormal heart rhythm]) (Resident #1) and failed to follow a physician order from a physician consultation visit for a blood pressure medication (Resident #2) for 2 of 3 residents reviewed for significant medication errors. Resident #1 did not receive 8 doses of warfarin, and Resident #2 did not receive 23 doses of blood pressure medication. The findings included: 1. The hospital discharge instructions for Resident #1 dated 4/10/2024 ordered warfarin 2.5 milligrams to be given daily except for Tuesday and Thursday. Resident #1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation and hypertension. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #1 to be severely cognitively impaired. The MDS did not document Resident #1 was taking anticoagulant medications. A nursing note written by the Assistant Director of Nursing (ADON) dated 4/10/2024 documented the ADON called the hospital to clarify the warfarin order. Review of Resident #1's medical record revealed no order for warfarin was written or in the medical record. Review of the medication administration record revealed Resident #1 did not receive 8 doses of warfarin (4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16 and 4/17/2024). Resident #1 was admitted to the hospital on 4/17/2024. The emergency room notes dated 4/17/2024 documented Resident #1 was admitted for an irregular heart rate and change in mental status. emergency room notes dated 4/17/2024 ordered lab work to check the efficiency of warfarin. The prothrombin time (PT) was 14.3 (normal range 11.8 to 14.4) and the International Normalized Ratio (INR) 1.1 (therapeutic range 2.0-3.0). This test determines if the warfarin is in therapeutic range. The notes documented the PT/INR was sub-therapeutic and Resident #1 was started on an injectable blood thinner. Resident #1 returned to the facility on [DATE]. Physician orders for Resident #1 revealed an order dated 4/18/2024 for apixaban (a blood thinner) 2.5 milligrams to be given 2 times per day. A physician note dated 4/23/2024 documented Resident #1 was discharged from the hospital on 4/18/2024 and warfarin was discontinued and apixaban was initiated. An interview was conducted with the ADON on 5/14/2024 at 2:04 PM. The ADON explained she was helping the Unit Manager (UM) with the admission of Resident #1 on 4/10/2024. The ADON reported the warfarin order was not clear, and she had called the hospital to talk to the discharging physician and she received clarification of the order. The ADON explained she had told the UM the clarified order for the warfarin and she thought the UM had entered the warfarin orders into the system. The ADON said that she was not aware Resident #1 had not received warfarin since 4/10/2024 until she was admitted to the hospital on 4/17/2024. The physician was interviewed on 5/14/2024 at 2:14 PM. The physician explained she was conducting a chart review of Resident #1 on 4/17/2024 and discovered the warfarin order from the hospital on 4/10/2024 had been clarified by the ADON, but an order had not been entered into the electronic charting system. The physician reported she call the Director of Nursing (DON) and reported the error and ordered warfarin for Resident #1 on 4/17/2024, but Resident #1 was sent to the hospital for an irregular heart rate and a change in her mental status. The physician explained she consulted with the emergency department physician, and they recommended apixaban for Resident #1. The physician reported that when Resident #1 returned to the facility, they started the apixaban. The physician stated that a blood thinner was used for stroke prevention in patients with atrial fibrillation. The physician reported Resident #1 did not experience any adverse effects from not taking the warfarin for 7 days. The UM was interviewed on 5/14/2024 at 2:35 PM. The UM explained he was the floor nurse when Resident #1 was admitted , and he and the ADON worked together to enter Resident #1's orders into the electronic documentation system. The UM said he had not understood the warfarin order for Resident #1 and had asked the ADON to call the hospital to get clarification. The UM reported the ADON had received clarification and he thought the ADON had entered the order into the system. The UM said that typically, during the morning meeting each day, the staff would review the admission charts for accuracy, but that did not happen with Resident #1 and that was why the warfarin order was missed. An interview with the DON was conducted on 5/14/2024 at 4:22 PM. The DON reported the morning meeting review of Resident #1's admission did not occur because the facility had just gone live with a new electronic documentation system and the process was not followed. The DON reported when the physician discovered the medication error, the facility immediately reviewed new admissions from the past 30 days and put a plan of correction in place to prevent future errors. The DON reported she expected the nurses to check behind each other and not assume someone else entered orders into the electronic documentation system and for the daily morning meeting to review all new admission orders against the electronic documentation system. 2. Resident #2 was admitted to the facility on [DATE] with diagnoses including congestive heart failure and diabetes. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #2 was cognitively intact. A nephrology (kidney doctor) note and physician order dated 3/25/2024 ordered amlodipine (a blood pressure medication) 10 milligrams to be administered 1 time per day. The physician orders for Resident #2 were reviewed. An order dated 3/29/2024 ordered amlodipine 5 milligrams to be administered 1 time per day. Review of the medication administration record revealed Resident #2 did not receive 23 doses of amlodipine 10 milligrams (3/26, 3/27, 3/28, 3/29, 3/30, 3/31, 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17/2024). Review of Resident #2's blood pressure results revealed the following: 3/7/2024 120/81 (normal) 4/3/2024 118/83 (normal) A physician note dated 4/2/2024 was reviewed. The physician note documented review of Resident #2's blood pressure results and noted consultations with psychiatry and optometry, but no mention was made of the nephrology consultation. The physician note documented Resident #2 was taking amlodipine 5 milligrams 1 time per day. A nurse practitioner note dated 4/16/2024 documented his diagnoses of hypertensive heart disease with kidney failure and noted his medication amlodipine 5 milligrams 1 time daily. The note documented need for cardiology and nephrology referrals. A physician order dated 4/17/2024 ordered amlodipine 10 milligrams to be administered 1 time per day. An interview was conducted with the Assistant Director of Nursing (ADON) on 5/14/2024 at 2:04 PM. The ADON explained she was auditing charts after the transcription error was found on 4/17/2024 and discovered the nephrology consultation note with the order to increase Resident #2's amlodipine to 10 milligrams per day. The ADON explained that when Resident #2 returned from the nephrology appointment, he had returned with a packet and the order was in the packet, but the nurse assigned to him had not reviewed the packet. The physician was interviewed on 5/14/2024 at 2:24 PM and reported she was not aware of the medication change ordered by the nephrologist. The physician explained that the blood pressure medication was used to help the kidneys when a patient had kidney disease and he did not have adverse effects from not receiving the increase in blood pressure medication for 23 days. The nurse practitioner was interviewed by phone on 5/14/2024 at 4:10 PM. The nurse practitioner reported she was aware Resident #2 had a nephrology consultation but was not certain when she became aware of the consultation and did not know the amlodipine order was changed during the consultation. The Director of Nursing (DON) was interviewed on 5/14/2024 at 4:22 PM. The DON explained Resident #2 took a packet with him to the nephrology consult that was returned with him with the order to increase the amlodipine to 10 milligrams, but that packet was not reviewed by his assigned nurse. The DON reported a new process was implemented to include a new form sent with residents when they go out to a physician visit and staff nurses are expected to review this packet upon the resident's return to the facility. This packet included resident medication information, demographics, and a form for new orders. The DON explained the residents who go out to a physician appointment are reviewed during the morning meeting and the packet is checked against the electronic documentation system for accuracy. The facility plan of correction dated 4/18/2024 was reviewed and it documented the discovery of the medication omission for Resident #1 by the physician on 4/17/2024. This error lead the facility to conduct audits on 4/17/2024 for all admissions in the past 30 days and during the audit process, it was discovered Resident #2 had a medication order from the nephrology consultant that was not transcribed into the system. A root cause analysis was conducted on 4/17/2024, and it was determined the facility failed to follow the process of using the admission check list and this resulted in the medication error for Resident #1 and the missed medication change for Resident #2. The facility audited all resident charts to check the accuracy of orders entered in to the electronic documentation system on 4/17/2024. No other errors were found. Education was provided by the DON on 4/17/2024 to the ADON, the UM, and all nursing staff related to transcriptions of orders, validation of order transcription, as well as medications that require lab monitoring. This education was provided to nurses in person or over the phone. The facility implemented an order listing report audit to be conducted 5 times per week for 12 weeks to cross reference physician orders with the electronic documentation system. New admission charts will be audited daily for validation of all medications, orders will be clarified, lab work will be obtained as needed and the orders will be checked for accuracy. An ad hoc Quality Assessment and Performance Improvement team met on 4/18/2024 to discuss the medication error and put the plan of correction in place. The facility plan of correction was validated on 5/14/2024 by reviewing the education provided to the nursing staff, reviewing the audits conducted on new admissions and residents returning from physician visits, interviewing nursing staff, the ADON, the Unit Manager, and the Director of Nursing regarding their procedures with new admissions and residents returning from physician visits. Quality Assessment and Performance Improvement ad hoc meeting notes from 4/18/2024 were reviewed. The facility plan of correction date of 4/18/2024 was validated.

Based on record review, Consultant Pharmacist, and physician interviews, the Consultant Pharmacist failed to provide recommendations when the facility failed to follow admission orders for warfarin (a blood thinning medication used to prevent stroke) for Resident #1, which resulted in Resident #1 missing 8 doses of warfarin (4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16 and 4/17/2024). This was for 1 of 3 residents reviewed for medication errors. The findings included: The hospital discharge instructions dated 4/10/2024 ordered warfarin 2.5 milligrams to be given daily except for Tuesday and Thursday. Resident #1 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation and hypertension. The admission Minimum Data Set, dated dated dated [DATE] assessed Resident #1 to be severely cognitively impaired. The MDS did not document Resident #1 was taking anticoagulant medications. A nursing note written by the Assistant Director of Nursing (ADON) dated 4/10/2024 documented the ADON called the hospital to clarify the warfarin order. Review of Resident #1's medical record revealed no order for warfarin was written or in the medical record. A pharmacist consultation note dated 4/16/204 was reviewed and the note did not indicate warfarin had not been transcribed from the hospital discharge orders. The note indicated recommendations had been made for a topical cream and an antipsychotic medication. Review of the medication administration record revealed Resident #1 did not receive 8 doses of warfarin (4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16 and 4/17/2024). The physician was interviewed on 5/14/2024 at 2:14 PM. The physician explained she was conducting a chart review of Resident #1 on 4/17/2024 and discovered the warfarin order from the hospital on 4/10/2024 had been clarified by the ADON, but an order had not been entered into the electronic charting system. The physician reported she called the Director of Nursing (DON) and reported the error and ordered warfarin for Resident #1 on 4/17/2024The physician reported Resident #1 did not experience any adverse effects from not taking the warfarin for 8 days. The Consultant Pharmacist was interviewed by phone on 5/14/2024 at 3:54 PM. The Pharmacist reported when the facility had a new admission, she reviewed the discharge hospital orders and checked those orders against the orders entered in the electronic documentation system. The Pharmacist reported she did not specifically recall reviewing Resident #1's hospital discharge orders. The Pharmacist explained the facility had changed electronic documentation systems and the hospital discharge orders had not been scanned into the system on 4/16/2024 when she reviewed Resident #1's medications. The DON was interviewed on 5/14/2024 at 4:22 PM. The DON reported she was not aware the Consultant Pharmacist was unable to review Resident #1's hospital discharge orders when she reviewed her admission records.

Based on record reviews and interviews with staff, Pharmacy Consultant and facility's Nurse Practitioner, the facility failed to act upon recommendations made by the Pharmacy Consultant for 1 of 5 residents whose medications were reviewed (Resident #18). The findings included: Resident #18 was most recently admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, heart disease, and hypertension. A review of the active physician's order revealed an order dated 11/20/22 for Apixaban (an anticoagulant) 2.5 milligrams (mg) one tablet by mouth two times a day related to presence of unspecified artificial hip joint. Another active physician's orders indicated an order dated Clopidogrel (an anticoagulant) 75 mg one tablet by mouth one time a day for history for deep vein thrombosis. A Pharmacy Consultation report dated 03/22/23 indicated Resident #18 received Apixaban 2.5 mg twice a day and Clopidogrel 75 mg every day. The report indicated a reevaluation of the continued use of both agents and to consider discontinued use of Clopidogrel for history of deep vein thrombosis. The facility's Nurse Practitioner responded on 03/24/23 and checked the box that indicated I accept the recommendations(s) above, please implement as written. Review of the March 2023 Medication Administration Record (MAR) revealed Resident #18 was administered Apixaban and Clopidogrel 3/24/23 through 3/31/23. A review of Resident #18's April 2023 and May 2023 Medication Administration Record (MAR) revealed she received both Apixaban and Clopidogrel every day. Resident #18's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact, and she received anticoagulant medication 7 of 7 days. An interview occurred with the Pharmacy Consultant on 05/17/23 at 1:16 PM. She stated Resident #18 could be on dual anticoagulant therapy, but she requested a recommendation to discontinue Clopidogrel in March. She stated she did not get notification of the Nurse Practitioner's response to her recommendation. She stated she would speak with the facility's staff to determine if they have addressed the recommendations. The Unit Manager was interviewed on 05/17/23 at 3:20 PM. She stated pharmacy recommendations were faxed or emailed to her by the Pharmacy Consultant. She stated she would follow up with the Medical Director or Nurse Practitioner regarding the Pharmacy Consultant's recommendations. She stated she did not process the order for Resident #18 on 3/24/23 because she thought the Medical Director wanted to continue both the Apixaban and Clopidogrel. A phone interview was conducted with the Nurse Practitioner on 05/17/23 at 2:46 PM, who stated she agreed with the pharmacy recommendation made in March to discontinue Resident #18's Clopidogrel and she expected the facility to follow through. The Director of Nursing (DON) was interviewed on 05/17/23 at 9:59 AM. She stated the Unit Manager received the Pharmacy Consultant's recommendations and reviewed them with the Nurse Practitioner and Medical Director. The Nurse Practitioner had the ability to discontinue medications in the resident's electronic medical record. She stated the discontinuation of the Clopidogrel recommendation would have shown up in the electronic medical record if the Nurse Practitioner put the order in, and the resident's nurse would have to acknowledge it since the order is flagged for acknowledgement in the resident's electronic medical record. She stated the discontinuation of Clopidogrel was not put in by the Nurse Practitioner. She stated she expected the pharmacy recommendation for Resident #18 to be completed if the Nurse Practitioner agreed with the recommendation.

Based on record reviews and interviews with the Nurse Practitioner and the Medical Director, the facility failed to ensure anticoagulation therapy was restarted after surgical procedure for 1 of 1 resident (Resident #40) reviewed for anticoagulant use. The findings included: Resident #40 was admitted on [DATE] with diagnoses that included atrial fibrillation (irregular heart rhythm), hypertension (high blood pressure), and history of a cerebral infarct (stroke). The resident's significant change Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively intact, required extensive assistance with activities of daily living, had an indwelling urinary catheter, and received anticoagulation therapy 7 out of 7 days. Resident #40's comprehensive care plan was last revised 4/26/2023 had a focus for risk complications related to anticoagulation therapy. Interventions included giving medication as ordered and calling Medical Director with any side effects. Resident #40's medical record included a visit summary from the surgical clinic dated 3/28/2023. The summary indicated the resident was evaluated and deemed a candidate for suprapubic catheter placement. The discharge plan included discontinuing her anticoagulant, Apixaban, three days prior to surgical procedure. The Medication Administration Record (MAR) for April 2023 revealed the anticoagulant Apixaban was discontinued on 4/17/2023. Resident #40's discharge summary from the surgical clinic dated 4/21/2023 indicated the resident had a suprapubic catheter placed. The discharge summary indicated the resident should resume taking the anticoagulant Apixaban on Monday (3 days post procedure). Nurse Practitioner (NP) #1 assessed Resident #40 on her return to the facility 4/21/2023. There was no indication she ordered the anticoagulant to be restarted 72 hours post procedure. Resident #40s MARs for April and May 2023 revealed the anticoagulant Apixaban was never restarted. A pharmacy review was conducted 4/18/2023 with no irregularities noted. A pharmacy review for May 2023 had not yet been completed. On 5/17/2023 at 10:17 AM an interview was conducted with the Medical Director. He stated he did not recall why Resident #40 was on an anticoagulant, he would have to go back and look at her medical record. He further stated he was not aware the anticoagulant was not restarted. On 5/17/2023 at 3:03 PM a phone interview was conducted with the Nurse Practitioner. She stated the anticoagulant was stopped due to the placement of the suprapubic catheter. She was not sure why the anticoagulant was not restarted. The resident returned from the clinic late on Friday and the discharge summary may not have been available to her at that time. She would have expected the anticoagulant to have been restarted 3 days post procedure per the surgical clinic's discharge summary. She further stated she had restarted the resident on anticoagulant 5/17/2023.

Based on record reviews, observations, Nurse Practitioner, Pharmacy Consultant, and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification survey on 11/18/21. This was for four deficiencies that were cited in the areas of Accuracy of Assessments, Reporting and Acting on Reports of Drug Irregularities, Drug Regimen is Free From Unnecessary Psychotropic Meds and Significant Med Errors. The duplicate citations during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program. The findings included: These citations are cross referenced to: F641- Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 4 of 16 sampled residents whose MDS were reviewed (Residents #9, #31, #55 & #9). During the facility's recertification survey of 11/18/21, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of smoking and disposition for 2 of 25 sampled residents reviewed. In an interview with the Administrator on 05/18/23 at 9:40 AM, she felt the repeat citation in MDS accuracy was felt to be related to human error. F756- Based on record reviews and interviews with staff, Pharmacy Consultant and facility's Nurse Practitioner, the facility failed to act upon recommendations made by the Pharmacy Consultant for 1 of 5 residents whose medications were reviewed (Resident #18). During the facility's recertification survey of 11/18/21, the Pharmacy Consultant failed to address the use of an as needed (PRN) psychotropic medication without a stop date for 1 of 6 residents reviewed for unnecessary medications. In an interview with the Administrator on 05/18/23 at 9:40 AM, she stated this error should have been addressed by the Pharmacist Consultant because she reviewed the orders. F758- Based on record review and staff interview, the facility failed to limit the timeframe for a psychotropic medication (any drug that affects the brain activities associated with mental processes and behavior) ordered to be given on an as needed (PRN) basis for 2 of 2 residents whose medications were reviewed (Residents #31 & #28). During the facility's recertification survey of 11/18/21 the facility failed to ensure an as needed (PRN) psychotropic medication was time limited in duration for 1 of 6 residents reviewed for unnecessary medications. In an interview with the Administrator on 05/18/23 at 9:40 AM, she felt like it was an oversight. F760- Based on record reviews and interviews with the Nurse Practitioner and the Medical Director, the facility failed to ensure anticoagulation therapy was restarted after surgical procedure for 1 of 1 resident (Resident #40) reviewed for anticoagulant use. During the facility's recertification survey of 11/18/21 the facility failed to ensure residents were free of significant medication errors for 1 of 1 reviewed for medication errors. In an interview with the Administrator on 05/18/23 at 9:40 AM, she stated this error should have been addressed by the Pharmacist Consultant because she reviewed the orders.

Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for 4 of 16 sampled residents whose MDS were reviewed (Residents #9, #31, #55 & # 60). Findings included: 1. Resident # 31 was admitted to the facility on [DATE]. Resident #31 had a physician's order dated 2/21/23 for Seroquel (an antipsychotic medication) 100 milligrams (mgs.) give 1 tablet by mouth 3 times a day for dementia with psychosis. Resident #31 had a physician's order dated 3/2/23 to decrease the Seroquel to 100 mgs - give 1/2 tablet by mouth 3 times a day. The significant change in status MDS assessment dated [DATE] indicated that Resident #31 had received an antipsychotic medication during the assessment period and a gradual dose reduction (GDR) for the antipsychotic medication had not been attempted. MDS Nurse #1 was interviewed on 5/17/23 at 10:10 AM. The MDS Nurse had reviewed the physician's orders for the Seroquel and verified that a GDR had been attempted. She indicated she missed the order for the GDR and she would complete a correction MDS. The Director of Nursing (DON) was interviewed on 5/18/23 at 10:18 AM. The DON stated she expected the MDS assessments to be accurate. 2. Resident #9 was admitted to the facility on [DATE]. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated that cognitive patterns and mood sections were not assessed. The assessment further indicated that the resident was able to make self-understood sometimes and able to understand others sometimes. MDS Nurse #1 was interviewed on 5/17/23 at 10:10 AM. She reported that Resident #9 was nonverbal but able to answer questions by shaking/nodding his head. She stated that the Social Services Director was responsible for completing cognitive patterns and mood sections of the MDS and she expected the Social Services Director to try to interview the resident. The Social Services Director was interviewed on 5/17/23 at 10:11 AM. She reported that she was responsible for completing cognitive patterns and mood sections on the MDS assessments. She stated that the resident was nonverbal, so she did not try to interview the resident. She indicated that she was new to MDS, started 2 months ago, and she was still learning. The Director of Nursing (DON) was interviewed on 5/18/23 at 10:18 AM. The DON stated she expected the MDS assessments to be accurate. 40197 3. Resident #55 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #55 had clear speech and was able to make self-understood and understood others. The Cognitive Patterns including the Brief Interview for Mental Status (BIMS), and the Mood sections were not marked as assessed. On 5/17/23 at 1:30 PM, an interview occurred with the MDS Nurse #2, who indicated the former Social Worker had completed the cognition and mood sections on Resident #55's quarterly MDS assessment dated [DATE]. She was unable to state why the sections were not completed correctly but an interview with Resident #55 should have been attempted for both sections. The Director of Nursing was interviewed on 5/18/23 at 10:16 AM and stated it was her expectation for all residents to be assessed accurately in the areas of cognition and mood. 46203 4. Resident #60 was admitted on [DATE] with diagnoses which included type 2 diabetes, hypertension, and chronic obstructive pulmonary disease with exacerbation. Resident #60's discharge Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was discharged to acute hospital setting and return was not anticipated. The discharge summary, dated 03/31/23, indicated Resident #60 participated in therapy during his stay and was discharged to another nursing home per resident/family request. The discharge instruction notes located in Resident #60's electronic medical record, dated 03/31/23, indicated the discharge destination was to another nursing home. On 05/17/23 at 1:34 PM an interview was conducted with MDS Nurse #1. She reviewed Resident #60's discharge MDS assessment dated [DATE] and stated the discharge was coded for acute hospital setting with return not anticipated. She reviewed the resident's discharge summary and stated the MDS assessment was coded in error. She stated the MDS assessment should have been coded to reflect the resident was discharged to another nursing home. During an interview with the Director of Nursing (DON) 05/17/23 at 3:15 PM she stated it was her expectation the MDS assessment be coded accurately.

Based on record reviews and staff interviews, the facility failed to transcribe the correct medication administration route for 3 of 5 residents reviewed for unnecessary medications (Residents #13, #55 and #47). The findings included: 1. Resident #13 was originally admitted to the facility on [DATE] with diagnoses which included gastro-esophageal reflux disease (GERD). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #13 was cognitively intact and was independent after setup with eating. The active May 2023 physician orders included an order dated 3/7/23 for Tums 500 milligrams (mg) give three tablets enterally (by a feeding tube) at bedtime for GERD. All other medications were written to be provided by mouth. On 5/16/23 at 11:25 AM, an interview occurred with Nurse #1 who was working the medication cart for Resident #13's hall and had administered medications earlier. The nurse confirmed Resident #13 received all his medications by mouth and did not have a feeding tube. Nurse #1 acknowledged the Medication Administration Record (MAR) read for Tums to be provided enterally, which was inaccurate as all his medications were provided by mouth. A phone interview was conducted with Nurse #2 on 5/16/23 at 1:52 PM and confirmed Resident #13 received all his medication by mouth and did not have a feeding tube. An interview was held with the Unit Manager on 5/17/23 at 11:02 AM. She was the nurse that had confirmed the Tums order for Resident #13. The Unit Manager explained she verified the medication, dose and frequency in the Electronic Medical System but must have hit the wrong button and chose enterally for the route rather than by mouth. On 5/18/23 at 10:16 AM, the Director of Nursing (DON) was interviewed and reviewed Resident #13's physician orders. She confirmed the route for the Tums was entered as enterally instead of by mouth. The DON felt it was an oversight that the nurse chose enteral rather than by mouth. The DON stated it was her expectation for all medication administration routes to be entered correctly when the order was received and verified. 2. Resident #55 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing). A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #55 was able to understand others and make self-understood. She required total assistance with eating and received 51% or more of calories and 501 milliliters (ml) or more of fluids via a feeding tube. Review of Resident #55's active care plan, last reviewed 3/1/23, revealed Resident #55 required a feeding tube. The active May 2023 physician orders included the following: An order dated 11/30/22 for Gabapentin 300 milligrams (mg). Give one capsule by mouth three times a day for peripheral neuropathy. An order dated 3/27/23 for Cyanocobalamin 500 micrograms (mcg). Give two tablets by mouth one time a day for Guillain-Barre syndrome. Vistaril 25 mg. Give one capsule by mouth every six hours as needed for pruritis (itching). All other medications were written to be provided through the gastric feeding tube. On 5/16/23 at 11:23 AM, an interview occurred with Resident #55 who stated she received supplemental tube feed during the evening hours and took all her medications via the feeding tube. She explained she had a tough time swallowing at times and did not like to take her medications by mouth. On 5/16/23 at 1:11 PM, an interview occurred with Nurse #1 who was working the medication cart for Resident #55's hall and had administered her medications earlier. The nurse confirmed Resident #55 did not take her medications by mouth but received all of them by the feeding tube. Nurse #1 was the nurse who had taken the order for Gabapentin 300mg. She reviewed the order and confirmed it should have read to take via the feeding tube and not by mouth. Nurse #2 was interviewed by phone on 5/16/23 at 1:52 PM and was familiar with Resident #55. She confirmed Resident #55 received all her medication via the feeding tube and not by mouth. The Wound Nurse was interviewed on 5/16/23 at 2:00 PM. She was the nurse that transcribed the Cyanocobalamin 500 mcg order for Resident #55. The Wound Nurse explained she entered the medication, dose and frequency into the Electronic Medical System but failed to change the medication route to enterally (feeding tube). On 5/18/23 at 10:16 AM, the Director of Nursing (DON) was interviewed and reviewed Resident #55's physician orders. She confirmed the route for the Gabapentin, Cyanocobalamin and Vistaril were entered as by mouth instead of enterally as Resident #55 preferred to receive her medications via the feeding tube. The DON felt it was an oversight and stated it was her expectation for all medication administration routes to be entered correctly when the order was received and verified. Multiple phone calls were made to Nurse #3 who had taken the order for Vistaril 25mg and were unsuccessful. 41437 3. Resident #47 was admitted to the facility on [DATE] with diagnoses that included Guillain-Barre syndrome. The resident's annual Minimum Data Set (MDS) dated [DATE] indicated the resident was cognitively impaired and required extensive assistance with all activities of daily living including eating. The resident's comprehensive care plan, last revised on 5/11/2023, contained a focus for nutritional risk related to chewing difficulties and altered consistency diet. The care plan indicated the resident had a percutaneous endoscopic gastrostomy (PEG) for medications only. Interventions included administering medications via PEG tube as ordered. Resident # 47's medical record contained the following physician orders: Crush each tablet and empty each capsule into at least 5ml of water or other appropriate liquid. Flush the tube with at least 30 ml of water or other appropriate liquid prior to and after each medication administration via tube separately. Flush between medications. The order was dated 1/24/2023. Give Sertraline 1 tablet by mouth every 12 hours for major depressive disorder. Give Percocet 5-325, 1 tablet by mouth every 12 hours for chronic pain. Give Gabapentin 600mg , 1 tablet by mouth two times a day for neuropathy. Give folic acid, 1 tablet by mouth in the morning for supplement. Give buspirone 15mg, 1 tablet by moth two times daily for anxiety. On 5/17/2023 at 10:15AM an interview was conducted with Resident #47. She stated she took all of her medications via PEG tube. She further stated she took all of her meals by mouth. On 5/17/2023 at 12:04 PM an interview was conducted with the Unit Manger. She stated she was covering the medication cart assigned to Resident #47. She stated she was very familiar with the resident. The resident originally had difficulty with swallowing which prompted the PEG placement for nutrition and medications. The resident had since regained some function and was taking an altered diet by mouth. However, all of her medications were still administered via the PEG tube. On 5/18/2023 at 10:00 AM an interview was conducted with the Director of Nursing (DON). She stated the resident takes nutrition by mouth and medications via PEG tube. She confirmed the resident was getting the medication via PEG tube and not by mouth. She felt is was an error in transcribing the medication order. It was her expectation all medication orders reflect the correct route of administration.

Based on record review, observation and staff interview, the facility failed to prevent injury (blister) from the baseboard heater to 1 (Resident #85) of 3 sampled residents. The findings include: The instruction/installation reference form of baseboard heater was reviewed. The form under cautions and warning statements revealed " high temperatures are present at outlet air openings. Keep electrical cords, drapes and other furnishings or objects clear of these openings. High temperatures, keep electrical cords, drapes and other furnishings away from the heater. " Resident #85 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The significant change in status MDS (Minimum Data Set) assessment dated [DATE] indicated that Resident #85 had memory and decision making problems. The care plan was reviewed. There was a care plan initiated on 10/16/12. The problem was " blister to right hand. " The goal was " blister will heal without signs of infection through next review date 11/20/12. " The approaches were " assess and record measurements as needed, observe for signs/symptoms of pain and intervene appropriately, treatment as ordered, observe for signs/symptoms of pain and observe standard precaution. " The nurse's notes were reviewed. The notes dated 10/10/12 at 3:30 PM revealed that while the nursing assistants were making rounds, Resident #85 was found to have her hand down beside the bed. When her hand was pulled up, a large fluid filled blister was noted on top of her right hand. The notes further indicated that the attending physician was informed and Silvadene cream was ordered. The notes at 3:45 PM indicated that Resident #85 was moved to the door side of the room. The weekly non pressure progress reports were reviewed. The report dated 10/11/12 indicated an intact fluid filled blister to right hand 3 x 2 cm (centimeter) in size and oozing serous fluid. The blister was treated with Silvadene and dry dressing daily. The telephone orders were reviewed. On 10/24/12, the attending physician had ordered to discontinue Silvadene cream to right hand. The new order was to clean the right hand blister with wound cleanser and apply Calcium Alginate and dry dressing daily. On 10/25/12, the Calcium Alginate was discontinued and was changed to Hydrogel. On 10/30/12 at 9:46 AM, Nurse #2 was interviewed. She stated that Resident #85 had a blister on her right hand from a baseboard heater. On 10/30/12 at 10:42 AM, Resident #85 was observed in low bed by the door. She had a dressing to her right hand. On 10/30/12 at 11:45 AM, the treatment nurse was interviewed. She stated that the blister on the resident's right hand was from the baseboard heater. On 10/31/12 at 10:45 AM, the administrative staff #5 was interviewed. He stated that he had heard of a resident, who was on low bed by the window, was found to have a blister from the baseboard heater. He further indicated that this resident was the only resident in the building on low bed. On 10/31/12 at 11:30 AM, the beds in rooms 2 W, 21 W, 25 W and 26 W were observed with the residents in bed. The beds were about 2-3 inches from the baseboard heaters. The heaters were turned on and the metal frames were hot when touched. On 10/31/12 at 11:35 AM, administrative staff members #1 and #2 were interviewed. Administrative staff member #2 stated that Resident #85 was found to have a blister on her hand. She added that the resident was on low bed by the window and her bed was moved immediately by the door. She also stated that department heads had to check bed placement during daily angel rounds. Administrative staff member #1 stated that all staff members were in-serviced to make sure beds were away from the wall/baseboard heaters at least 6-12 inches. She added that Resident #85 was found with her hand hanging off the bed between the bed and the heater. The in-service records dated 10/11/12 were reviewed. The in-service topics included making sure all items were clear of the baseboard/wall heat. All items (bed, linens, cords, furniture) were removed from baseboard areas if found. Patient's safety and fire hazards were discussed. Staff members were reminded to check rooms during rounds for resident's safety and fire hazards. The facility's plan of action dated 10/10/12 was reviewed. The problem was " resident's right hand found having fluid filled blister (top of hand). Hand was hanging off bed between bed and heater. Hand was not on heater or against wall. Bed was in lowest position r/t (related to) fall risk and anxiety. " The goal was " to have no injuries related to any environmental hazards (walls, beds, side rails, etc). " The approaches were " order for first aide to blister, resident's bed immediately moved to opposite side of room, 100% body audit done on all residents that are placed beside wall/near heaters, in-serviced all staff on importance of keeping beds 6-12 inches away from the walls, department heads to check placement of beds during daily angel rounds and nursing administration to do spot checks throughout day on positioning of beds. " There was no documentation that bed placement was checked during the daily angel rounds or the nursing administration had conducted spot checks of bed positioning. On 10/31/12 at 1:57 PM, Nurse #3 was interviewed. She stated that she was assigned to Resident #85 when the blister was found on the resident's hand. She indicated that the resident's bed was a low bed by the window where the baseboard heater was located. She revealed that the resident had behaviors of swinging her arms and legs off the bed. She reported that on 10/10/12, the nursing assisted had reported to her that Resident #85 had a blister on her right hand. She revealed that the heater was turned on at that time. She believed that the blister was from the heater because she was found with her hand between the bed and the heater. The resident's bed was moved by the door right after the incident. On 10/31/12 at 2:43 PM, nursing assistants (NAs) #1 and #2 were interviewed. NAs #1 and #2 reported that they were making rounds when Resident #85 was found with her legs and right hand lying off the bed. They went in the room to reposition her. She was on low bed by the window. Her right hand was off the bed between the bed and the heater. When they pulled her right hand up, a blister was noted on top of her hand. They informed Nurse #3 immediately. NA #2 reported that the base board heater was turned on when they found her. On 11/1/12 at 10:15 AM, the treatment nurse was observed during the dressing change. The blister was observed on top on her hand just above the ring finger. The treatment nurse was observed to clean the blister with wound cleanser and Hydrogel was applied and covered with a dry dressing. On 11/1/12 at 10:24 AM, the treatment nurse was interviewed. She indicated that she had worked at the facility for [AGE] years and she had no knowledge that Resident #85 had blister in the past. The only blisters she had known were on her heel which already had healed up and the blister on her right hand (10/10/12). On 11/1/12 at 11:35 AM, OT (occupational therapist) #1 was interviewed. She stated that therapy was working on Resident #85 due to the edema on her right hand. She reported that OT was working on the resident for ROM (range of motion) exercises and splinting starting 9/17/12. She further stated that diathermy therapy was started on 10/11/12, right after the blister was found.