Every finding on record at Waters of Memphis a Rehabilitation & Nursing CTR

Based on facility policy review, personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Registered Nurse (RN) using another RN's (RN C) Tennessee license. Imposter Nurse A was hired on 02/21/2025 and worked at the facility from 02/25/2025 to 04/23/2025. The findings include: Review of a facility policy title Abuse Program Policy dated 05/15/2023, revealed .Pre-employment Screening of Potential Employees.Prior to a new employee starting a working schedule.Obtain a copy of the state license of any individual being hired for a position.Complete a criminal background check per state statute on all new hires. Review of an Application for Employment dated 02/05/2025, revealed a Social Security Number (SSN) block was scratched out and a SSN was printed above the block that did not match the I-9 (Employment Eligibility Verification) form and a birth date that did not match the I-9 form. Review of the Background Screening Report dated 02/17/2025, revealed the SSN and the birthdate did not match the SSN and the birthdate listed on the I-9 (Employment Eligibility Verification) form. A note on the background check revealed, .UNABLE TO VALIDATE SSN. Review of a W-4 form dated 02/21/2025, revealed a SSN that did not match the background check. Review of the I-9 form used to verify the identity and legal authorization of individuals hired for employment in the United States dated 02/24/2025, revealed Imposter Nurse A's legal first and last name, along with a copy of her Social Security Card issued on 04/12/2022 and a valid Driver's license from the State of Tennessee. The birthdate listed on the I-9 form was different than the birthdate listed on the background check for Imposter Nurse A. Review of the personnel file for Imposter Nurse A revealed no evidence that an Abuse registry check was done prior to hire. Review of the Time Card for Imposter Nurse A for February 2025, revealed she worked in this facility on February 21, 25, 26, 27, and 28. Review of the Time Card for Imposter Nurse A for March 2025, revealed she worked in this facility on March 1, 2, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 19, and 23. Review of the Personnel Change Form dated 04/23/2025, revealed .TERMINATION.Voluntary - Reason: unable to uphold weekend schedule obligations.Last Day Worked, 3/23/25. Review of a QuickConfirm License Verification Report dated 10/02/2025, revealed the last name on the validated license did not match Imposter Nurse A's last name. There was no evidence in Imposter Nurse A's personnel file that a License Verification was done prior to the hire date of 02/25/2025. During an interview on 10/02/2025 at 9:15 AM, the Director of Nursing (DON) confirmed Imposter Nurse A worked in the facility in February and March, 2025 as a Unit Manager but kept coming in when she wanted. That was addressed and she just quit coming in to work. During an interview on 10/02/2025 at 10:10 AM, the Human Resource (HR) Representative confirmed Imposter Nurse A was a walk-in and did not provide a resume. During an interview on 10/02/2025 at 11:48 AM, the Administrator confirmed the HR Department in house does all the checks that included ordering the background checks. The Administrator stated that Corporate is a back-up for this process. There was no evidence that the facility questioned the differences in names, birth dates, or Social Security Numbers on the pre-employment forms submitted by Imposter Nurse A. Imposter Nurse A was hired as a Registered Nurse to render nursing services, and she was only terminated for a voluntary termination. The facility employed an unqualified person.

Based on policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of an injury of unknown origin for 1 of 3 (Resident #1) sampled residents reviewed for abuse. The findings include: 1. Review of the facility policy titled ABUSE PREVENTION PROGRAM, dated 10/22/2022, revealed .It is the policy of this facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings .Investigation .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .For any incident involving suspicion of abuse, neglect, or mistreatment, the Administrator or person appointed by the Administrator will gather facts prior to making a determination to conduct an abuse investigation .The final investigation report will be completed within the required timeframe allowed by Tennessee Department of Health .The final report shall include facts determined during the process of the investigation .The final investigation shall also include a conclusion of the investigation based on known facts . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Sepsis, Protein-Calorie Malnutrition, Dementia, Contracture (a condition of hardening and shortening of tendons, muscles or other tissues, leading to possibly rigidity of joints and deformity) of Right Knee, Contracture of Left Knee, Dysphagia,(swallowing difficulties) and Altered Mental Status. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 2 which indicated Resident #1 was severely cognitively impaired. Resident #1 was dependent on staff to perform Activities of Daily Living (ADLs) and had impairment in bilateral upper and lower extremities. Review of the nursing progress notes revealed, .5/9/2025 .Pt [patient] confused at this time grabbing for things and speaking incoherently .5/15/2025 .Midline [a type of intravenous access inserted in a vein in the upper arm to provide fluids] placed .to right arm .5/17/2025 .Vitals wnl [within normal limits] Midline noted to Rt [right] Forearm, patent flushes easily .5/18/2025 .Midline to the RUE [right upper extremity]. Patent and free of infiltration .5/19/2025 .Midline to the RUE. Patent and free of infiltration .5/19/2025 .Writer was asked to assist the nursing aide with repositioning resident. Upon arrival to room, resident was observed hold aide tightly by the shirt. Resident was educated on the harm it would cause on himself. The resident then proceeded to snatch his arm from the aide .5/21/2025 . new order X-Ray to R [right] [NAME] [shoulder] d/t [due to] pain .Discontinue midline .5/22/2025 .Late entry for 5/22/25 [2025] .Per physician's order, midline removed at this time. Writer noticed edema to right extremity and that resident groaned and moaned out in pain when arm touched. Midline removed at this time with no issues, tip still intact .Writer noticed no visible bruising to extremity .5/22/2025 .Radiology results for right shoulder .There is no bone abnormality to suggest a displaced fracture. There is an anterior dislocation of the humerus .CONCLUSION: anterior dislocation. Order placed to send patient to hospital for evaluation . Review of the Physician/Practitioner Progress Notes revealed, .5/10/2025 Contractures present to multiple extremities. Normal range of motion. No tenderness .swelling .of both rt/lt [right/left] arms and hands .5/12/2025 .swelling .of both rt/lt arms and hands .5/15/2025 Swelling .both rt/lt [right/left] arms and hands .5/16/2025 .swelling of .both rt/lt arms and hands .5/19/2025 .swelling of .both rt/lt arms and hands .5/20/2025 .swelling of .both rt/lt arms and hands .5/21/2025 . swelling of .both rt/lt arms and hands .5/22/2025 .swelling of .both rt/lt arms and hands . Review of the facility investigation revealed the following: a. A handwritten statement by the Assistant Director of Nursing (ADON) for Certified Nursing Assistant (CNA) M dated 5/22/2025. b. A handwritten statement by the ADON for CNA N dated 5/23/2025. c. A typed timeline dated 5/21/22 (2025) through 5/22/2025. Review of the facility timeline provided by the Administrator dated 5/21/22 (2025) through 5/22/2025, revealed .CNA statements .Licensed Practical Nurse [LPN] Statements .Registered Nurse placing Midline [statement]: Reported to me that she did not require any assistance when placing his [Resident #1's] Midline .stated .usually document if .request assistance from staff or if the resident is combative usually document it and she did not have any issues with him .Conclusion: Based on the investigation, it was determined that the manipulation of the right extremity was dislocated during the placement of the midline . During a telephone interview on 6/24/2025 at 12:10 PM, the ADON was asked did Resident #1 have any swollen limbs, including bruises. The ADON stated, .on admission [Named LPN A] noted edema to his right arm .no bruising . The ADON was asked did the resident complain of pain. The ADON stated, .I pulled his midline out .he arm was really swollen .it was IV [intravenous therapy-a tube inserted in a vein to provide fluids into the bloodstream] .didn't look like it had infiltrated [when fluid administered through an IV line leaks out of the v in and into the surrounding tissue] right upper inside of his arm .when I raised his arm up to put on a pillow is when he made a facial grimace .the family requested the x-ray .told the Nurse Practitioner they thought his arm was dislocated . The ADON confirmed that the x-ray showed Resident #1 had a dislocated shoulder. The ADON was asked what happened to his shoulder. The ADON stated, .I'm going to be honest I don't know . The ADON confirmed she had talked to RN L who had placed Resident #1's midline. The ADON stated, .if they [residents] are combative or having a hard time with the resident, will ask for assistance with staff, but she said she didn't need it with him .he was a little fellow . the way his midline was placed, would have to turn his arm around she may had put her hand on his shoulder to get in place .I had to turn his arm up .the day I took his midline out was the first day I ever saw him . During a telephone interview on 6/24/2025 at 3:36 PM, RN L who had placed Resident #1's midline was asked if the surveyor could read her statement that she gave to the ADON on 5/22/2025. RN L said that she had not spoken to anyone from the facility since she left the facility after she put in Resident #1's midline. RN L stated, I remember him [referring to Resident #1] .midline right brachial [ major blood vessel of the upper arm] attempted one time . RN L said she didn't remember him (Resident #1) being in pain or screaming out. RN L was asked did she have to manipulate his right arm to put in the midline and when she left did, she have any concerns that she had dislocated his right shoulder. RN L stated, No, absolutely not . During a telephone interview on 6/25/025 at 12:25 PM, the Certified Occupational Therapist Assistant (COTA) confirmed he did some of Resident #1's therapy 4 or 5 times a week and that his arms were not contracted. The COTA stated, .tried to maintain what he had .range of motion for his upper extremities . During a telephone interview on 6/25/2025 at 2:21 PM, the Medical Director was asked what he thought happened to Resident #1's right shoulder. The Medical Director stated, .don't know what happened .he didn't fall .he was bed bound .it is possible he came to us with that injury . During a telephone interview on 6/25/2025 at 5:16 PM, LPN F stated, .I put in the order for the midline .I went on break and when I came back, it [referring to the midline placement] was done .I went and checked on him [Resident #1] he was baseline the same as when he got here . LPN F confirmed she didn't see any concerns with the midline placement. During an interview on 6/27/2025 at 1:13 PM, the ADON confirmed she did not complete a written statement. The ADON stated, .the day I removed his [Resident #1] midline was the first day I had ever laid eyes on the man . The ADON was informed that [Named RN L] who had placed Resident #1's midline stated that she never talked to anyone from the facility after she had left the facility. The ADON was asked how she had spoken to RN L, who placed Resident #1's midline, because the company RN L worked for stated they do not give out employee's telephone numbers. The ADON stated, .I don't know how they did it .somehow she was on the phone . During a telephone interview on 6/27/2025 at 2:50 PM, the Administrator confirmed he based his outcome that Resident #1's dislocated shoulder was caused by the RN (L) who had placed the midline on 5/15/2025, on the ADON's statement. The Administrator stated, .the way it was expressed .per the ADON, she said his [referring to Resident #1] arm would have to be pushed back . The Administrator acknowledged that he now wasn't sure how Resident #1 had dislocated his right shoulder. The Administrator stated, .there are other grounds or facts that he is swinging .swatting at staff while giving care and was admitted to us with swollen extremity, it very well could be during his behavior his dislocation could have been from that .family made the statement that it is dislocated [referring to Resident #1's right shoulder] they were sure .they could have done it themselves . The Administrator was asked if he should have done a thorough investigation on Resident #1's dislocated right shoulder. The Administrator stated, .I would have a clearer picture .I would say a more extensive investigation of the matter would have helped . The facility was unable to provide a written statement from the ADON, statements from nursing staff who provided care to Resident #1, or staff education following Resident #1's injury of unknown origin. The facility provided two statements only from CNA staff. The investigation included a statement from RN L documented by the ADON; however, RN L denied that she had spoken to anyone from the facility about the incident. RN L denied any concerns with the placement of the midline.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 5 of 24 staff members Certified Nurse Assistant (CNA#1, #2, #3, #4, #6) failed to perform hand hygiene during meal services. The number of meal trays served on 9/10/2023 for lunch were 73. The number of meal trays served for breakfast on 9/11/2023 were 72. The findings include: 1. Review of the facility's policy titled, Meal Service, dated 9/5/2023 revealed .It is the policy of this facility that all residents are provided adequate supervision to meet each residents nursing and personal care needs including meals service and assistance with eating .Staff providing direct care by passing meals/trays will wash their hands before serving the food .There is no bare hand contact with ready to eat foods . Review of the facility's undated policy titled, Hand Hygiene Guidelines, revealed .When hands are visibly soiled, exposure to a spore forming organism has been suspected .hands should be washed with a non-microbial or anti-microbial soap . Review of the facility's undated policy titled, Resident Rights, revealed .The facility must care for you in a manner and environment that enhances or promotes your quality of life . 2. Observation in the resident's room on 9/10/2023 at 12:54 PM, revealed CNA #1 entered Resident #5's room with her lunch tray, placed the tray on the over bed table, pulled the resident up in the bed, and then proceeded to set up the resident's tray. CNA #1 did not perform hand hygiene prior to setting up Resident #5's tray. 3. Observation in the resident's room on 9/10/2023 at 1:08 PM, revealed CNA #3 entered Resident #75's room with his lunch tray, placed the tray on the over bed table, donned gloves, pulled the privacy curtain, and moved the resident up in the bed. CNA #3 doffed her gloves, removed the sandwich from the plastic bag with her bare hands and the straw from the wrapper, and then performed hand hygiene. CNA #3 failed to perform hand hygiene prior to donning gloves and after doffing gloves and touched the resident's food with her bare hands. 4. Observation in the resident's room on 9/11/2023 at 7:28 AM, revealed CNA #4 entered Resident #281's room, placed the food tray on the over the bed table, picked up the bed remote and raised the head of bed, did not perform hand hygiene, opened the residents butter and spooned it in the oatmeal, opened packets of sugar and poured on the oatmeal, spread jelly on the toast, turned on the light, did not perform hand hygiene, went outside the resident's room and got the resident some coffee, returned to the room and opened packets of artificial sweetener and pour in the resident's coffee, removed the paper from a straw and placed the straw in the resident's drink. CNA #4 failed to perform hand hygiene while assisting Resident #281 with dining. 5. Observation in the resident's room on 9/11/2023 at 7:32 AM, revealed CNA #2 entered Resident #7's room with her breakfast tray, set the tray on the over bed table, returned to the 100 Hall, obtained a towel from the clean linen cart, and placed the towel on the resident's chest at her request. CNA #2 removed the meal tray lid, picked up the knife, cut the hard-boiled egg in half with her right hand while she held the egg in place with her bare left hand, picked up toast with her bare left hand and used the knife to spread jelly on the toast with her right hand. CNA #2 failed to perform hand hygiene and touched Resident #7's food with her bare hand. 6. Observation in the resident's room on 9/11/2023 beginning at 7:42 AM, revealed CNA #4 entered Resident #15's room, placed the food tray on the over bed table, put sugar and butter in the resident's oatmeal, picked up the resident's remote and readjusted the bed. CNA #4 pulled the resident's draw sheet from under him putting her right hand under his back and her left hand on his right shoulder to reposition the resident, moved the over bed table closer to Resident #15 and did not perform hand hygiene. CNA #4 returned to the meal cart, retrieved Resident #8's food tray, entered Resident #8's room, placed the food tray on the over bed table and lifted the lid off. CNA #4 picked up and placed a chair near the resident, sat down in the chair to assist Resident #8 with his meal. CNA #4 failed to perform hand hygiene during dining. 7. Observation in the resident's room on 9/11/2023 at 7:44 AM, revealed CNA #1 entered Resident #71's room with his breakfast tray. CNA #1 placed the tray on Resident #71's over bed table, removed the lid, moved the over bed table to the opposite side of the bed, added sugar to the resident's oatmeal, and placed a straw in his juice. CNA #1 touched Resident #71's toast with her left hand and spread jelly on the toast with her right hand using a fork. CNA #1 then held the other half of Resident #71's toast with her left hand and spread jelly on the toast using a fork. CNA #1 failed to perform hand hygiene and touched Resident #71's food with her bare hand. 8. Observation in the resident's room on 9/11/2023 at 7:58 AM, revealed CNA #1 entered Resident #25's room with his breakfast tray. CNA #1 placed the resident's tray on his over bed table, removed the lid from the tray, and added sugar to the resident's oatmeal and pepper to his eggs. CNA #1 picked up a slice of Resident #25's toast with her left land and used a fork to spread jelly on the toast with her right hand, and then returned it to his plate. CNA #1 picked up the second half of Resident #25's toast with her left hand and spread jelly on the toast with a fork using her right hand, and then returned it to his plate. CNA #1 picked up the third half of Resident #25's toast with her left hand and spread jelly on the toast with a fork using her right hand, and then returned it to his plate. CNA #1 failed to perform hand hygiene and touched Resident #25's food with her bare hand. 9. Observation in the resident's room on 9/11/2023 at 8:03 AM, revealed CNA #6 entered Resident #333's room, placed the resident food tray on the over bed table, used the resident fork to put a hole in his juice drink, placed the fork back on the food tray for the resident to use, removed the straw paper and placed the straw in the juice, lifted the resident's bed sheet and asked another staff member to assist her with repositioning the resident. CNA #6 donned gloves, assisted Resident #333 reposition himself in bed, removed her gloves, failed to perform hand hygiene, moved the resident's over bed table closer to him, and left the resident's bedside. 10. During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON) confirmed staff should wash their hands after touching contaminated items, after repositioning resident up in bed, and after removing their gloves. The DON confirmed the staff should not use their bare hands to pick up the resident's food, and staff should wash their hands after they assist a resident with repositioning in bed.

Based on policy review, observation, and interview, the facility failed to maintain and enhance resident's dignity and respect when 7 of 24 (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, LPN #2, Unit Manager #1, Unit Manager #2, Certified Nursing Assistant (CNA) #1, CNA #4, CNA #6) staff members failed to knock before entering resident rooms, when 1 of 24 (LPN #1) staff members stood to assist Resident #45 with meals, when 1 of 24 (CNA #4) staff members did not use proper courtesy titles, and when 1 of 4 (RN #1) nurses failed to provide privacy for 1 of 5 (Resident #46) residents observed during medication administration. The findings include: 1. Review of the facility's undated policy titled, Dignity, revealed .will not refer .as feeder .Staff will not stand to feed .Privacy .Staff will knock prior to entering a resident's room .Staff will provide privacy for residents .curtain must be pulled anytime .resident needs .privacy . Review of the facility's undated policy titled, Resident Rights, revealed .The facility must care for you in a manner and environment that enhances or promotes your quality of life . Review of the undated facility's undated policy titled, Insulin Pens, revealed .Administer the insulin affording privacy . 2. Observations during dining revealed the following: a. On 9/10/2023 at 12:54 PM, CNA #1 failed to knock or ask permission to enter Resident #40's room. b. On 9/10/2023 at 12:57 PM, LPN #2 failed to knock or ask permission to enter Resident #27's room. c. On 9/10/2023 at 1:01 PM, Unit Manager #2 failed to knock or ask permission to enter Resident #18's room. d. On 9/10/2023 1:05 PM, Unit Manager #1 failed to knock or ask permission to enter Resident #16's room. e. On 9/10/2023 at 1:13 PM, CNA #1 failed to knock or ask permission to enter Resident #64's room. f. On 9/10/2023 at 1:21 PM, LPN #1 stood at Resident #17's bedside while she assisted the resident with her lunch tray. Resident #17 was not at eye level with LPN #1. g. On 9/11/2023 at 7:44 AM, CNA #1 failed to knock or ask permission to enter Resident #71's room. h. On 9/11/2023 at 7:46 AM, CNA #4 entered Resident #8's room, placed the food tray on the over the bed table, lifted the lid off the tray, and stated, She is a feeder. i. On 9/11/2023 at 7:58 AM, CNA #6 did not knock or ask for permission to enter Resident #75's room. 3. Observation in the resident's room during medication administration on 9/12/2023 at 12:45 PM, revealed Registered Nurse (RN) #1 lifted Resident #45's gown, exposed her abdomen, and administered an insulin injection. RN #1 failed to close the door or the privacy curtain, and Resident #45 was visible to anyone walking in the hallway. During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON), confirmed that staff should not stand over residents when assisting with meals, staff should not refer to residents as feeders, staff should knock before entering a resident's room and staff should provide privacy when administering insulin in the abdomen by pulling the curtain.

Based on policy review, observation, and interview, the facility failed to provide effective housekeeping to maintain a sanitary environment for 3 of 53 (room [ROOM NUMBER], #230, and #307) resident rooms observed. The findings include: 1. Review of the facility's undated policy titled, GENERAL CLEANING POLICIES AND PROCEDURES RESIDENT ROOM - CLEAN revealed .To provide a clean, attractive and safe environment for residents .Clean .toilet .Dust Mop the Resident Room and Bathroom Floors .Wet Mop the Resident Room and Bathroom Floors .Clean and Sanitize Toilets .Use a separate cloth and a disinfectant to wipe every surface area of the commode including the tank .Flush the toilet as the final step to insure all cleaner is removed from the toilet bowl water . 2. Observations in room [ROOM NUMBER] on 9/10/2023 at 10:16 AM and 12:57 PM, 9/11/2023 at 7:50 AM, and 9/12/2023 at 12:35 PM, revealed a floor fan with a heavy build-up of dust particles hanging on the front and back casing of the fan against the wall at the foot of the resident's bed. The fan was blowing on the resident. During an interview on 9/12/2023 at 2:47 PM, Unit Manager #2 was asked should the resident's fan be covered in dust particles. Unit Manager #2 stated, No . 3. Observation in the room [ROOM NUMBER] on 9/10/2023 at 10:21 AM, 11:02 AM, 12:20 PM, and 1:02 PM, revealed the bathroom floor was observed with a large amount of smeared brown stains on the bathroom floor and leading to the resident's bedside. During an interview on 9/10/2023 at 1:02 PM, the Housekeeping Director was asked if she could tell me what the brown stains were in the resident's room. The House Keeping Director stated, .BM [bowel movement] . The Housekeeping Director was asked how often the rooms are cleaned. The Housekeeping Director stated, .three times a day .we had one housekeeper here today .normally have three [housekeepers] .I came in at 10:00 AM to help out . 4. Observation in room [ROOM NUMBER] on 9/10/2023 at 10:50 AM, 12:25 PM, 4:07 PM, on 9/11/2023 at 7:56 AM and 5:14 PM, and on 9/12/2023 at 9:12 AM, revealed a strong odor at the doorway, inside the room, and in the bathroom of room [ROOM NUMBER]. During an observation and interview on 9/10/2023 at 10:50 AM, Licensed Practical Nurse (LPN) #4 was asked what the strong smell was. LPN #4 stated, .we can smell it out in the hallway .it smells like urine . LPN #4 entered the resident's bathroom and noted the toilet filled with urine. LPN #4 was asked should the resident's room and bathroom have a strong odor of urine. LPN #4 stated, .No .it could be in the mattress .not sure where the odor is coming from . During an interview on 9/12/2023 at 5:40 PM, the Administrator was asked should the residents' room and bathroom have a strong odor. The Administrator stated, .No . The Administrator was asked how often the residents rooms are cleaned. The Administrator stated, .we clean his room [ROOM NUMBER] times a day at 7:00 AM, 12:00 PM, and between 3:00 PM and 4:00 PM. The Administrator was asked should a resident's room have smeared brown stains on the floor of the bathroom and the room. The Administrator stated, .No .

Based on policy review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of infection were used when 2 of 4 (Licensed Practical Nurse (LPN) #3, and LPN #5) nurses failed to perform hand hygiene and clean equipment after use during medication administration. The findings include: 1. Review of the facility's undated policy titled, Hand Hygiene Guidelines revealed .The scope of this guideline includes all interdisciplinary members .and individuals that partake in the resident's plan of care .Handwashing items .soap and water .Paper towels .Waterless Alcohol Based Agent .When hands are visibly soiled, exposure to a spore forming organism has been suspected .before and after eating, and after using the restroom hands should be washed .Allow hands to completely dry prior to applying gloves or interacting with a resident . 2. Observation in the resident's room on 9/12/2023 at 4:59 PM, revealed LPN #5 performed hand hygiene, removed Resident #32's medications from the med cart, placed the medication in a plastic medication cup, transferred the medication to a plastic pouch, crushed the medication using the pill crusher, and returned the medication to the plastic medication cup. LPN #5 gathered supplies from the med cart, locked the med cart, and went to Resident #32's bedside. LPN #5 placed the supplies on a barrier on the over bed table, closed the blinds, and donned gloves. LPN #5 paused Resident #32's feeding pump, removed the tubing, and covered it with a plastic tip. LPN #5 removed a 60 ml syringe from the plastic bag hanging on the pole, removed a stethoscope from around her neck, and checked tube placement. LPN #5 positioned the ear piece and ear tubing of the stethoscope around her neck after checking placement. LPN #5 administered Resident #32's medication. LPN #5 went to the bathroom with the same gloved hands and rinsed the syringe with water, returned the syringe to the plastic bag, hung it on the pole, reattached tubing to the resident, and restarted the feeding pump. LPN #5 failed to remove her gloves and perform hand hygiene after touching contaminated objects in the resident's room. LPN #5 returned to her med cart and positioned her stethoscope around her neck. LPN #5 failed to clean her stethoscope after use. 3. Observation in the resident's room during medication administration on 9/13/2023 at 8:29 AM, revealed LPN #3 performed hand hygiene, prepared Resident #10's medication, locked her med cart, knocked on the resident's door, entered the resident's room, and administered the resident's medications. LPN #3 failed to perform hand hygiene prior to administering medication after touching contaminated objects on the medication care. LPN #3 donned gloves, removed the resident's nasal spray from a plastic bag, and handed it to the resident who self-administered (per self-administration plan) the nasal spray. 4. During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON) confirmed staff should perform hand hygiene before donning, after doffing gloves, and after touching contaminated objects in the resident's room. During an interview on 9/14/23 at 8:00 AM, the DON confirmed staff should clean the equipment before and after use.

Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services for an indwelling urinary catheter (a tube in the bladder that drains the urine) for 2 of 2 (Resident #22 and #41) sampled residents reviewed for indwelling catheters. The findings include: 1. Review of the facility's policy titled, Perineal / Incontinence Care, dated 1/1/2020, revealed .Perform hand hygiene .Put on gloves .Wash all soiled skin areas, washing from front to back, rinse and dry very well, especially between skin folds .Remove gloves .Wash hands . Review of the facility's undated policy titled, Indwelling Urinary Catheter Care, revealed .Wash hands and don gloves .Assist the resident to lie on back and expose perineal area .Soap one cloth at a time and wash genitalia using proper aseptic technique .In male resident, wash the penis first .Cleanse catheter area by washing urethral area first followed by cleansing proximal 1/3 of catheter. Change cloth as necessary .Rinse area with remaining cloth using clean surfaces with each wipe .Gently pat dry area with towel from anterior to posterior .Turn resident to the side and wash/rinse perianal area. Dry area .Remove gloves and wash hands . Review of the facility's undated policy titled, Hand Hygiene Guidelines, revealed .Apply generous amount of soap to hands and rub hands together vigorously for at least 20 seconds . 2. Review of the medical record revealed Resident #22 was admitted on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Major Depressive Disorder, and Neuromuscular Dysfunction of Bladder. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #22 had a Brief Interview for Metal Status (BIMS) score of 12, which indicated he was moderately cognitively impaired, and had an indwelling urinary catheter. Review of the Physician's Orders dated 8/1/2023, revealed .Catheter: Size 16fr [16 French] .Indwelling . Observation in the resident's room on 9/13/2023 at 9:48 AM, revealed Certified Nursing Assistant (CNA) #7 gathered her supplies, knocked on the door and entered Resident #22's room, placed the supplies on the over bed table, exited the room, donned her gown and mask, reentered the room, and went into the bathroom. CNA #7 filled the basin with warm water and placed the basin on the over bed table. CNA #7 donned her gloves, adjusted the bed with the remote, Resident #22 positioned himself onto his back. CNA #7 pulled back the blanket, removed the front side of the brief, applied a bath blanket, picked up the washcloth, submerged it in the water and applied soap. CNA #7 cleaned down the shaft of the penis, discarded the wash cloth, and with a clean wash cloth rinsed the penis. CNA #7 removed her gloves, donned new gloves, and failed to perform hand hygiene. CNA #7 wiped down the catheter tubing with a wet washcloth, removed her gloves, donned new gloves, and failed to perform hand hygiene. CNA #7 dried the catheter tubing with a dry washcloth, removed her gloves, donned new gloves, and failed to perform hand hygiene. Resident #22 rolled to his left side, CNA #7 grabbed a washcloth soaked with water, wiped from front to back, grabbed a dry washcloth, dried from front to back, positioned Resident #22 on his back, and applied a new brief. Resident #22's catheter tubing was not secured with a securement. 3. Review of the medical record revealed Resident #41 was admitted on [DATE], with diagnoses of Diabetes, Major Depression, Hypertension, and Retention of Urine. Review of the quarterly MDS dated [DATE], revealed Resident #41 had a BIMS score of 12, which indicated he was moderately cognitively impaired, and had a indwelling urinary catheter. Review of Physician's Orders dated 9/14/2023, revealed .Catheter .Indwelling 16 FR 10 cc [cubic centimeters] bulb .Obstructive Uropathy . Observation in the resident's room on 9/13/2023 at 11:05 AM, revealed CNA #4 knocked on the door and entered Resident #41's room, entered the bathroom, and washed her hands for only 10 seconds. CNA #4 gathered her supplies and placed them on the over bed table and exited the room to don her gown and mask. CNA #4 entered Resident #41's room, donned her gloves, entered the bathroom, and filled the basin with warm water. CNA #4 placed the basin on the over bed table, removed her gloves, entered the bathroom, and washed her hands for only 8 seconds. CNA #4 donned her gloves, opened the cabinet, and retrieved a brief, pulled the privacy curtain, turned back the blanket, adjusted Resident #41 in bed, removed the front side of the brief, submerged a washcloth in water and applied soap. CNA #4 pulled back the foreskin of the penis, cleaned around the tip of the penis. A large amount of dark stains were noted on the washcloth. CNA #4 proceeded to clean down the catheter tubing using the soiled washcloth. CNA #4 dried around the penis and the tubing with a clean washcloth, using the same gloved hands. CNA #4 rolled Resident #41 on his left side and the resident was noted with a moderate amount of bowel movement. CNA #4, with the same gloved hand, wiped Resident #41 with his brief from front to back, and failed to change her gloves and perform hand hygiene. CNA #4 used a wet, soapy washcloth and wiped Resident #41's perineum using a back and forth motion, then placed the washcloth in the trash bag. The washcloth was noted with a large amount of brown stains. CNA #4, with the same gloved hands, used a wet washcloth and wiped the perineum with a back and forth motion and placed the washcloth in a trash bag. CNA #4 retrieved bath towel and dried Resident #41's perineum with a back-and-forth motion; the bath towel was noted with a small amount of brown stain. CNA #4 applied Resident #41's brief, replaced his blanket, emptied the basin into the toilet, placed the basin on the sink, removed her gloves, removed her gown, and washed her hands for 10 seconds. CNA #4 failed to clean and dry the basin following catheter care. During an interview on 9/13/2023 at 11:25 AM, CNA #4 was asked should she wipe back and forth with the same washcloth during catheter and incontinent care. CNA #4 stated, .No . CNA #4 was asked should she have changed gloves and performed hand hygiene before starting catheter and incontinent care. CNA #4 stated, .Yes . CNA #4 was asked how long she should have washed her hands. CNA #4 stated, .30 seconds . CNA #4 was asked when she should have changed her gloves during indwelling catheter care and incontinent care. CNA #4 stated, .I'm not sure . Observation and interview in the resident's room on 9/13/2023 at 11:41 AM, CNA #4 entered Resident #22's room, pulled back his blanket and loosened his brief. CNA #4 was asked should the indwelling catheter be secured. CNA #4 stated, .Yes ma'am .to keep it from pulling . During an interview on 9/13/2023 at 1:07 PM, the Director of Nursing (DON) was asked to tell about the process for indwelling catheter care. The DON was asked when a resident has had a bowel movement how should staff clean the peri area. The DON stated, .wash their hands .don new gloves .clean from front to the back with each stroke using a different washcloth . The DON was asked should the staff member use the same washcloth in a back-and-forth motion to provide peri care to a resident who had a bowel movement. The DON stated, .No . clean with a different washcloth .if soiled they should change their gloves .wash their hands . The DON was asked how long the staff members should wash their hands. The DON stated, .for 20-30 seconds . The DON was asked should a resident's catheter be secured. The DON stated, .Yes . The DON was asked if the staff member change or remove their gloves should they perform hand hygiene. The DON stated .Yes .

Based on policy review, medical record review, review of facility investigation, and interview, the facility failed to provide documentation for an investigation of an allegation of abuse and failed to ensure a thorough investigation was completed for 1 of 5 (Resident #67) sampled residents reviewed for an allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse Prevention, dated 1/19/2017, revealed, .It is the policy of the facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. The following Procedures shall be implemented when an employee .becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party .All incidents will be documented, whether or not abuse occurred, was alleged or suspected .Any incident or allegation involving abuse or mistreatment will result in an abuse investigation .the Administrator or designee will investigate the allegation and obtain a copy of any documentation relative to the incident .the investigation team will follow the investigation procedures outlined in this policy. The Charge Nurse must complete an incident report and obtain a written, signed and dated statement from the person reporting the incident. A completed copy of the incident reported and written statements from the witnesses .will be provided to the Administrator. The final investigation report will be completed within the required timeframe allowed by the Tennessee Department of Health of the reported incident. The final report shall include facts determined during the process of the investigation, review of the medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts. The Administrator or person in charge of the facility will review the report. The Administrator or designee is then responsible for forwarding a final written report of the results of the investigation and any corrective action taken to the Department of Public Health .The findings of such investigation will be provided to the Administrator within 5 working days of occurrence of such incidents. The Administrator shall either rule out or substantiate the allegation of abuse. When an alleged or suspected case of abuse or neglect is reported to the Administrator, the Administrator or person in charge of the facility, will notify the following persons or agencies of such incident immediately .State Licensing and Certification Agency, Resident Representative, Attending Physician, Law Enforcement Officials .The investigator will submit a final report of the conclusion of the investigation in writing within 5 days of the incident. The final investigation report shall contain the following .Name, age, Diagnosis and mental status of the resident allegedly abused or neglected. The original allegation facts determined during the process of the investigation, review of the medical record and interview of witnesses .Conclusion of the investigation based on known facts .If the allegation is determined to be valid and the perpetrator is an employee, include on a separate sheet the employee's name, address, phone number, title, date of hire, copies of previous disciplinary actions and current status (still working, suspended or terminated) .Attach a summary of all interviews conducted, with names, addresses, phone numbers and willingness to testify of all witnesses .Upon receiving information concerning a report of abuse, the Administrator or Director of Nursing will request that a representative of the Social Services department monitor resident's feelings concerning the incident as well as the resident's reaction to his/her involvement in the investigation .the Social Service representative will provide the Administrator and the Director of Nursing with a written report of his/her findings in the resident's medical record. The facility shall report to the state nurse aide registry or licensing authorities any substantiated abuse determined by the facility investigation . 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Osteoarthritis, Depression, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #67 had a BIMS of 14, which indicated he was cognitively intact with no behaviors exhibited, and required extensive assistance of 1 to 2 staff members for most ADLs. Review of the Concern and Comment Report, dated 8/28/2023, revealed Resident #67's wife reported to the Director of Social Services that Resident #67's cell phone was broken. During an interview on 9/10/2023 at 11:16 AM, Resident #67 reported that an employee snatched his cell phone out of his hand because he called his wife when his call light wasn't answered timely. During an interview on 9/11/2023 at 11:35 AM, Resident #67's spouse confirmed that he told her that a CNA snatched the phone out of his hand, and it broke. Resident #67's spouse confirmed that she reported the incident to the Director of Social Services. During an interview on 9/11/2023 at 12:15 PM, the Director of Social Services confirmed an investigation was not completed into the incident regarding Resident #67's broken cell phone. During an interview on 9/11/2023 at 2:18 PM, the Director of Social Services confirmed Resident #67's wife reported to her that his cell phone was broken by a staff member. The Director of Social Services confirmed that she did not complete a thorough resident interview, obtain staff witness statements, or complete a thorough investigation. During an interview on 9/11/2023 at 2:47 PM, the Administrator confirmed that she was not made aware that Resident #67's wife reported on 8/28/2023 that a staff member had snatched his cell phone from his hand and broken it. The Administrator confirmed that she was made aware of the incident on 9/11/2023 and an investigation was begun at that time. The Administrator confirmed the incident should have been investigated timely.

Based on policy review, medical record review, and interview, the facility failed to timely report an allegation of abuse for 1 of 5 (Resident #67) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the policy titled, Abuse Prevention Program, dated 1/19/2017, revealed .It is the policy of this facility to prevent resident abuse .The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident .Abuse Reporting .All personnel must promptly report any incident or suspected incident of resident abuse .Any alleged violations involving mistreatment, abuse .misappropriation of resident's property .MUST be reported to the Administrator and Director of Nursing .the person(s) observing an incident of resident abuse or suspecting resident abuse must IMMEDIATELY report such incidents to the Charge Nurse, regardless of time lapse since the incident occurred. The Charge Nurse will immediately report the incident to the Administrator or to the individual in charge of the facility . 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Osteoarthritis, Depression, and Anxiety Disorder. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #67 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated he was cognitively intact with no behaviors exhibited, and required extensive assistance of 1 to 2 staff members for most activities of daily living (ADLs). Review of the Concern and Comment Report, dated 8/28/2023, revealed .Spouse reported cell phone has been broken .SW [Social Worker] f/u [follow up] with resident's spouse re: [regarding] Reimbursement of cell phone in person [symbol for and] on telephone call .[Director of Social Services signature] .8/31/2023 . During an interview on 9/10/2023 at 11:16 AM, Resident #67 alleged that a staff member had snatched his cell phone from his hand and broken it. During an interview on 9/11/2023 at 11:35 AM, Resident #67's spouse confirmed that he told her a Certified Nursing Assistant (CNA) snatched his cell phone from his hand and broke it. Resident #67's spouse confirmed that she reported the allegation to the Director of Social Services, who told her the facility would replace the phone. During an interview on 9/11/2023 at 12:15 PM, the Director of Social Services was asked for a copy of the investigation into the incident where Resident #67's cell phone had been broken. The Director of Social Services confirmed she only had a Concern and Comment Report that she filled out. The Director of Social Services confirmed that Resident #67's spouse told her that a staff member broke it and when she asked the resident what happened to his phone, he had just said it was broken. The Director of Social Services stated, I got 2 different stories, so I didn't do anything further. During an interview on 9/11/2023 at 2:18 PM, the Director of Social Services was asked about Resident #67's broken cell phone. The Director of Social Services stated, His wife actually called and told me a couple of days ago he reported his cell phone got broken .she said the young lady snatched it and broke it .that was the end of August .I went to the room .and asked [named Resident #67] can you tell you about your cell .he said it's broken, see it's broken, it's over there .I didn't dress out to go in .stuck my head in the door . The Director of Social Services confirmed Resident #67 was in isolation due to a Covid-19 diagnosis and she did not enter the room to complete a thorough interview. The Director of Social Services confirmed she did not obtain statements from staff. The Director of Social Services confirmed that she reported Resident #67's cell phone was broken to the Administrator, but she did not report that the resident's spouse stated a staff member had broken the phone. During an interview on 9/11/2023 at 2:47 PM, the Administrator was asked when she was made aware of Resident #67's broken cell phone. The Administrator stated, .End of August .reported that his phone was broken, and the wife had asked for reimbursement . [I was] only told that the phone was broken, brought a reimbursement form to sign off on . The Administrator was asked was she told at that time that the resident alleged a staff member had broken the phone. The Administrator stated, No, I was never told that, she told me today [named the Director of Social Services]. The Administrator was asked what should have been done when Resident #67's spouse reported to the Director of Social Services that his cell phone had been broken. The Administrator stated, It should be reported to me immediately as the Abuse Coordinator . The Administrator was asked what the facility's process was when an allegation of abuse was reported to a staff member. The Administrator stated, Immediately start our investigation, normally send the [named the Director of Social Services] down with one other staff member to interview .I call the family .also start staff interviews, pull timelines of when staff members work, see who worked .interview all interviewable residents .skin audits .report it to the State .complete an incident report .make sure medical director is aware, ombudsman, APS [Adult Protective Services] .police as well. Then all of the staff is pretty much a part .any confidential witness statements, any staff or residents in the areas . The Administrator was asked did she agree that this incident should have been reported and investigated. The Administrator stated, Yes, I agree.

Based on policy review, medical record review, facility investigation, and interview, the facility failed to ensure residents' were free from abuse for 1 of 5 (Resident #67) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Abuse Prevention dated 1/19/2017, revealed .It is the policy of the facility to prevent resident abuse, neglect, mistreatment and misappropriation of resident property. Each resident receives care and services in a person-centered environment in which all individuals are treated as human beings. Abuse is the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, mental anguish or deprivation by an individual, including caretaker .Verbal Abuse .Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability . Neglect/Mistreatment .means failure to provide, or willful withholding of adequate medical care .personal care or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish or mental illness of a resident . 2. Review of the medical record revealed Resident #67 was admitted to the facility on [DATE], with diagnoses of Chronic Obstructive Pulmonary Disease, Osteoarthritis, Depression, and Anxiety. Review of the admission MDS dated [DATE], revealed Resident #67 had a BIMS of 14, which indicated he was cognitively intact with no behaviors exhibited, and required extensive assistance of 1 to 2 staff members for most ADLs. Review of the Concern and Comment Report, dated 8/28/2023, revealed .Spouse reported cell phone has been broken .SW [Social Worker] f/u [follow up] with resident's spouse re: [regarding] Reimbursement of cell phone in person [symbol for and] on telephone call . [Director of Social Services signature] .8/31/2023 . During an interview conducted on 9/10/2023 at 11:16 AM, Resident #67 stated, .an employee came in here and snatched the phone out of my hand .because I call my wife all the time when I need something when they don't come answer my call light . During an interview conducted on 9/11/2023 at 11:35 AM, Resident #67's spouse was asked about the resident's cell phone. Resident #67's spouse confirmed that he told her that a CNA snatched the phone out of his hand, and it broke. Resident #67's spouse confirmed that she reported to the Director of Social Services that her husband had told her a CNA had snatched his phone from his hand and it had broken, and that the Director of Social Services told her the facility would replace the phone. During an interview on 9/11/2023 at 12:15 PM, the Director of Social Services was asked for a copy of the investigation into the incident where Resident #67's cell phone was broken when a CNA snatched it from his hands. The Director of Social Services confirmed she only had a Concern and Comment Report that she filled out. The Director of Social Services confirmed that Resident #67's spouse told her that a staff member broke it and when she asked the resident about the cell phone, he just said it was broken. The Director of Social Services stated, I got 2 different stories, so I didn't do anything further. During an interview on 9/11/2023 at 2:18 PM, the Director of Social Services confirmed that after Resident #67's wife reported that the resident's cell phone was broken she went to his room to ask him about the incident, but he was positive for Covid-19 and she did not enter the room to speak with the resident. The Director of Social Services confirmed that she asked the staff members who were at the Nursing Station about the incident, she could not remember the names or how many staff members were present, and the staff denied any knowledge of the cell phone being broken. The Director of Social Services confirmed she failed to obtain any written statements from staff regarding the broken cell phone. The Director of Social Services was asked did she report the incident to anyone. The Director of Social Services stated, I want to say [named Unit Manager #1] .I think I brought it up in clinical [meeting] .but we didn't know the true details until today . The Director of Social Services stated, She didn't say snatched. She said he said she broke it . The Director of Social Services was asked did Resident #67's spouse not tell you that a staff member had snatched it from him. The Director of Social Services stated, She said he reported to her that a staff member broke it. Today she said he said she [staff member] snatched it. The Director of Social Services confirmed that if a resident reported that a staff member destroyed their personal property the incident should be fully investigated, staff statements should be obtained, an incident report should be completed, and the Administrator should be notified. The Director of Social Services was asked did she feel like she completed a thorough investigation of the incident. The Director of Social Services stated, .It wasn't as thorough as it should have been .I guess I should have went farther with it .to get more details, I was just trying to not have the wife upset, satisfy her, and satisfy him. The Director of Social Services confirmed that she reported Resident #67's cell phone was broken to the Administrator, but she did not report that the resident's spouse stated a staff member had broken the phone. During an interview on 9/11/2023 at 2:47 PM, the Administrator was asked when she was made aware of Resident #67's broken cell phone. The Administrator stated, End of August .reported that his phone was broken, and the wife had asked for reimbursement . [I was] only told that the phone was broken, brought a reimbursement form to sign off on and that's the process we follow to get [give] to corporate . The Administrator was asked was she told at that time that the resident alleged a staff member had broken the phone. The Administrator stated, No, I was never told that, she [named the Director of Social Services] told me today [9/11/2023]. The Administrator confirmed that she started the investigation into the incident today when she was made aware that Resident #67 alleged a staff member had broken his cell phone. The Administrator was asked what should have been done when Resident #67's spouse reported to the Director of Social Services that his cell phone had been broken. The Administrator stated, It should be reported to me immediately as the Abuse Coordinator .it's up to us to investigate and find the truth in it . The Administrator was asked what the facility's process was when an allegation of abuse was reported to a staff member. The Administrator stated, Immediately start our investigation, normally send the [named the Director of Social Services] down with one other staff member to interview .I call the family .this is our process .also start staff interviews, pull timelines of when staff members work, see who worked .interview all interviewable residents .skin audits .report it to the State .complete an incident report .make sure medical director is aware, ombudsman, APS [Adult Protective Services] as well .police as well. Then all of the staff is pretty much a part .any confidential witness statements, any staff or residents in the areas The Administrator was asked did she agree that this incident should have been reported and investigated. The Administrator stated, Yes, I agree.

Based on policy review, job description review, pharmacy service agreement, medical record review, observation, and interview the Quality Assurance Performance Improvement (QAPI) committee failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns related to ensuring significant heart and [CONDITION(S)] medications and other medications were administered as ordered by the physician, ensure irregularities in the resident's drug regimen were identified and developing corrective actions designed to effect change at the systems level to prevent quality of life, quality of care, or safety problems; and monitor the effectiveness of its performance activities to ensure that improvements were sustained, which had the likelihood to result in serious harm or injury to a resident. The facility failed to ensure the QAPI committee reviewed and validated systemic problems and determined a system was in place to identify and determine underlying causes of medication administration and pharmacy issues for 31 of 33 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31) reviewed that required medications. The facility's failure resulted in Immediate Jeopardy when these residents who required significant medications such as cardiac medications, [CONDITION(S)] medications, diabetes medications, antibiotic medications, gastrointestinal medications, and medications for mental health disorders did not receive their scheduled medications as ordered by the physician. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy for F-867 on [DATE] at 4:08 PM, in the conference room. The facility was cited Immediate Jeopardy at F-684, F-756, F-760, F-835, and F-867. The facility was cited at F-684 and F-760 at a scope and severity of K, which is Substandard Quality of Care. The IJ existed from [DATE] through [DATE]. An acceptable Removal Plan for F-867, which removed the immediacy of the jeopardy, was received on [DATE] at 2:16 PM, was validated onsite by the surveyors on [DATE] through observations, review of records, review of audits, meeting minutes and staff interviews. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program and Plan, revised 2017, revealed .It is the mission of Quality Assurance and Performance Improvement Program and Plan to develop, implement, and maintain an effective, comprehensive, and data driven QAPI Program in accordance with Federal Guidelines that focuses on indicators of outcomes of quality of care and quality of life for our residents. The objective of the QAPI Program and Plan is to identify the high risk, problem prone, and high volume areas to evaluate for improvement and identify, collect, and use data relevant to the unique characteristics and needs of our residents .The QAPI Program is ongoing and comprehensive to address the full range of care and services provided by the facility .The Administrator is accountable for the QAPI Program and assumes full responsibility. The QAPI Program: Is defined, implemented, and maintained. Addresses identified priorities, quality deficiencies, and opportunities for improvement. Is sustained during transitions in leadership and staffing. Is adequately resourced including staff time, equipment, and technical training as needed. Identifies and prioritizes problems and opportunities based on performance indicator data, resident input, and other information. Implements actions aimed at performance improvement to address gaps in systems and the effectiveness of the corrective actions. Evaluates implemented corrective actions and tracks performance to ensure improvements are realized and maintained. Has clear expectations for safety, quality, rights, choice, and respect .The QAPI Committee and Meetings: The Administrator delegates the necessary authority for the QAPI Committee to establish, maintain, and oversee the QAPI Program. The QAPI Committee is responsible to identify and respond to quality deficiencies and oversight the QAPI Program throughout the facility; the committee develops and implements corrective actions, monitors to ensure performance goals or targets are achieved, and revisits corrective actions when necessary .The committee collects data from various sources related to high risk, high volume, and problem prone issues, consider the incidence, prevalence, and severity of problems in those areas, and the collected data is analyzed to identify performance indicators signaling a deviation from expected performance. The issue is studied using a Root Cause Analysis [RCA] process to determine underlying causes and contributing factors .Data is analyzed using a Root Cause Analysis to determine underlying causes of problems and impact on facility systems .The Plan Do Study Act [PDSA] Cycle is used to test the corrective actions recommended .RCA completed to prevent reoccurrence and reduce possible adverse events . Review of the undated Administrator job description revealed .The Administrator leads and directs the overall operation of the facility in accordance with resident needs, federal and state government regulations and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives .Demonstrates knowledge .in directing the overall operation of the facility's delivery of care .Works with the facility management staff and consultants in planning all aspects of facility's operations, including setting priorities and job assignments. Monitors each department's activities, communicates policies, evaluates performance, provides feedback and assists, coaches and disciplines as needed .Maintains a working knowledge and ensures compliance with all governmental regulations and company Quality Assurance Standards .Supervises, conducts and participates in department and facility education activities and staff meetings .Is aware of, and adheres to, Resident's Bill of Rights and Confidentiality of Resident Information .Ensures understanding of, and compliance with, all rules regarding resident's rights . Review of the undated DON job description revealed .Under the supervision of the Administrator, the Director of Nursing has the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff, in addition to the supervision of the Therapy Department and its' functions within the facility. In the absence of the Administrator, the DON assumes responsibility for the facility. The DON is responsible for the overall management of resident care 24 hours a day, seven [7] days per week. The DON is delegated the responsibility for carrying out the assigned duties in accordance with current existing federal and state regulations and established company policies and procedures .Demonstrates knowledge .in planning delivery of care. Demonstrates knowledge, skills and techniques necessary to care for residents .Acts appropriately under the direction of the Administrator and acts as an active member of the interdisciplinary team. Demonstrates ability to adjust to changes in shift assignments to meet resident and family needs. Ensures the residents receive skilled nursing and rehabilitation services, as needed .Develops and periodically updates statements of philosophy and objectives that define the type of nursing care the facility proposes to provide. Ensures that these are understood and implemented by nursing personnel. Supervises, evaluates, counsels, and disciplines inter-departmental personnel .Participates in all screening processes prior to admission. Assesses items needed by the facility to meet resident needs. Participates in coordination of resident services through departmental and appropriate staff committee meetings [i.e. Quarterly Quality Assurance and Assessment, Pharmacy Services, Therapy Services, Infection Control and Resident Care policy and procedure meeting). Plans staff development programs that will enhance staff knowledge of quality resident care. Conducts periodic review to ensure all documentation is informative and descriptive of nursing care and of the resident's response to that care .Conducts periodic review to ensure that the nursing requirements of each resident admitted to the facility are reviewed and that the physician is consulted in planning resident care . Review of the facility's pharmacy service agreement titled, [Named Pharmacy] Pharmacy Services Agreement [Named Facility] Rehabilitation & Nursing Center, dated [DATE], revealed .Pharmacy Consulting Services - Exhibit A .[Named Pharmacy] will provide pharmacy consulting services in conjunction with Facility's duties under applicable law. Such duties may include as applicable, monthly inspections of each of the Facility's nursing stations, the drug storage area, and medical records to monitor compliance with pharmacy policies and procedures and state and federal regulations; the provision of a written report regarding the inspections and the results of the drug regimen review, noting any irregularities or other areas of concern .Quality Assurance Meetings. [Named Pharmacy] will participate in regularly scheduled quarterly quality assurance meetings with the Facility's staff to review issues regarding pharmacy procedures . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Cap [capsule] 180 mg [milligrams] SR [sustained release] give 1 tablet by mouth at bedtime related to Essential [Primary] Hypertension . Review of the Nurse Practitioner (NP) Progress Note dated [DATE], revealed .Patient seen today after nurse report patient has been acting more confused than normal .Her blood pressure was in the 90s systolically. She is currently on [MEDICATION(S)] 180 mg at night. She had to be sternal rub to elicit a response .[CONDITION(S)] hold [MEDICATION(S)], give 500 normal saline bolus x [times]1 . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Cap 180 mg SR hold . Review of Resident #1's medical record from [DATE] - [DATE], revealed [MEDICATION(S)] Cap 180 mg SR continued to be held. During an interview on [DATE] at 4:00 PM, the Admission Nurse stated, .I don't know why it [[MEDICATION(S)]] is on hold and why it is still being held. That order was for a hypotensive episode [DATE] .The nurse practitioner that ordered the hold on [DATE] at 11:39 AM failed to complete the order with no documented reason or how many days and when to flip back from on hold to resume or discontinue .She [NP] saw her one more time [DATE] and never returned to the facility .no one ever discontinued the [MEDICATION(S)] or resumed it . The Admission Nurse confirmed the facility and pharmacist failed to notify the physician of the continued hold of a hypertensive medication for 5 months. During a telephone interview on [DATE] at 12:13 PM, the Pharmacist stated, .We have been sending [MEDICATION(S)] HCL SR 180 mg at bedtime since [DATE] .We never received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1] [MEDICATION(S)] 180 mg to be held. We have been sending a weekly supply since August of 2021 .the latest seven-day supply was sent on [DATE] . Review of the Pharmacy Consult Note dated [DATE], revealed .[Named Resident #1] no recommendations . Observations, medical record review, and interviews during the survey revealed Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 did not receive their anticonvulsant medications, antiarrhythmic medications, antihypertensive medications, antibiotics, antiplatelet medications, antidiabetic medications, medications to treat [CONDITION(S)] (elevated cholesterol and triglycerides), dietary supplements/vitamins, medications to treat Gout, antidepressant medications, medications to treat Gastroesophageal Reflux Disease, medications to treat muscle spasms, medications to treat enlarged prostate, antiparkinson medications, antipsychotic medications, antianxiety medications, and medications to treat dementia. Refer to F-684 and F-760. Review of the facility's QAPI minutes dated [DATE], revealed no documentation of review or actions implemented from the monthly Pharmacy Consultant Report. During an interview on [DATE] at 10:58 AM, the Administrator was asked if the committee reviewed, discussed, developed, and implemented any actions related to medication administration by nursing, medications, and the Pharmacy Consultant Report findings in the QAPI meetings. The Administrator stated, .Nothing .We did nothing and did not go over the Pharmacy Consultant Report .I have been here since August [2021] . During an interview on [DATE] at 10:58 AM, the Assistant Director of Nursing (ADON) was asked if nursing provided any medication related information to the QAPI committee and was the nursing management team aware of the Pharmacy Consultant Report findings. The ADON stated, .No .I knew nothing about them [Pharmacy Consultant Report] or any findings . During an interview on [DATE] at 10:58 AM, the Regional Nurse Consultant stated, .This is something we now recognize and will be working on . During a telephone interview on [DATE] at 11:43 AM, the Medical Director stated, .I was unaware of these issues you discovered .They didn't catch this .Definite changes are coming . During an interview on [DATE] at 1:46 PM, the Administrator was asked what involvement she had with QAPI. The Administrator stated, .I am responsible for QAPI. I oversee it .Nothing was brought to my attention about pharmacy by nursing . The surveyors verified the Removal Plan by: 1. A 30 day look back was conducted on all residents facility-wide by licensed nurses to establish a targeted list of residents who have been identified as failing to have received their ordered medications as evidenced by the lack of documentation on the Medication Administration Record (MAR) which shows holes in the documentation indicating no administration of that medication on a specific day/date at the ordered time. Residents who had evidence of missing medications were assessed for any adverse signs/symptoms that could result in not having received the medications as ordered by the physician. The focus medications were heart, [CONDITION(S)] related, diabetes, gastrointestinal health, and mental health. No significant adverse signs/symptoms were identified. The surveyors reviewed the audits, interviewed the Regional Director of Operations (RDO), the Medical Director, the Administrator, and nurses on all shifts. 2. MAR documentation will be reviewed at the end of each shift by a second nurse to ensure all medications have been administered timely. The 2nd nurse will audit the medication cart to ensure all medications were given as ordered. Any concerns will be addressed. The surveyors interviewed nurses working on all medication carts, reviewed in-service materials and post-tests. Return demonstration was observed of a 2nd nurse reviewing documentation of the MAR and medication cart audit. 3. The QAPI Committee was in-serviced by the Regional Director of Operations (RDO) on all aspects, principles, and objectives for the QAPI program, including the agenda plan and tools. Systematically timed audits and review of information to be completed in order to identify deficits in the current programs and systems. The QAPI program is to be led by the Administrator. A post-test requiring 100% accuracy to pass was required following the in-service. The surveyors reviewed the audit form, in-service material, post-tests, and signature sheets. 4. The RDO or Regional Nurse Consultant (RNC) will be onsite at least 3 days weekly for 4 weeks. Daily updates will be provided by a Regional Team member to the Regional Vice President (RVP) for 4 weeks with focus on medication administration and pharmacy services oversight. The frequency of further oversight will be determined at the end of the 4 weeks by the Regional Vice President (RVP), RDO, and RNC. The RDO will monitor any written action plan weekly until resolved. A member of the Regional Team will attend weekly QAPI meetings. When QAPI meeting return to monthly, a Regional Team member will attend monthly QAPI meetings for at least 6 months. The surveyors interviewed members of the Regional Team, the Administrator, the DON, and members of the Interdisciplinary Team (IDT). The facility's noncompliance at F-867 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, job description review, pharmacy service agreement, medical record review, observation, and interview, the facility Administration failed to administer the facility in a manner to provide oversight of pharmacy services, failed to provide oversight of nursing services administration of medications to the residents which included the administration of significant medications and other medications, and failed to ensure residents received the highest level of care possible for 30 of 33 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31) reviewed that required medications such as cardiac medications, [CONDITION(S)] medications, diabetes medications, gastrointestinal medications, and medications for mental health disorders. These failures resulted in Immediate Jeopardy when Administration failed to have a system in place to ensure care and services were provided safely for residents requiring pharmacy and nursing services. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for F-835 on 2/12/2022 at 4:08 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-684, F-756, F-760, F-835, and F-867. The facility was cited F-684 and F-760 at a scope and severity of K, which is Substandard Quality of Care. The IJ existed from 1/29/2022 through 2/14/2022. An acceptable Removal Plan for F-835, which removed the immediacy of the jeopardy, was received on 2/13/2022 at 2:16 PM, and was validated onsite by the surveyors on 2/14/2022 through observations, review of records, review of audits, and staff interviews. The findings include: Review of the undated Administrator job description revealed .The Administrator leads and directs the overall operation of the facility in accordance with resident needs, federal and state government regulations and company policies/procedures so as to maintain quality care for the residents while achieving the facility's business objectives .Demonstrates knowledge .in directing the overall operation of the facility's delivery of care .Works with the facility management staff and consultants in planning all aspects of facility's operations, including setting priorities and job assignments. Monitors each department's activities, communicates policies, evaluates performance, provides feedback and assists, coaches and disciplines as needed .Maintains a working knowledge and ensures compliance with all governmental regulations and company Quality Assurance Standards .Supervises, conducts and participates in department and facility education activities and staff meetings .Is aware of, and adheres to, Resident's Bill of Rights and Confidentiality of Resident Information .Ensures understanding of, and compliance with, all rules regarding resident's rights . Review of the undated Director of Nursing job description revealed .Under the supervision of the Administrator, the Director of Nursing has the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff .In the absence of the Administrator, the DON assumes responsibility for the facility. The DON is responsible for the overall management of resident care 24 hours a day, seven [7] days per week. The DON is delegated the responsibility for carrying out the assigned duties in accordance with current existing federal and state regulations and established company policies and procedures .Demonstrates knowledge .in planning delivery of care. Demonstrates knowledge, skills and techniques necessary to care for residents .Acts appropriately under the direction of the Administrator and acts as an active member of the interdisciplinary team. Demonstrates ability to adjust to changes in shift assignments to meet resident and family needs. Ensures the residents receive skilled nursing and rehabilitation services, as needed .Develops and periodically updates statements of philosophy and objectives that define the type of nursing care the facility proposes to provide. Ensures that these are understood and implemented by nursing personnel. Supervises, evaluates, counsels, and disciplines inter-departmental personnel .Participates in all screening processes prior to admission. Assesses items needed by the facility to meet resident needs. Participates in coordination of resident services through departmental and appropriate staff committee meetings (i.e. Quarterly Quality Assurance and Assessment, Pharmacy Services, Therapy Services, Infection Control and Resident Care policy and procedure meeting). Plans staff development programs that will enhance staff knowledge of quality resident care. Conducts periodic review to ensure all documentation is informative and descriptive of nursing care and of the resident's response to that care .Conducts periodic review to ensure that the nursing requirements of each resident admitted to the facility are reviewed and that the physician is consulted in planning resident care . Review of the facility's policy titled, Administrative Management, reviewed 12/2008, revealed .Our facility's governing body is the supreme authority and has full legal authority and responsibility for the management and operation of our facility. The Administrator is accountable to the governing body. The Administrator has been given the authority and responsibility for the management of the nursing home and the implementation of the facility's policies. The Administrator shall assure the provision of appropriate fiscal resources and personnel required to meet the needs of residents admitted . Review of the facility's pharmacy service agreement titled, [Named Pharmacy] Pharmacy Services Agreement [Named Facility] Rehabilitation & Nursing Center, dated 8/16/2021, revealed .Pharmacy Consulting Services - Exhibit A .[Named Pharmacy] will provide pharmacy consulting services in conjunction with Facility's duties under applicable law. Such duties may include as applicable, monthly inspections of each of the Facility's nursing stations, the drug storage area, and medical records to monitor compliance with pharmacy policies and procedures and state and federal regulations; the provision of a written report regarding the inspections and on the results of the drug regimen review, noting any irregularities or other areas of concern .Quality Assurance Meetings. [Named Pharmacy] will participate in regularly scheduled quarterly quality assurance meetings with the Facility's staff to review issues regarding pharmacy procedures . Observations, medical record review, and interviews during the survey revealed Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31 did not receive their anticonvulsant medications, antiarrhythmic medications, antihypertensive medications, antibiotics, antiplatelet medications, antidiabetic medications, medications to treat [CONDITION(S)] (elevated cholesterol and triglycerides), dietary supplements/vitamins, medications to treat Gout, antidepressant medications, medications to treat [CONDITION(S)], medications to treat muscle spasms, medications to treat enlarged prostate, antiparkinson medications, antipsychotic medications, antianxiety medications, and medications to treat dementia. Refer to F-684 and F-760. During an interview on 2/12/2022 at 10:58 AM, the Administrator was asked if the QAPI committee reviews, discusses, develops, and implements any actions related to nursing medication administration, medications administered, and Pharmacy Consultant Report findings in QAPI meetings. The Administrator stated, .Nothing .We did nothing and did not go over the Pharmacy Consultant Report .I have been here since August [2021] . During a telephone interview on 2/12/2022 at 11:43 AM, the Medical Director stated, .I was unaware of these issues you discovered .They didn't catch this .Definite changes are coming . During an interview on 2/12/2022 at 1:46 PM, the Administrator stated, .I have been here since August [2021] and I have had four DONs [Director of Nursing] since I have been here with the latest started two days ago .Nothing was brought to my attention about pharmacy by nursing .I had no idea there were these issues . The surveyors verified the Removal Plan by: 1. A 30 day look back was conducted on all residents facility-wide by licensed nurses to establish a targeted list of residents who have been identified as failing to have received their ordered medications as evidenced by the lack of documentation on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Residents who had evidence of missing medications were assessed for any adverse signs/symptoms that could result in not having received the medications as ordered by the physician. The focus was heart and/or [CONDITION(S)] related medications, diabetes, gastrointestinal health, and mental health. No significant adverse signs/symptoms were identified. The surveyors reviewed the audits, interviewed the Regional Director of Operations (RDO), the Medical Director, the Administrator, and nurses on all shifts. 2. Documentation on the MARs will be reviewed at the end of each shift by a 2nd licensed nurse and an audit of the medication cart to ensure all medications were administered as ordered. Any concerns will be immediately addressed. The Administrator and the Interdisciplinary Team (IDT) will provide oversight to include pharmacy services. The RDO and the Regional Nurse Consultant (RNC) will review the resources available to the Administrator, DON, and the IDT to include outside vendors/providers with the focus on needed Pharmacy Consultant oversight to validate and ensure compliance with care and service with focus on the pharmacy. The pharmacy provider will provide a Pharmacy Consultant visit weekly for 4 weeks. A Regional team member will be onsite in the facility daily until compliance with pharmacy oversight has been authorized by the state. The RDO will monitor at least weekly for a period of 3 months to validate with the Administrator to ensure pharmacy oversight is adequate. The surveyors interviewed the Administrator, the Medical Director, the RDO, the RNC, and reviewed the scheduled plan of the Pharmacy Consultant visits to perform audits and interviewed nurses providing resident care. 3. The Administrator and the IDT were in-serviced by the RDO on 2/13/2022 as to the required resources available from the pharmacy oversight/review services. The process of attaining the services was explained in the in-service to the Administrator and the IDT. The surveyors reviewed the in-service, reviewed post tests and sign-off documentation of staff and interviewed members of the IDT. 4. The RDO or RNC will be onsite at least 3 days weekly for 4 weeks. Daily updates will be provided by a Regional Team member to the Regional Vice President for 4 weeks with focus on medication administration and pharmacy services oversight. The RDO will monitor any written action plan weekly until resolved. A member of the Regional Team will attend weekly QAPI meetings. When QAPI meeting return to monthly, a Regional Team member will attend monthly QAPI meetings for at least 6 months. The surveyors interviewed members of the Regional Team, the Administrator, the DON, and members of the IDT. The facility's noncompliance at F-835 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on policy review, pharmacy service agreement, medical record review, observation, and interview, the facility failed to ensure residents were free from significant medication errors when significant medications including cardiac medications, antiarrhythmics, antihypertensive, anticonvulsant, and antiplatelets were not administered as ordered. One or more unit doses scheduled to be administered prior to 2/8/2022 were observed in the medication carts and had not been administered for 22 of 33 sampled residents (Resident #1, #2, #3, #4, #5, #6, #9, #10, #12, #14, #15, #16, #18, #19, #20, #21, #22, #24, #25, #27, #28, and #30). The facility's failure resulted in Immediate Jeopardy when these residents failed to receive the necessary significant medications resulting in a likelihood of a serious adverse outcome such as cardiac complications, seizures, risk of bleeding, or death. The facility had a census of 63. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 2/11/2022 at 5:36 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-760. The facility was cited F-760 at a scope and severity of K, which is Substandard Quality of Care. The IJ existed from 1/29/2022 through 2/13/2022. An acceptable Removal Plan for F-760, which removed the immediacy of the jeopardy, was received on 2/12/2022 at 6:02 PM, and was validated onsite by the surveyors on 2/14/2022 through observations, review of records, review of audits, and staff interviews. The findings include: Review of the facility's policy titled, Physician's Care, reviewed 12/2008, revealed .The Physician will provide orders which enable the interdisciplinary team to develop a comprehensive treatment plan including medications .Such orders will be updated and revised at appropriate intervals . Review of the facility's pharmacy service agreement titled, [Named Pharmacy] Pharmacy Services Agreement [Named Facility] Rehabilitation & Nursing Center, dated 8/16/2021, revealed .Pharmacy Consulting Services - Exhibit A .[Named Pharmacy] will provide pharmacy consulting services in conjunction with Facility's duties under applicable law. Such duties may include as applicable, monthly inspections of each of the Facility's nursing stations, the drug storage area, and medical records to monitor compliance with pharmacy policies and procedures and state and federal regulations; the provision of a written report regarding the inspections and on the results of the drug regimen review, noting any irregularities or other areas of concern .Quality Assurance Meetings. [Named Pharmacy] will participate in regularly scheduled quarterly quality assurance meetings with the Facility's staff to review issues regarding pharmacy procedures . Review of the facility's undated policy titled, Medication Administration, revealed .Purpose: To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration .Licensed professional nurses administer medications according to times documented on the Medication Administration Record .Medication Administration Record will be signed after for each medication administered to the resident . Review of the facility's undated policy titled, Section 5.0 Medication Administration, revealed .5.1: Drug Administration-General Guidelines .Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known. The licensed nurse is aware of an indication for the resident receiving medication, usual dose, parameters and routes, contraindications, allergies, precautions, and side effects .Procedure: Medications are administered in accordance with written orders of the attending physician .Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's MAR [Medication Administration Record] at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications . Review of the facility's undated policy titled, Change in Resident's Condition or Status, revealed .Policy: It is the policy of the facility to ensure that the resident's attending physician and Representative are notified of changes in the resident's condition or status .The nurse will notify the resident's attending physician when: The resident repeatedly refuses treatment or meds [2 times consecutively or 3 times in a 7 day period] .A significant change in condition is a decline or improvement in the resident's status that requires interdisciplinary review and/or revision of the care plan . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] .[MEDICATION(S)] 500 mg [an anticonvulsant] tab [tablet] give 1 tablet by mouth two times a day related to Seizures . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 500 mg scheduled to be given on 2/3/2022 at 9:00 AM, and [MEDICATION(S)] 500 mg scheduled 2/4/2022 at 5:00 PM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 1:30 PM, the Assistant Director of Nursing (ADON) confirmed the medications were in the cart and had not been administered to Resident #1 as ordered by the Physician. She stated, .Yeah, I see it .I don't know why the [MEDICATION(S)] was not given . During an interview on 2/9/2022 at 12:13 PM, the Pharmacist stated, .We only send out a 7-day supply of medications for all Ms. [Named Resident #1] meds [medications] and it was delivered 2/3/2022 . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Active Orders Report dated 2/8/2022, revealed .[start date 2/2/2022] [MEDICATION(S)] [HCL] tablet 200 mg [a medication used to treat irregular heart rate] give 1 tablet by mouth two times a day related to [CONDITION(S)] [irregular heart rate] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 200 mg scheduled to be given 2/4/2022 at 5:00 AM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 2:00 PM, the ADON confirmed the observations of the [MEDICATION(S)] 200 mg doses that remained in the medication cart and had not been administered. She stated, .Yeah, I see it .I don't know why was not given . During an interview on 2/9/2022 at 12:13 PM the Pharmacist stated, .We only send out a 7-day supply of medications for all Ms. [Resident #2] meds [medications] and it was delivered 1/27/2022 and 2/3/2022 .[MEDICATION(S)] were in that delivery . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Active Orders Report dated 2/8/2022, revealed .[date start 12/27/2021] [MEDICATION(S)] [a medication used to treat Diabetes] 5 mg by mouth two times a day for Type 2 Diabetes Mellitus .[start date 1/7/2022] [MEDICATION(S)] Tablet 7.5-325 mg [[MEDICATION(S)]-Acetaminophen] give 1 tablet [a narcotic used to treat pain] by mouth every 6 hours as needed for pain . Review of the admission MDS assessment dated [DATE], revealed Resident #3 scored an 11 on the BIMS assessment, which indicated moderately impaired for daily decision-making task. Observation of the 100 Hall Medication Cart on 2/11/2022 at 1:00 PM, revealed [MEDICATION(S)] 5 mg scheduled to be given on 2/10/2022 at 5:00 PM, remained in the medication cart and had not been administered. During an interview on 2/11/2022 at 3:20 PM, Licensed Practical nurse (LPN) #3 confirmed the [MEDICATION(S)] 5 mg scheduled for 2/10/2022 at 5:00 PM was in the medication cart and had not been administered to Resident #3 as ordered by the Physician. During an interview on 2/13/2022 at 1:30 PM, Resident #3 stated, .I have not gotten my pain pill today. I asked for it this morning. When I asked the nurse, she told me the pharmacy hadn't delivered it . During an interview at the 100 Hall Nurses' Station on 2/13/2022 at 1:35 PM, LPN #4 was informed Resident #3 was requesting a pain pill. She stated, .Oh, I have already given him one . LPN #4 was asked to reveal the narcotic sheet and count. She was unable to do so and stated, .Oh, it is over here . and went to a drawer at the Nurses' Station. She pulled out an empty [MEDICATION(S)]-Acetaminophen card with Resident #3's name on it and a Controlled Drug Receipt Record/Disposition Form with Resident #3's name on it. The last dose of [MEDICATION(S)]/Acetaminophen 7.5 mg-325 mg tablet was documented as administered on 2/12/2022 at 9:00 AM and was given by LPN #4 with a no tablets left in the card. When LPN #4 was asked why she said she had not given him one today, 2/13/2022, she stated, .Oh, I ordered it yesterday per the computer and it hadn't come in yet . She would not answer the question asked. LPN #4 was asked what the status of the order was. She stated, .I don't know .No, I have not followed up . The House Supervisor stated, .I will find out why it did not come last night, and we can go to back up and get him one for now. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 scored 15 on the BIMS assessment which indicated no cognitive impairment for daily decision-making tasks. Review of Resident #4's Active Orders Report dated 2/8/2022, revealed .[start date 9/1/2021] [MEDICATION(S)] 10MG TAB Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION [MEDICATION(S)] 80MG TABS [a diuretic used to treat Heart Failure and Hypertension] Give 1 tablet by mouth one time a day every Tue [Tuesday], Thu [Thursday]. Sat [Saturday], Sun [Sunday] for [CONDITION(S)] .[MEDICATION(S)] TAB 25 MG [a medication used to treat Hypertension] Give 2 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .[MEDICATION(S)] HCL 100MG TABS [a medication used to treat Hypertension] Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the unit dose of [MEDICATION(S)] 100 mg scheduled for 2/4/2022 at 2:00 PM, the [MEDICATION(S)] 25 mg scheduled 2/4/2022 at 5:00 PM, the [MEDICATION(S)] 25mg scheduled 2/5/2022 at 8:00 AM, the [MEDICATION(S)] 10 mg scheduled 2/5/2022 at 9:00 AM, and the [MEDICATION(S)] 80 mg scheduled 2/5/2022 at 9:00 AM, remained in the medication cart and not been administered. During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the cart and had not been administered to Resident #4 as ordered by the Physician. During an interview on 2/13/2022 at 11:40 AM, when Resident #4 was asked if he received his medications as ordered, he stated, .I go to [CONDITION(S)] 3 days .some days I don't get them .She [nurse] don't give me my pills when I get back [from [CONDITION(S)]]. I tell them, but I don't always get them .I have to wait till the next day . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 15 on the BIMS assessment which indicated he had no cognitive impairment for daily decision-making tasks. Review of Resident #5's Active Orders Report dated 2/8/2022, revealed .[start date 7/1/2021] [MEDICATION(S)] 10MG TAB Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION .[MEDICATION(S)] TAB 12.5 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .[MEDICATION(S)] HCL 100MG TABS Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the unit dose of [MEDICATION(S)] 100 mg scheduled to be given on 2/2/2022 and 2/5/2022 at 2:00 PM, the [MEDICATION(S)] 12.5 mg scheduled 2/2/2022 at 5:00 PM and 2/5/2022 at 8:00 AM and 5:00 PM, and the [MEDICATION(S)] 10 mg scheduled 2/5/2022 at 8:00 AM, remained in the medication cart and had not been administered. Review of Resident #5's MAR dated 2/1/2022-2/28/2022, revealed a 3 [code for absent from facility] and a nurse's initials for the [MEDICATION(S)] 10 mg that was scheduled on 2/5/2022 at 8:00 AM and was not given on the day of [CONDITION(S)]. During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the cart and had not been administered to Resident #5 as ordered by the Physician. During an interview on 2/11/2022 at 11:48 AM, Resident #5 was asked if he received his medications as ordered on the days he went to the [CONDITION(S)] clinic. He stated, .Sometimes I do .Yeah they do when they want to . Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Active Orders Report dated 2/8/2022, revealed .[start date 1/28/2022] [MEDICATION(S)] Tablet 25 MG [a medication used to treat Hypertension] Give 25 mg by mouth two times daily for [CONDITION(S)] [Hypertension] .[MEDICATION(S)] [an antiplatelet, blood thinner] Tablet 75 MG Give 75 mg by mouth one time a day .[MEDICATION(S)] Tablet 600 MG [an antibiotic] Give 600 mg by mouth two times daily for Bacterial Infection for 14 days . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 75 mg scheduled for 2/3/2022 and 2/5/2022 at 9:00 AM, the [MEDICATION(S)] 25 mg scheduled 2/2/2022 and 2/5/2022 at 7:00 AM and a unit dose of [MEDICATION(S)] 25 mg scheduled to be given on 2/4/2022 and 2/5/2022 at 8:00 PM, remained in the medication cart and had not been administered. There were 2 medication cards of [MEDICATION(S)] 600 mg scheduled for two times a day. There were 21 tablets remaining from the cards delivered on 1/29/2022. There should only have been 7 tablets remaining after the medication was administered two times each day starting on 1/29/2022. Observation of the 300 Hall Medication Cart on 2/13/2022 at 2:10 PM, revealed 13 tablets of [MEDICATION(S)] remained in the cart from the cards delivered on 1/29/2022. The order for the [MEDICATION(S)] 600 mg for 14 days should have been completed on 2/11/2022. During an interview on 2/13/2022 at 2:12 PM, LPN #2 was asked if the antibiotic [MEDICATION(S)] had been administered as ordered. LPN #2 stated, Probably not. Looks like there are too many . During an interview on 2/13/2022 at 2:15 PM, the ADON was asked if the antibiotic [MEDICATION(S)] had been administered as ordered. The ADON stated, .could have been given from the Cubix [backup supply medications] . During an interview on 2/14/2022 at 12:06 PM, the Pharmacist was asked if [MEDICATION(S)] was stocked in backup supply. The Pharmacist stated, .[MEDICATION(S)] [brand name for [MEDICATION(S)]] is never stocked in the Cubix as backup . During an interview on 2/14/2022 at 1:45 PM, the Physician confirmed he was not aware Resident #6 had not been administered the antibiotic as ordered. During an interview on 2/14/2022 at 2:16 PM, the DON was asked if the antibiotic had been given as ordered. The DON stated, .They [tablets] shouldn't be still in the cart . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Active Orders Report dated 2/8/2022, revealed .[start date 7/1/2021] [MEDICATION(S)] TAR [[MEDICATION(S)]] TAB 25 MG Give 0.5 tablet by mouth every 12 hours related to ESSENTIAL (PRIMARY) HYPERTENSION .take ½ tab to equal 12.5mg. HOLD FOR HEART RATE LESS THAN 55 . Review of the MAR dated 2/2022, revealed no documentation that the [MEDICATION(S)] 12.5 mg had been administered on 2/3/2022 at 8:00 PM and here was no documentation of a heart rate of less than 60. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAR TAB 25 MG Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 25 mg scheduled to be given on 2/6/2022 at 6:00 AM, remained in the medication cart and had not been administered. Review of the MAR dated 2/2022, revealed no documentation on 2/3/2022 at 10:00 PM and 2/3/2022 at 6:00 AM that the [MEDICATION(S)] 25 mg had been administered. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] 40 MG TABS Give 1 tablet by mouth two times a day related to Heart Failure .[MEDICATION(S)] TAB 25 MG Give 1 tablet by mouth two times a date related to ESSENTIAL (PRIMARY) HYPERTENSION Hold for heart rate less than 55 .[MEDICATION(S)] 1000 mg tabs Give 1 tablet by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC [CONDITION(S)] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the [MEDICATION(S)] 25 mg scheduled to be administered on 2/5/2022 at 5:00 PM, [MEDICATION(S)] 40 mg scheduled 2/5/2022 at 5:00 PM, and [MEDICATION(S)] HCL 1000 mg scheduled 2/5/2022 at 4:00 PM, remained in the medication cart and had not been administered as ordered. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] TAB 25 MG Give 0.5 tablet by mouth in the morning related to ESSENTIAL (PRIMARY) HYPERTENSION .[start date 8/25/2021] [MEDICATION(S)] 5 MG TAB Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION hold if SBP [systolic blood pressure] less than 110 . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed a unit dose of [MEDICATION(S)] 5 mg with a scheduled date of 2/3/2022 at 8:00 AM, remained in the medication cart and had not been administered. Review of the MAR dated 2/1/2022-2/28/2022, revealed no documentation the [MEDICATION(S)] 25 mg had been administered on 2/3/2022 at 6:00 AM as ordered. Review of the medical record, revealed Resident #15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Active Orders Report dated 2/8/2022, revealed .[start date 1/21/2022] [MEDICATION(S)] TAB 50MG [a medication used to treat irregular heart rate] Give 1 tablet by mouth one time a day related to UNSPECIFIED [CONDITION(S)] .[MEDICATION(S)] 40MG Give 1 tablet by mouth two times a day related to [CONDITION(S)] .[MEDICATION(S)] HCL Tablet 50 MG Give 50 mg by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 40 mg with a scheduled date of 2/2/2022 at 5:00 PM and [MEDICATION(S)] 50 mg with a scheduled date of 2/3/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of Resident #15's MAR dated 2/2022, revealed no documentation the [MEDICATION(S)] 50 mg had been administered on 2/2/2022 at 8:00 PM as ordered. There was no documentation [MEDICATION(S)] 50 mg had been administered on 2/3/2022 at 6:00 AM as ordered. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Active Orders Report dated 2/8/2022, revealed .[start date 10/27/2021] [MEDICATION(S)] [MEDICATION(S)] Tablet 25 MG Give 25 mg by mouth two times a day for HYPERTENSION hold for SBP [systolic blood pressure] < [symbol for less than] 90, HR [Heart Rate] < 55 . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 2.5 mg with a scheduled date of 2/6/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of the MAR dated 2/2022, revealed [MEDICATION(S)] 25 mg had a code of 4 indicating a pulse was below 60. There was no documentation Resident #16's pulse had been assessed at 8:00 PM on 2/6/2022. During an interview on 2/8/2022 at 2:30 PM, the Admissions Nurse stated, .Not in the program for the nurse to auto document a pulse . The Admissions Nurse confirmed there was no documentation Resident #16's pulse had been assessed on 2/6/2022 at 8:00 PM. Review of the medical record, revealed Resident #18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Active Orders Report dated 2/8/2022, revealed .[start date 9/14/2021] [MEDICATION(S)] TAB 3.125 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 300 Hall Mediation Cart on 2/8/2022 at 2:00 PM, revealed the [MEDICATION(S)] 3.125 mg with a scheduled date of administration 2/7/2022 at 5:00 PM, remained in the medication cart and had not been administered. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Active Orders Report dated 2/8/2022, revealed, .[start date 2/4/2022] [MEDICATION(S)] [MEDICATION(S)] tablet 5 mg give 5 mg by mouth one time a day for [CONDITION(S)] [hypertension] .[MEDICATION(S)] 20 mg give 20 mg by mouth one time a day for [CONDITION(S)] .[MEDICATION(S)] Tablet 25 mg [a diuretic used to treat Hypertension] give 25 mg by mouth one time a day for [CONDITION(S)] . Observation of the 200 Hall Medication Cart on 2/8/2022 at 1:30 PM, revealed the unit dose of [MEDICATION(S)] [MEDICATION(S)] 5 mg and [MEDICATION(S)] 20 mg with a scheduled date for administration of 2/6/2022 at 9:00 AM, remained in the medication cart and had not been administered. Observation of the 200 Hall Medication Cart on 2/8/2022 at 1:30 PM, revealed the medication card had 29 of 30 [MEDICATION(S)] 25 mg pills dispensed remained in the card which reflected one pill had been administered since 2/5/2022. During a telephone interview on 2/8/2022 at 12:13 PM, the Pharmacist stated, .We delivered a 7-day supply of medications for Mr. [Named Resident #19] and it was delivered 2/5/2022 early morning at 2:00 AM . During an interview on 2/8/2022 at 1:30 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #19 as ordered by the Physician. She stated, .Yeah, I see it .I have no explanation . Review of the medical record revealed, Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Active Orders Report dated 2/8/2022, revealed .[start date 9/22/2021] [MEDICATION(S)] HCL 200 mg Give 1 tablet by mouth in the morning for Cardiovascular, [MEDICATION(S)] [MEDICATION(S)] Give 12.5 mg by mouth two times a day for Hypertension . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 200 mg with a scheduled date of 2/1/2022 and 2/8/2022 at 8:00 PM, and [MEDICATION(S)] 25 mg ½ tablet, 12.5 mg, scheduled for 2/8/2022 at 9:00 AM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medications remained in the medication cart and had not been administered to Resident #20 as ordered by the Physician. Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] HCL tablet 50 mg Give 50 mg by mouth every 8 hours for Hypertension .[MEDICATION(S)] tablet 25 mg [a medication used to treat Hypertension] Give 1 tablet by mouth one time a day for Hypertension . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] HCL 50 mg scheduled for 2/4/2022 at 10:00 PM and [MEDICATION(S)] 25 mg scheduled 2/2/2022 at 9:00 AM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #21 as ordered by the Physician. Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] HCL 50 mg with a scheduled date of 2/10/2022 at 2:00 PM, remained in the medication cart and had not been administered. During an interview on 2/11/2022 at 3:20 PM, LPN #3 confirmed the medications were in the medication cart and had not been administered to Resident #21 as ordered by the Physician. Review of Resident #21's MAR dated 2/2022, revealed [MEDICATION(S)] 25 mg dated 2/2/2022 at 9:00 AM and [MEDICATION(S)] HCL 50 mg dated 2/4/2022 at 10:00 PM, were not documented as having been administered. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR. Medical record review revealed, Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #22's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] tablet 10 mg [a medication used to treat Hypertension and chest pain] Give 1 tablet by mouth three times a day for Hypertension . Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] 10 mg scheduled for 2/9/2022 at 10:00 PM, remained in the medication cart and had not been administered. During an interview on 2/11/2022 at 3:20 PM, LPN #3 confirmed the medication was in the medication cart and had not been administered to Resident #22 as ordered by the Physician. Review of the medical record revealed, Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's Active Orders Report dated 2/8/2022, revealed, .[start date 1/17/2022] [MEDICATION(S)] tablet 25 mg [a medication used to treat Hypertension] give 25 mg by mouth two times a day for Hypertension .[MEDICATION(S)] HCL tablet 100 mg give 100 mg by mouth three times a day for Hypertension . Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] HCL 100 mg with a scheduled date of 2/10/2022 at 2:00 PM and [MEDICATION(S)] 25 mg scheduled 2/10/2022 at 2:00 PM, remained in the medication cart and had not been administered. During an interview on 2/11/2022 at 3:20 PM, LPN #3 confirmed the medications were in the medication cart and had not been administered to Resident #24 as ordered by the Physician. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's Active Orders Report dated 2/8/2022, revealed .[start date 9/4/2021] [MEDICATION(S)] tablet 12.5 mg Give 1 tablet by mouth two times a day for Hypertension . Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] 12.5 mg scheduled to be given on 2/10/2022 at 4:00 PM, remained in the medication cart and had not been administered. During an interview on 2/11/2022 at 3:20 PM LPN #3 confirmed the medications were in the medication cart and had not been administered to Resident #25 as ordered by the Physician. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] Tablet 12.5 mg Give 12.5 mg by mouth two times a day for Hypertension .[MEDICATION(S)] HCL tablet 0.1 mg Give 0.1 mg by mouth two times a day for Hypertension .[MEDICATION(S)] tablet 5

Based on policy review, pharmacy service agreement, medical record review, observation and interview, the facility failed to ensure the pharmacist identified irregularities in Resident #1's cardiac drug regimen when conducting the monthly Medication Regimen Review (MRR) and failed to ensure the pharmacist identified medications were not being administered as scheduled which had the likelihood to cause serious adverse outcomes. The facility's failure resulted in Immediate Jeopardy for 31 of 33 sampled residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, and #31), that required significant medications, such as cardiac medications, [CONDITION(S)] medications, diabetes medications, antibiotics, gastrointestinal medications, and medications for mental health disorders and did not receive their scheduled medications as ordered by the physician. The facility had a census of 63. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 2/11/2022 at 5:36 PM, in the Conference Room. The IJ existed from 1/29/2022 through 2/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/12/2022 at 6:02 PM, and was validated onsite by the surveyors on 2/14/2022 through observations, review of audits, record review, and staff interviews. The findings include: Review of the facility's policy titled, Physician's Care, reviewed 12/2008, revealed .The Physician will provide orders which enable the interdisciplinary team to develop a comprehensive treatment plan including medications .Such orders will be updated and revised at appropriate intervals . Review of the facility's pharmacy service agreement titled, [Named Pharmacy] Pharmacy Services Agreement [Named Facility] Rehabilitation & Nursing Center, dated 8/16/2021, revealed .Pharmacy Consulting Services - Exhibit A .[Named Pharmacy] will provide pharmacy consulting services in conjunction with Facility's duties under applicable law. Such duties may include, as applicable, monthly inspections of each of the Facility's nursing stations, the drug storage area, and medical records to monitor compliance with pharmacy policies and procedures and state and federal regulations; the provision of a written report regarding the inspections and the results of the drug regimen review, noting any irregularities or other areas of concern .Quality Assurance Meetings. [Named Pharmacy] will participate in regularly scheduled quarterly quality assurance meetings with the Facility's staff to review issues regarding pharmacy procedures . Review of the facility's undated policy titled, Medication Administration, revealed .Purpose: To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration .Licensed professional nurses administer medications according to times documented on the Medication Administration Record [MAR] .Medication Administration Record will be signed after for each medication administered to the resident . Review of the facility's undated policy titled, Section 5.0 Medication Administration, revealed .5.1: Drug Administration-General Guidelines .Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so .Procedure: Medications are administered in accordance with written orders of the attending physician .Only the licensed or legally authorized personnel who prepare medication may administer it . Review of the medical record, revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Seizures, Hypertension, [CONDITION(S)], and Alzheimer's Disease. Review of the Physician Orders documented the following: a. 7/21/2021, .[MEDICATION(S)] Cap [capsule] 180 mg [milligram] SR [sustained release] give 1 tablet by mouth at bedtime related to Essential [Primary] Hypertension [high blood pressure] . b. 7/21/2021, .[MEDICATION(S)] 500 mg [an anticonvulsant] tab [tablet] give 1 tablet by mouth two times a day related to Seizures . Review of the Nurse Practitioner (NP) Progress Note dated 9/7/2021, revealed .Patient seen today after nurse report patient has been acting more confused than normal .Her blood pressure was in the 90s systolically. She is currently on [MEDICATION(S)] 180 mg at night. She had to be sternal rub to elicit a response .[CONDITION(S)] hold [MEDICATION(S)], give 500 normal saline bolus x [times]1 . Review of the Physician Orders documented the following: a. 9/8/2021, [MEDICATION(S)] Cap 180 mg SR hold . b. The [MEDICATION(S)] Cap 180 mg SR continued to be on hold from 9/8/2021 through 2/9/2022 Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose [MEDICATION(S)] 500 mg (a medication for seizures) that was to be administered on 2/3/2022 at 9:00 AM and [MEDICATION(S)] 500 mg that was to be administered on 2/4/2022 at 5:00 PM, remained in the medication cart and had not been administered. Review of Resident #1's record dated 9/8/2021 - 2/8/2022, revealed [MEDICATION(S)] Cap 180 mg SR continued to be on hold and had not been administered to the resident, and there were no Pharmacist recommendations to notify the physician or resume the [MEDICATION(S)]. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse stated, .I don't know why it is on hold and why it is still being held. That order was for a hypotensive episode 9/8/2021 .The Nurse Practitioner that ordered the hold on 9/8/2021 at 11:39 AM failed to complete the order with no documented reason or how many days and when to flip back from on hold to resume or discontinue .She [NP] saw her one more time 9/13/2021 and never returned to the facility .no one ever discontinued the [MEDICATION(S)] or resumed it . The Admission Nurse confirmed the facility and pharmacist failed to notify the physician of the continued hold of a hypertensive medication for 5 months. During a telephone interview on 2/9/2022 at 12:13 PM, the Pharmacist stated, .We have been sending [MEDICATION(S)] HCL SR 180 mg at bedtime since August 2021 .We never received an order for her [Resident #1] [MEDICATION(S)] 180 mg to be held. We have been sending a weekly supply since August of 2021 .the latest seven-day supply was sent on 2/3/2022 . Review of the monthly Pharmacy MRR Consultation Notes dated 10/2021 to 1/24/2022, revealed .[Resident #1] no recommendations . The Pharmacist failed to address the [MEDICATION(S)] medication that had been withheld for 5 months. During an interview on 2/8/2022 at 1:30 PM, the Assistant Director of Nursing (ADON) confirmed the [MEDICATION(S)] medications were in the cart and had not been administered to Resident #1 as ordered by the Physician. She stated, .Yeah, I see it .I don't know why the [MEDICATION(S)] was not given . During an interview on 2/9/2022 at 12:13 PM, the Pharmacist stated, .We only send out a 7-day supply of medications for all Ms. [Named Resident #1] meds [medications] and it was delivered 2/3/2022 . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Heart Failure, Hypertension, [CONDITION(S)] Heart Disease, [CONDITION(S)], Chronic Obstructive Pulmonary Disease, [CONDITION(S)] and [CONDITION(S)]. Review of Resident #2's Active Orders Report dated 2/8/2022, revealed .[start date of 1/25/2022] [MEDICATION(S)] Tablet 40 mg [a medication for high cholesterol] Give 40 mg by mouth at bedtime related to [CONDITION(S)] [high cholesterol and triglycerides] .[start date 2/2/2022] [MEDICATION(S)] [HCL] tablet 200 mg give 1 tablet by mouth two times a day related to [CONDITION(S)] [an irregular heartbeat] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] tablet 40 mg dated 1/29/2022 that was to be administered at 9:00 PM, [MEDICATION(S)] 200 mg dated 2/4/2022 and to be administered at 5:00 AM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 2:00 PM, the ADON confirmed the dose of [MEDICATION(S)] 40 mg tablet scheduled to have been administered at 9:00 PM on 1/29/2022 and the dose of [MEDICATION(S)] 200 mg dated 2/4/2022 that was to be administered at 5:00 AM, remained in the medication cart and had not been administered. She stated, .Yeah, I see it .I don't know why was not given . During an interview on 2/9/2022 at 12:13 PM, the Pharmacist stated, .We only send out a 7-day supply of medications for all Ms. [Named Resident #2] meds [medications] and it was delivered 1/27/2022 and 2/3/2022 .[MEDICATION(S)] and [MEDICATION(S)] were in that delivery . There was no evidence the Pharmacist identified these concerns when conducting the monthly MRR. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Hypertension, [CONDITION(S)], Peripheral Vascular Disease and Diabetes Mellitus Type 2. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderately impaired for daily decision making. Review of Resident #3's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] 80 mg 1 tablet by mouth at bedtime for [CONDITION(S)] .[MEDICATION(S)] 5 mg [a medication used to treat elevated blood sugar] by mouth two times a day for Type 2 Diabetes Mellitus .[start date 1/7/2022] [MEDICATION(S)] Tablet 7.5-325 mg [[MEDICATION(S)]-Acetaminophen] [a medication used to treat pain] give 1 tablet by mouth every 6 hours as needed for pain . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 80 mg that was to be given at 8:00 PM on 2/4/2022 remained in the medication cart and had not been administered. Observation of the Medication Cart on 2/11/2022 at 1:00 PM, revealed [MEDICATION(S)] 5 mg dated 2/10/2022 and to be administered at 5:00 PM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medication was in the cart and had not been administered to Resident #3 as ordered by the Physician. During an interview on 2/11/2022 at 3:20 PM, Licensed Practical Nurse (LPN) #3 confirmed the dose of [MEDICATION(S)] 5 mg that was to be administered on 2/10/2022 at 5:00 PM was still in the medication cart and had not been administered to Resident #3 as ordered by the Physician. During an interview on 2/13/2022 at 1:30 PM, Resident #3 stated, .I have not gotten my pain pill today. I asked for it this morning. When I asked the nurse, she told me the pharmacy hadn't delivered it . During an interview on 2/13/2022 at 1:35 PM, LPN #4 was advised Resident #3 was requesting a pain pill. She stated, .Oh, I have already given him one . LPN #4 was asked to reveal the narcotic sheet and count. She was unable to produce the narcotic sheet and stated, .Oh, it is over here . and proceeded to the Nurse's Station and accessed a drawer. She removed an empty [MEDICATION(S)]-Acetaminophen card with Resident #3's name and a Controlled Drug Receipt Record/Disposition Form with Resident #3's name and the last dose of [MEDICATION(S)]/Acetaminophen 7.5 mg-325 mg tab documented was administered on 2/12/2022 at 9:00 AM and was given by LPN #4. When LPN #4 was asked why she said she not given him one today, 2/13/2022, she stated, .Oh, I ordered it yesterday per the computer and it hadn't come in yet . She would not answer the question asked. LPN #4 was asked what the status of the order was, and she stated, .I don't know .No, I have not followed up . LPN #4 was asked about a pain pill for Resident #3 since he was in pain. The House Supervisor answered and stated, . I will find out why it did not come last night, and we can go to back up and get him one for now. There was no documentation in the monthly MRR conducted by the Pharmacist that these concerns had been identified. Review of the medical record review, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Hypertension, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Congestive Heart Failure, [CONDITION(S)] Heart Disease, [CONDITION(S)] Unspecified, Type 1 Diabetes Mellitus, and Gout. Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 scored 15 on the BIMS assessment which indicated no cognitive impairment for daily decision-making tasks. Review of Resident #4's Active Orders Report dated 2/8/2022, revealed .[start date 9/1/2021] CALCITRIOL CAP [capsule] 0.25MCG [micrograms] [treatment for low calcium levels] Give 1 capsule by mouth one time a day .[MEDICATION(S)] TAB [tablet] 100 MG [to decrease blood uric acid levels and used to treat [NAME] Arthritis] GIve 1 tablet by mouth one time a day .[MEDICATION(S)] 10MG TAB Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION .Folic Acid Tablet 1 MG Give 1 mg by mouth one time a day .[MEDICATION(S)] 80MG TABS [a diuretic used to treat Heart Failure and Hypertension] Give 1 tablet by mouth one time a day every Tue [Tuesday], Thu [Thursday]. Sat [Saturday], Sun [Sunday] for [CONDITION(S)] .[MEDICATION(S)] TAB 25 MG Give 2 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .[MEDICATION(S)] HCL [[MEDICATION(S)]] 100MG TABS Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the following medications remained in the medication cart: a. A unit dose of [MEDICATION(S)] 100 mg scheduled to be administered on 2/4/2022 at 2:00 PM b. A unit dose of [MEDICATION(S)] 25 mg scheduled to be administered on 2/4/2022 at 5:00 PM c. A unit dose of [MEDICATION(S)] 25mg scheduled to be administered on 2/5/2022 at 8:00 AM d. A unit dose of [MEDICATION(S)] 100 mg scheduled to be administered on 2/5/2022 at 9:00 AM e. A unit dose of [MEDICATION(S)] 10 mg scheduled to be administered 2/5/2022 at 9:00 AM f. A unit dose of Calcitrol 0.25 mcg scheduled to be administered on 2/5/2022 at 9:00 AM g. A unit dose of Folic Acid 1 mg scheduled to be administered on 2/5/2022 at 9:00 AM h. A unit dose of [MEDICATION(S)] 80 mg scheduled to be administered on 2/5/2022 at 9:00 AM During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the cart and had not been administered to Resident #4 as ordered by the Physician. During an interview on 2/13/2022 at 11:40 AM, Resident #4 was asked if he received his medications as ordered. He stated, .I go to [CONDITION(S)] 3 days .some days I don't get them .She [nurse] don't give me my pills when I get back [from [CONDITION(S)]]. I tell them, but I don't always get them .I have to wait till the next day . There was no documentation in the monthly MRR conducted by the Pharmacist that these concerns had been identified. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease, Dependence on Renal [CONDITION(S)], Essential Hypertension, [CONDITION(S)], Type 2 Diabetes Mellitus, [CONDITION(S)], Chronic Congestive Heart Failure, and Major Depressive Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 15 on the BIMS assessment which indicated he had no cognitive impairment for daily decision making. Review of Resident #5's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] 10MG TAB Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION .CALCITROL CAP 0.25MCG Give 1 capsule by mouth one time a day .[MEDICATION(S)] TAB 12.5 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .[MEDICATION(S)] HCL 100MG TABS Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION .SERTALINE TAB 100 MG Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER .[start date 1/13/2022] [MEDICATION(S)] Tablet Delayed Release 40 MG Give 1 tablet by mouth one time a day for abdominal pain . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed unit doses of [MEDICATION(S)] 100 mg scheduled for administration at 2:00 PM on 2/2/2022 and 2/5/2022, [MEDICATION(S)] 12.5 mg scheduled to be administered at 5:00 PM on 2/2/2022 and at 8:00 AM and 5:00 PM on 2/5/2022, [MEDICATION(S)] 10 mg and Calcitrol 0.25 mcg that was scheduled to be given on 2/5/2022 at 8:00 AM, [MEDICATION(S)] 40 mg and [MEDICATION(S)] HCL 100 mg scheduled to be administered at 9:00 AM on 2/5/2022, remained in the medication cart and had not been administered. Review of Resident #5's MAR dated 2/2022, revealed a 3 [a code for absent from the facility] and an employee initials that the following medications were not given on the days the resident went to [CONDITION(S)]: a. [MEDICATION(S)] 10 mg scheduled at 8:00 AM on 2/5/2022 b. Calcitrol 0.25 mcg scheduled at 8:00 AM on 2/5/2022 c. [MEDICATION(S)] 40 mg scheduled at 9:00 AM on 2/5/2022 d. [MEDICATION(S)] HCL 100 mg scheduled at 9:00 AM on 2/5/2022 at 9:00 AM During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the cart and had not been administered to Resident #4 as ordered by the Physician on the days the resident went out of the facility to [CONDITION(S)]. During an interview on 2/11/2022 at 11:48 AM, Resident #5 was asked if he received his medications as ordered on the days he went to the [CONDITION(S)] clinic, he stated, .Sometimes I do .Yeah they [nurses] do when they want to . There was no documentation in the monthly MRR conducted by the Pharmacist that the concerns of the resident not receiving the prescribed medications on the days he went out of the facility for the [CONDITION(S)] treatments had been identified. Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of Traumatic Amputation of Two or More Toes, [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction, Pressure Injury to Sacral Region Stage 4, Chronic Congestive Heart Failure, Peripheral Vascular Disease, End Stage Renal Disease, Renal [CONDITION(S)], Essential Hypertension, Type 1 Diabetes Mellitus, and Right Leg Below Knee Amputation. Review of Resident #6's Active Orders Report dated 2/8/2022, revealed .[start date 1/28/2022] [MEDICATION(S)] Tablet 25 MG Give 25 mg by mouth two times daily for [CONDITION(S)] [Hypertension] .[MEDICATION(S)] Tablet 20 MG Give 20 mg by mouth at bedtime related to Coronary Atherosclerosis .[MEDICATION(S)] Tablet 75 MG [to prevent heart attacks or strokes] Give 75 mg by mouth one time a day .[MEDICATION(S)] Tablet 600 MG Give 600 mg by mouth two times daily for Bacterial Infection for 14 days .[MEDICATION(S)] Tablet Delayed Release 40 MG [to treat gastroesophageal reflux disease] Give 40 mg by mouth two times daily . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the following medications that remained in the medication cart: a. A unit dose of [MEDICATION(S)] 40 mg scheduled to be given on 1/31/2022 at 7:00 AM and 4:00 PM b. [MEDICATION(S)] 75 mg scheduled to be administered on 2/3/2022 and 2/5/2022 at 9:00 AM c. [MEDICATION(S)] 25 mg scheduled to be given on 2/2/2022 and 2/5/2022 at 7:00 AM and a unit dose dated 2/4/2022 and 2/5/2022 to be administered at 8:00 PM d. [MEDICATION(S)] 20 mg to be administered on 2/3/2022 at 8:00 PM Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed 2 medication cards of [MEDICATION(S)] 600 mg (a medication to treat bacterial infections) scheduled to be administered two times each day. There were 21 tablets remaining on the cards that were delivered on 1/29/2022. If administered as scheduled, two times each day, there should have been 7 tablets remaining after the medication was started on 1/29/2022. Observation of the 300 Hall Medication Cart on 2/13/2022 at 2:10 PM, revealed 13 tablets remained in the cart on the cards that were delivered on 1/29/2022. The order for the [MEDICATION(S)] 600 mg for 14 days should have been completed on 2/11/2022. During an interview on 2/13/2022 at 2:12 PM, when asked if the antibiotic [MEDICATION(S)] had been administered as ordered, LPN #2 stated, Probably not. Looks like there are too many . During an interview on 2/13/2022 at 2:15 PM, when asked if the antibiotic [MEDICATION(S)] had been administered as ordered, the ADON stated, .could have been given from the Cubix [backup supply medications] . During an interview on 2/14/2022 at 12:06 PM, when asked if [MEDICATION(S)] was stocked in the backup supply, the Pharmacist stated, .[MEDICATION(S)] [brand name for [MEDICATION(S)]] is never stocked in the Cubix as backup . During an interview on 2/14/2022 at 1:45 PM, the Physician confirmed he was not aware Resident #6 had not been administered the antibiotic as ordered. During an interview on 2/14/2022 at 2:16 PM, when asked if the antibiotic had been given as ordered, the DON stated, .They [tablets] shouldn't be still in the cart . There was no documentation in the monthly MRRs conducted by the Pharmacist that these concerns had been identified. Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Hypertension, Nicotine Dependence, and Vitamin B12 Deficiency [CONDITION(S)]. Review of Resident #7's Active Orders Report dated 2/8/2022, revealed .[start date 2/3/2022] Nicotine patch 24 hr [hour] 14 mg/24 hr - apply 1 patch transdermally in the morning every day for control withdrawal related to nicotine dependence, cigarettes and remove per schedule . During an interview on 2/8/2022 at 1:45 PM, Resident #7's daughter stated to LPN #2, .My dad has been here since 1/31/2022 [the daughter stated this date but Resident #7 was actually admitted on [DATE]] and still does not have his nicotine patch .do you know the status? . LPN #2 responded, .I don't know, it has been ordered .I ordered it on 2/3/2022 . During an interview on 2/8/2022 at 1:45 PM, LPN #2 was asked what was the status of the patch that was ordered on 2/3/2022 and still had not arrived. She stated, .I don't know . Observation at the 100 Hall Nurse's Station on 2/8/2022 at 1:50 PM, revealed the Admission Nurse called the pharmacy and asked the status of the nicotine patch for Resident #7. She revealed the pharmacy stated the facility had been notified the patch was not covered by insurance and requested the facility to authorize them to send it. No one in the facility had authorized the request so the pharmacy did not send the nicotine patch for the resident or notify the physician. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses of Fracture of Right Arm, [CONDITION(S)], Polyneuropathy, Essential Hypertension, [CONDITION(S)], and Protein-Calorie Malnutrition. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 15 on the BIMS assessment which indicated she had no cognitive impairment for daily decision-making tasks. Review of Resident #8's Physician's Orders dated 1/2022, revealed .[MEDICATION(S)] HCL Tablet 5 MG [ a muscle relaxant] Give 1 tablet by mouth at bedtime .[MEDICATION(S)] Tablet 40 MG [to treat high cholesterol] Give 1 tablet by mouth at bedtime .[MEDICATION(S)] Sodium Tablet 75 MCG [treatment for low [CONDITION(S)] function] Give 1 tablet by mouth one time a day . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] HCL 5 mg scheduled to be administered at 8:00 PM on 2/7/2022 and [MEDICATION(S)] 40 mg to be given at 8:00 PM on 2/7/2022, remained in the medication cart and had not been administered. Review of Resident #8's MAR dated 2/2022, revealed the [MEDICATION(S)] HCL 5 mg was not documented as administered on 2/2/2022 and 2/7/2022. [MEDICATION(S)] 75 mcg was not documented as administered on 2/3/2022, and [MEDICATION(S)] 40 mg was not documented as administered on 2/2/2022 and 2/7/2022. During an interview on 2/13/2022 at 11:57 AM, when asked if she received her medications, Resident #8 stated, .Sometimes they don't bring my early morning [CONDITION(S)] [[MEDICATION(S)]] pill . There was no documentation in the monthly MRR conducted by the Pharmacist that these concerns had been identified. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, [CONDITION(S)] Affecting Left Side, Protein-Calorie Malnutrition, Pseudobulbar Affect, Chronic Ulcer of Lower Leg, Major Depressive Disorder, Convulsions, Restlessness and Agitation. Review of Resident #9's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAB 15MG Give 1 tablet by mouth at bedtime for appetite enhancement .[MEDICATION(S)] TAR [[MEDICATION(S)]] TAB 25MG Give 0.5 tablet by mouth every 12 hours related to ESSENTIAL (PRIMARY) HYPERTENSION .take ½ tab to equal 12.5mg . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 15mg dated 2/2/2022 and timed 8:00 PM remained in the medication cart and had not been administered. Review of the MAR dated February 2022, revealed no documentation that [MEDICATION(S)] 15 mg and [MEDICATION(S)] 12.5 mg had been administered on 2/3/2022 at 8:00 PM. There was no documentation in the monthly MRR conducted by the Pharmacist that these concerns had been identified. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Essential Hypertension, [CONDITION(S)], Chronic Obstructive Pulmonary Disease, Protein-Calorie Malnutrition, and Epileptic Seizures. Review of Resident #10's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAR TAB 25MG Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION .[start date 9/10/2021] Accu-checks bid [twice daily] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 25 mg that was scheduled to be administered at 6:00 AM on 2/6/2022, remained in the medication cart and had not been administered. Review of the MAR dated February 2022, revealed no documentation at 10:00 PM on 2/3/2022 and 6:00 AM on 2/3/2022 that the [MEDICATION(S)] 25 mg had been administered. There was no documentation at 6:00 AM on 2/3/2022 and 2/4/2022 and 6:00 AM on 2/13/2022 that the Accu-checks had been obtained as ordered by the Physician. During an interview on 2/13/2022 at 12:23 PM, Resident #8 (the roommate of Resident #10) stated, .They should check my roommate's sugar level every morning before 7 [7:00 AM]. Not last night they didn't [check the blood sugar] . During a telephone interview on 2/13/2022 at 1:27 PM, Registered Nurse (RN) #1 was asked if the blood sugar level had been checked for Resident #10 on the morning of 2/13/2022. RN #1 stated, .I can't remember . There was no documentation in the monthly MRR conducted by the Pharmacist that concerns had been identified. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Alcoholic [CONDITION(S)] of the Liver Without Ascites, Chronic Obstructive Pulmonary Disease, Essential Hypertension, Gastrointestinal Hemorrhage, Gastro-[CONDITION(S)] Reflux Disease with Esophagitis, Cocaine Dependence, and Chronic [CONDITION(S)] C. Review of the quarterly MDS dated [DATE], revealed Resident #11 scored 15 on the BIMS assessment which indicated no cognitive impairment for daily decision-making tasks. Review of Resident #11's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] PANTROPRAZOLE TAB 40MG Give 1 tablet by mouth two times a day . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed [MEDICATION(S)] 40 mg scheduled to be given on 2/2/2022 at 4:00 PM remained in the medication cart and had not been administered. During an interview on 2/13/2022 at 11:40 AM, Resident #11 stated, .If I miss my pain pills, it's when pharmacy don't deliver them .I get the others most of the time . There was no documentation in the monthly MRR conducted by the Pharmacist that concerns had been identified. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Essential (Primary) Hypertension, [CONDITION(S)], [CONDITION(S)], Diabetic [CONDITION(S)], and Type 2 Diabetes Mellitus. Review of Resident #12's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] 40MG TABS Give 1 tablet by mouth two times a day related to Heart Failure .[MEDICATION(S)] TAB 80MG Give 1 tablet by mouth at bedtime related to [CONDITION(S)] .[MEDICATION(S)] TAB 25MG Give 1 tablet by mouth two times a date related to ESSENTIAL (PRIMARY) HYPERTENSION Hold for heart rate less than 55 .[MEDICATION(S)] 1000mg tabs Give 1 tablet by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC [CONDITION(S)] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM the following medications remained in the medication cart: a. [MEDICATION(S)] 80 mg scheduled to be given at 9:00 PM on 2/5/2022 b. [MEDICATION(S)] 25 mg scheduled to be given at 5:00 PM on 2/5/2022 c. [MEDICATION(S)] 40 mg scheduled to be given at 5:00 PM on 2/5/2022 d. [MEDICATION(S)] HCL 1000 mg scheduled to be given at 4:00 PM on 2/5/2022 There was no documentation in the monthly MRR conducted by the Pharmacist that concerns had been identified. Review of the medical record, revealed Resident #13 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Chronic Systolic Congestive Heart Failure, Ischemic [CONDITION(S)], [CONDITION(S)] Heart Disease, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, [CONDITION(S)], Severe Protein-Calorie Malnutrition, Absence of Right and Left Foot, and Essential Primary Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #13 scored a 13 on the BIMS assessment which indicated he had no cognitive impairment for daily decision-making tasks. Review of Resident #13's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAB 80 MG Give 1 tablet by mouth at bedtime related to [CONDITION(S)] . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the [MEDICATION(S)] 80 mg scheduled to be administered at 8:00 PM on 2/3/2022 remained in the medication cart and had not been administered. Review of the eMar Medication Administration Progress Notes dated 1/1/2022 through 2/8/2022, revealed documentation Resident #13 had refused medications daily. During an interview on 2/13/2022 at 11:15 AM, Resident #13 stated, .I don't take my pills. Just don't want them . There was no documentation the Pharmacist had identified the continued refusals of medications by Resident #13 during the MRR. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], Essential Primary Hypertension, Type 2 Diabetes Mellitus, Central Cord Syndrome of Cervical Spine, [CONDITION(S)], and Chronic Pain. Review of Resident #14's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] TAB 25MG Give 0.5

Based on policy review, medical record review, observation and interview, the facility failed to ensure medications were administered as ordered by the Physician as evidenced by the dated and timed unit doses of medications remaining in the medication carts and had not been administered for 26 of 33 sampled residents (Resident #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #14, #15, #16, #17, #18, #19, #21, #23, #24, #25, #26, #27, #28, #29, #30, and #31). These failures resulted in Immediate Jeopardy when these residents failed to receive their prescribed medications had the likelihood of a serious adverse outcome and unstable decline in the residents' medical conditions. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury harm, impairment, or death to a resident. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for on 2/11/2022 at 5:36 PM, in the conference room. The facility was cited Immediate Jeopardy at F-684. The facility was cited at F-684 a scope and severity of K, which is Substandard Quality of Care. The IJ existed from 1/29/2022 through 2/13/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 2/12/2022 at 6:02 PM, and was validated onsite by the surveyors on 2/14/2022 through observations, review of records, review of audits, and staff interviews. The findings include: Review of the facility's policy titled, Physician's Care, reviewed on 12/2008, revealed .The Physician will provide orders which enable the interdisciplinary team to develop a comprehensive treatment plan including medications .Such orders will be updated and revised at appropriate intervals . Review of the facility's undated policy titled, Medication Administration, revealed .Purpose: To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration .Licensed professional nurses administer medications according to times documented on the Medication Administration Record .Medication Administration Record will be signed after for each medication administered to the resident . Review of the facility's undated policy titled, Section 5.0 Medication Administration, revealed .Drug Administration-General Guidelines .Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after sufficient information regarding the resident's condition and expected outcomes of medication therapy is known. The licensed nurse is aware of an indication for the resident receiving medication, usual dose, parameters and routes, contraindications, allergies, precautions, and side effects .Procedure: Medications are administered in accordance with written orders of the attending physician .Only the licensed or legally authorized personnel who prepare medication may administer it. This individual records the administration on the resident's MAR [Medication Administration Record] at the time the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Active Orders Report dated 2/8/2022, revealed .[start date 1/25/2022] [MEDICATION(S)] Tablet 40 mg [milligrams] [a medication used to treat high cholesterol and triglycerides] Give 40 mg by mouth at bedtime related to [CONDITION(S)] [elevated cholesterol and triglycerides] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] tablet 40 mg scheduled to be given on 1/29/2022 at 9:00 PM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 2:00 PM, the Assistant Director of Nursing (ADON) confirmed the [MEDICATION(S)] tablet 40 mg scheduled to be given on 1/29/2022 at 9:00 PM remained in the medication cart and had not been administered. She stated, .Yeah, I see it .I don't know why was not given . During an interview on 2/9/2022 at 12:13 PM the Pharmacist stated, .We only send out a 7-day supply of medications for all Ms. [Named Resident #2] meds [medications] and it was delivered 1/27/2022 and 2/3/2022 .[MEDICATION(S)] .were in that delivery . Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] 80 mg 1 tablet [a medication used to treat high cholesterol and triglycerides] by mouth at bedtime for [CONDITION(S)] . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 80 mg dated 2/4/2022 and timed 8:00 PM, remained in the medication cart, not administered. Review of Resident #3's MAR dated 2/2022, revealed the [MEDICATION(S)] 80 mg scheduled 2/4/2022 at 8:00 PM was not documented as administered. During an interview on 2/8/2022 at 1:00 PM the ADON confirmed the medication was in the cart and had not been administered to Resident #3 as ordered by the Physician. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum data Set (MDS) assessment dated [DATE], revealed Resident #4 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated no cognitive impairment for daily decision-making tasks. Review of the Active Orders Report dated 2/8/2022, revealed .[start date 9/1/2021] CALCITROL CAP [capsule] 0.25 MCG [micrograms] [a calcium supplement] Give 1 capsule by mouth one time a day .[MEDICATION(S)] TAB [tablet] 100 MG [a medication used to treat high uric acid that may cause Gout or kidney stones] Give 1 tablet by mouth one time a day .Folic Acid Tablet 1 MG [a dietary supplement] Give 1 mg by mouth one time a day . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the unit doses of [MEDICATION(S)] 100 mg scheduled to be administered 2/5/2022 at 9:00 AM, Calcitrol 0.25 mcg scheduled 2/5/2022 at 9:00 AM, and Folic Acid 1 mg scheduled 2/5/2022 at 9:00 AM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the cart and had not been administered to Resident #4 as ordered by the Physician. During an interview on 2/13/2022 at 11:40 AM, Resident #4 was asked if he received his medications as ordered and he stated, .I go to [CONDITION(S)] 3 days .some days I don't get them .She [nurse] don't give me my pills when I get back [from [CONDITION(S)]]. I tell them, but I don't always get them .I have to wait till the next day . Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored 15 on the BIMS assessment which indicated he had no cognitive impairment for daily decision-making tasks. Review of Resident #5's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] CALCITROL CAP 0.25 MCG Give 1 capsule by mouth one time a day .[MEDICATION(S)] TAB 100 MG [an antidepressant] Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER .[start date 1/13/2022] [MEDICATION(S)] Tablet Delayed Release 40 MG [a medication used to treat Gastroesophageal Reflux Disease] Give 1 tablet by mouth one time a day for abdominal pain . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the unit doses of Calcitrol 0.25 mcg scheduled to be given 2/5/2022 at 8:00 AM, [MEDICATION(S)] 40 mg scheduled 2/5/2022 at 9:00 AM, and [MEDICATION(S)] 100 mg scheduled 2/5/2022 at 9:00 AM, remained in the medication cart and were not administered. Review of Resident #5's MAR dated 2/1/2022-2/28/2022, revealed a 3 [code for absent from facility] and nurse's initials for Calcitrol 0.25 mcg scheduled to be given 2/5/2022 at 8:00 AM, [MEDICATION(S)] 40 mg scheduled 2/5/2022 at 9:00 AM, and [MEDICATION(S)] 100 mg scheduled 2/5/2022 at 9:00 AM were not given on the day of [CONDITION(S)]. During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #5 as ordered by the Physician. During an interview on 2/11/2022 at 11:48 AM, Resident #5 was asked if he received his medications as ordered on the days he went to the [CONDITION(S)] clinic. He stated, .Sometimes I do .they [nurses] do when they want to . Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Active Orders Report dated 2/8/2022, revealed .[start date 1/28/2022] [MEDICATION(S)] Tablet 20 MG Give 20 mg by mouth at bedtime related to Coronary Atherosclerosis .[MEDICATION(S)] Tablet Delayed Release 40 MG Give 40 mg by mouth two times daily . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 40 mg scheduled to be given on 1/31/2022 at 7:00 AM and 4:00 PM, and the [MEDICATION(S)] scheduled 2/3/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of the medical record, revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Active Orders Report dated 2/8/2022, revealed .[start date 2/3/2022] Nicotine patch 24 hr [hour]14 mg/24 hr - apply 1 patch transdermally in the morning every day for control withdrawal related to nicotine dependence, cigarettes and remove per schedule . Observation and interview at the 100 Hall Nurses' Station on 2/8/2022 at 1:45 PM, Resident #7's daughter stated to Licensed Practical Nurse [LPN] #2, .My dad has been here since 1/31/2022 [the daughter stated this date but Resident #7 was actually admitted on [DATE]] and still does not have his nicotine patch .do you know the status? . LPN #2 responded, .I don't know .it has been ordered .I ordered it on 2/3/2022 . During an interview on 2/8/2022 at 1:45 PM, LPN #2 was asked what the status of the medication was if the nicotine patch was ordered on 2/3/2022 and today, 5 days later, the resident has not received it. She stated, .I don't know . Observation at the 100 Hall Nurses' Station on 2/8/2022 at 1:50 PM, the Admission Nurse called the pharmacy and asked the status of the nicotine patch for Resident #7. She revealed the pharmacy stated they had notified the facility the patch was not covered and requested authorization by the facility to send the patch. No one authorized the medication, so the pharmacy did not send the nicotine patch. Review of the medical record, revealed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 15 on the Brief Interview for BIMS assessment, which indicated she had no cognitive impairment for daily decision-making tasks. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] Tablet 40 MG Give 1 tablet by mouth at bedtime .[MEDICATION(S)] Sodium Tablet 75 MCG [a medication used to treat [CONDITION(S)]] Give 1 tablet by mouth one time a day . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit doses of [MEDICATION(S)] 5 mg scheduled to be administered on 2/7/2022 at 8:00 PM and [MEDICATION(S)] 40 mg scheduled 2/7/2022 at 8:00 PM, remained in the medication cart. Review of Resident #8's MAR dated 2/2022, revealed [MEDICATION(S)] 5 mg was not documented as administered on 2/2/2022 and 2/7/2022. [MEDICATION(S)] 75 mcg was not documented as administered on 2/3/2022, and [MEDICATION(S)] 40 mg was not documented as administered on 2/2/2022 and 2/7/2022. During an interview on 2/13/2022 at 11:57 AM, when asked if she received her medications, Resident #8 stated, .Sometimes they don't bring my early morning [CONDITION(S)] [[MEDICATION(S)]] pill . Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Active Orders Report dated 2/8/2022, revealed .[MEDICATION(S)] TAB 15MG [an antidepressant] Give 1 tablet by mouth at bedtime for appetite enhancement . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 15mg scheduled for 2/2/2022 at 8:00 PM, remained in the medication cart. Review of Resident #9's MAR dated 2/2022, revealed there was no documentation that [MEDICATION(S)] 15 mg had been administered on 2/3/2022 at 8:00 PM. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS dated [DATE], revealed Resident #11 scored 15 on the BIMS assessment which indicated no cognitive impairment for daily decision-making tasks. Review of the Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] TAB 40MG Give 1 tablet by mouth two times a day . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the unit dose of [MEDICATION(S)] 40mg scheduled to be given on 2/2/2022 at 4:00 PM, remained in the medication cart. During an interview in the resident's room on 2/13/2022 at 11:40 AM, Resident #11 stated, .If I miss my pain pills it's when pharmacy don't deliver them .I get the others most of the time . Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] TAB 80MG Give 1 tablet by mouth at bedtime related to [CONDITION(S)] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 80 mg scheduled to be given on 2/5/2022 at 9:00 PM, remained in the medication cart and not administered. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] tab 20mg Give 1 tablet by mouth at bedtime related to MIXED [CONDITION(S)] . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 20 mg scheduled to be given 2/3/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of the medical record, revealed Resident #15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Active Orders Report dated 2/8/2022, revealed .[start date 1/21/2022] [MEDICATION(S)] TAB 80MG Give 1 tablet by mouth at bedtime related to [CONDITION(S)] . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 80 mg scheduled to be administered on 2/3/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of Resident #15's MAR dated 2/2022, revealed no documentation the [MEDICATION(S)] 80 mg had been administered on 2/2/2022 at 8:00 PM as ordered. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Active Orders Report dated 2/8/2022, revealed .[start date 10/27/2021] Famotidine Tablet [a medication used to treat Gastroesophageal Reflux Disease (GERD)] Give 20 mg by mouth two times a day for GERD . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of Famotidine 20 mg scheduled to be given 2/4/2022 and 2/7/2022 at 5:00 PM, remained in the medication cart and had not been administered. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE], revealed Resident #17 scored a 15 on the BIMS assessment which indicated she had no cognitive impairment for daily decision-making tasks. Review of Resident #17's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] POT [Potassium] CL [Chloride] MICRO TAB 20 MEQ [milliequivalent] [a potassium supplement] Give 1 tablet by mouth one time a day related to [CONDITION(S)] .[start date 12/22/2021] [MEDICATION(S)] HCL Capsule Delayed Release Sprinkle 20 MG [an antidepressant] Give 1 capsule by mouth one time a day related to Major Depressive Disorder . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit doses of [MEDICATION(S)] HCL 20 mg scheduled to be given on 2/6/2022 at 9:00 AM and Potassium Chloride 20 meq scheduled 2/6/2022 at 9:00 AM, remained in the medication cart and had not been administered. During an interview in the resident's room on 2/13/2022 at 12:27 PM, Resident #17 was asked if she received the medications the physician ordered. Resident #17 stated, .There has been several times I didn't get my medicines . Review of the medical record, revealed Resident #18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAB 5MG Give 1 tablet by mouth two times a day for muscle spasm .[MEDICATION(S)] TAB HCL 5MG [a medication used to treat dementia] Give 1 tablet by mouth two times a day related to Unspecified Dementia . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the [MEDICATION(S)] 5 mg and [MEDICATION(S)] 5 mg scheduled to be given 2/7/2022 at 4:00 PM, remained in the medication cart and had not been administered. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Active Orders Report dated 2/8/2022 revealed, .[start date 2/4/2022] [MEDICATION(S)] Calcium tablet [a medication used to treat high cholesterol and triglycerides] 40 mg by mouth at bedtime for [CONDITION(S)] .Tamsulosin HCL capsule 0.4 mg [a medication used to treat enlarged prostate] give 1 capsule by mouth at bedtime for [CONDITION(S)] [enlarged prostate] .[MEDICATION(S)] Sodium Tablet 100 mcg give 1 tablet by mouth one time a day for Low [CONDITION(S)] Hormone .Omeprazole capsule delayed release 40 mg [a medication used to treat GERD] give 1 capsule by mouth one time a day for GERD .Potassium Chloride ER tablet extended release 20 meq give 1 tablet by mouth one time a day .Hydrocortisone Tablet 5 mg [a steroid] give 15 mg by mouth one time a day for Allergy 3 tabs to equal 15 mg before breakfast .Hydrocortisone Tablet 5 mg give 5 mg by mouth one time a day for Allergy give 5 mg before supper . Observation of the 200 Hall Medication Cart on 2/8/2022 at 1:30 PM, revealed the unit doses of [MEDICATION(S)] Calcium 40 mg and Tamsulosin HCL 0.4 mg scheduled to be given on 2/5/2022 at 8:00 PM, the [MEDICATION(S)] Sodium 100 mcg and Omeprazole 40 mg scheduled 2/6/2022 at 6:00 AM, and Potassium Chloride 20 meq scheduled 2/6/2022 at 9:00 AM, remained in the medication cart and had not been administered. Observation of the 200 Hall Medication Cart on 2/8/2022 at 1:30 PM, revealed 21 of the 24 Hydrocortisone 5 mg tablets dispensed remained in the card which reflected only 3 pills had been administered since 2/5/2022. Review of Resident #19's MAR dated 2/2022, revealed the [MEDICATION(S)] Calcium tablet 40 mg and Tamsulosin 0.4 mg scheduled to be given on 2/5/2022 at 8:00 PM was not given because the medication was not in the facility (but it had been delivered on that morning of 2/5/2022). The unit dose dated on the card to be given on 2/5/2022 at 8:00 PM was in the medication cart and had not been administered. During a telephone interview on 2/8/2022 at 12:13 PM, the Pharmacist stated, .We delivered a 7-day supply of medications for Mr. [Named Resident #19] and it was delivered 2/5/2022 early morning at 2:00 AM . During an interview on 2/8/2022 at 1:30 PM the ADON confirmed the medications were in the medication cart and had not been administered to Resident #19 as ordered by the Physician. She stated, .Yeah, I see it .I have no explanation . Review of the medical record, revealed Resident #21 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #21's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] tablet 10 mg [a medication used to treat muscle spasms] Give 10 mg by mouth four times a day for Muscle Spasms .[MEDICATION(S)] tablet Give 10 mg by mouth at bedtime for [CONDITION(S)] .[MEDICATION(S)] tablet 5 mg [a medication used to treat allergies] Give 5 mg by mouth at bedtime for Allergies . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 10 mg scheduled to be given on 2/4/2022 at 8:00 PM, the [MEDICATION(S)] 10 mg and [MEDICATION(S)] 5 mg scheduled for 2/4/2022 at 9:00 PM, remained in the medication cart and had not been administered. Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] 10 mg scheduled for 2/10/2022 at 4:00 PM, remained in the medication cart and had not been administered. Review of Resident #21's MAR dated 2/2022, revealed the [MEDICATION(S)] 10 mg scheduled for 2/4/2022 at 8:00 PM, the [MEDICATION(S)] 10 mg and [MEDICATION(S)] 5mg scheduled for 2/4/2022 at 9:00 PM, were not documented as administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #21 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR. During an interview on 2/11/2022 at 3:20 PM, LPN #3 confirmed the medications were in the medication cart and had not been administered to Resident #21 as ordered by the Physician. Medical record review revealed, Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Active Orders Report dated 2/8/2022, revealed .[start date 12/3/2021] [MEDICATION(S)] 40 mg give 1 tablet by mouth one time a day for Gastro-[CONDITION(S)] Reflux Disease .Tamsulosin HCL 0.4 mg give 2 capsules by mouth at bedtime for Urine Retention . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit doses of [MEDICATION(S)] 40 mg scheduled for 2/8/2022 at 6:00 AM and Tamsulosin 0.4 mg scheduled 2/4/2022 at 8:00 PM, remained in the medication cart. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #23 as ordered by the Physician. Review of the medical record revealed, Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's Active Orders Report dated 2/8/2022, revealed, .[start date 1/17/2022] [MEDICATION(S)] tablet Give 100 mg by mouth two times a day for Gout . Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] 100 mg scheduled to be given on 2/10/2022 at 5:00 PM, remained in the medication cart and had not been administered. During an interview on 2/11/2022 at 3:20 PM, LPN #3 confirmed the medications were in the medication cart and had not been administered to Resident #24 as ordered by the Physician. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's Active Orders Report dated 2/8/2022, revealed .[start date 9/4/2022] [MEDICATION(S)] tablet 80 mg Give 1 tablet by mouth one time a day for Elevated Cholesterol . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 80 mg scheduled to be given on 2/7/2022 at 5:00 PM, remained in the medication cart and had not been administered. Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] 80 mg scheduled 2/10/2022 at 5:00 PM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #25 as ordered by the Physician. During an interview on 2/11/2022 at 3:20 PM LPN #3 confirmed the medications were in the medication cart and had not been administered to Resident #25 as ordered by the Physician. Medical record review revealed, Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] HCL 20 mg [an antidepressant] Give 1 tablet by mouth one time a day for Depression . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] HCL 20 mg scheduled to be given on 2/4/2022 at 9:00 AM remained in the medication cart. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medication was in the medication cart and had not been administered to Resident #26 as ordered by the Physician. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] Folic Acid tablet 1 mg Give 2 tablet by mouth two times a day Supplement . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of Folic Acid 1 mg scheduled to be given on 2/9/2022 at 9:00 PM, remained in the medication cart and had not been administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medication was in the medication cart and had not been administered to Resident #27 as ordered by the Physician. Review of the medical record, revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's Active Orders Report dated 2/8/2022, revealed .[start date 1/27/2022] [MEDICATION(S)] Sodium 20 mg [a medication used to treat high cholesterol and triglycerides] give 20 mg by mouth at bedtime for [CONDITION(S)] .[MEDICATION(S)] HCL tablet 50 mg Give 50 mg by mouth at bedtime for Depression . Observation of the 200 Hall Medication Cart on 2/8/2022 at 1:30 PM, revealed the unit doses of [MEDICATION(S)] Sodium 20 mg and [MEDICATION(S)] HCL 50 mg scheduled to be given 2/4/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of Resident #28's MAR dated 2/2022, revealed the [MEDICATION(S)] Sodium 20 mg and [MEDICATION(S)] HCL 50 mg scheduled to be given 2/4/2022 at 8:00 PM, was not documented as administered. During an interview on 2/8/2022 at 1:30 PM, the ADON confirmed the medication was in the medication cart and had not been administered to Resident #28 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR. She stated, .it is blank .can't make this stuff up dear God .meds not right . Medical record review revealed, Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Re[TRUNCATED]

Based on policy review, medical record review, observation, and interview, the facility failed to ensure the medical record was accurate for medications administered to 24 of 33 sampled residents (Resident #2, #3, #4, #5, #6, #9, #10, #11, #12, #14, #15, #16, #17, #18, #19, #20, #23, #24, #25, #26, #27, #29, #30, and #31) reviewed for medication administration. The findings include: Review of the facility's undated policy titled, Medication Administration, revealed .Purpose: To ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration .Licensed professional nurses administer medications according to times documented on the Medication Administration Record [MAR] .Medication Administration Record will be signed after for each medication administered to the resident . Review of the medical record, revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Active Orders Report dated 2/8/2022, revealed .[start date 1/25/2022] [MEDICATION(S)] Tablet 40 mg Give 40 mg [milligrams] by mouth at bedtime related to [CONDITION(S)] [elevated cholesterol and triglycerides] .2/2/2022 order [MEDICATION(S)] [HCL] [[MEDICATION(S)]] tablet 200 mg give 1 tablet by mouth two times a day related to [CONDITION(S)] [irregular heart rate] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] tablet 40 mg scheduled for administration on 1/29/2022 at 9:00 PM, [MEDICATION(S)] 200 mg scheduled 2/4/2022 at 5:00 AM, remained in the medication cart and had not been administered. Review of Resident #2's Medication Administration Record (MAR) dated 1/2022 and 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] tablet 40 mg scheduled 1/29/2022 at 9:00 PM and the [MEDICATION(S)] 200 mg scheduled 2/4/2022 at 5:00 AM, had been administered. During an interview on 2/8/2022 at 2:00 PM, the Assistant Director of Nursing (ADON) confirmed the [MEDICATION(S)] tablet 40 mg scheduled on 1/29/2022 at 9:00 PM and the [MEDICATION(S)] 200 mg tablet scheduled 2/4/2022 at 5:00 PM doses remained in the medication cart, and had not been administered. She stated, .Yeah, I see it .I don't know why was not given . During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 1/2022 and 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Active Orders report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] 5 mg by mouth two times a day for Type 2 Diabetes Mellitus . Observation of the 100 Hall Medication Cart on 2/10/2022 at 1:00 PM, revealed [MEDICATION(S)] 5 mg scheduled to be administered on 2/10/2022 at 5:00 PM, remained in the medication cart and had not been administered. Review of Resident #3's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 5 mg scheduled 2/10/2022 at 5:00 PM had been administered. During an interview on 2/8/2022 at 1:00 PM the ADON confirmed the medication was in the cart and had not been administered to Resident #3 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Active Orders Report dated 2/8/2022, revealed .[start date 9/1/2021] CALCITROL CAP [capsule] 0.25 MCG [micrograms] [a calcium supplement] Give 1 capsule by mouth one time a day .[MEDICATION(S)] TAB [tablet] 100 MG [a medication used to treat elevated uric acid] Give 1 tablet by mouth one time a day .[MEDICATION(S)] 10 MG TAB Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION Folic Acid Tablet 1 MG [a dietary supplement] Give 1 mg by mouth one time a day .[MEDICATION(S)] 80 MG TABS [a diuretic] Give 1 tablet by mouth one time a day every Tue [Tuesday], Thu [Thursday]. Sat [Saturday], Sun [Sunday] for [CONDITION(S)] .[MEDICATION(S)] TAB 25 MG Give 2 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .[MEDICATION(S)] HCL [[MEDICATION(S)]] 100 MG TABS Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the unit dose of [MEDICATION(S)] 100 mg scheduled 2/4/2022 at 2:00 PM, the [MEDICATION(S)] 25 mg scheduled 2/4/2022 at 5:00 PM, the [MEDICATION(S)] 25 mg scheduled 2/5/2022 at 8:00 AM, the [MEDICATION(S)] 100 mg scheduled 2/5/2022 at 9:00 AM, the [MEDICATION(S)] 10 mg scheduled 2/5/2022 at 9:00 AM, the Calcitrol 0.25 mcg scheduled 2/5/2022 at 9:00 AM, the Folic Acid 1 mg scheduled 2/5/2022 at 9:00 AM, and the [MEDICATION(S)] 80 mg scheduled 2/5/2022 at 9:00 AM, remained in the medication cart and had not been administered. Review of Resident #4's MAR dated 2/2022, revealed a check mark and nurse's initials [MEDICATION(S)] 100 mg had been administered on 2/4/2022 at 2:00 PM, [MEDICATION(S)] 25 mg had been given on 2/4/2022 at 5:00 PM, [MEDICATION(S)] 25mg had been given on 2/5/2022 at 8:00 AM, [MEDICATION(S)] 100 mg had been given on 2/5/2022 at 9:00 AM, [MEDICATION(S)] 10 mg had been given on 2/5/2022 at 9:00 AM, Calcitrol 0.25 mcg had been administered on 2/5/2022 at 9:00 AM, Folic Acid 1 mg given on 2/5/2022 at 9:00 AM, and [MEDICATION(S)] 80 mg given on 2/5/2022 at 9:00 AM. During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the cart and had not been administered to Resident #4 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Active Orders report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAB 12.5 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION .[MEDICATION(S)] HCL 100MG TABS Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed the unit dose of [MEDICATION(S)] 100 mg scheduled 2/2/2022 and 2/5/2022 at 2:00 PM, the [MEDICATION(S)] 12.5 mg scheduled 2/2/2022 at 5:00 PM and 2/5/2022 at 8:00 AM and 5:00 PM, the [MEDICATION(S)] 10 mg scheduled 2/5/2022 at 8:00 AM, the Calcitrol 0.25 mcg scheduled 2/5/2022 at 8:00 AM, the [MEDICATION(S)] 40 mg scheduled 2/5/2022 at 9:00 AM, and the [MEDICATION(S)] HCL 100 mg scheduled 2/5/2022 at 9:00 AM, remained in the medication cart and had not been administered. Review of Resident #5's MAR dated 2/1/2022 through 2/28/2022, revealed a check mark and nurse's initials indicating [MEDICATION(S)] 100 mg scheduled 2/2/2022 at 2:00 PM, and the [MEDICATION(S)] 12.5 mg scheduled 2/5/2022 at 8:00 AM and 5:00 PM, had been administered. During an interview on 2/8/2022 at 2:45 PM, the ADON confirmed the medications were in the cart and had not been administered to Resident #5 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Active Orders Report dated 2/8/2022, revealed .[start date 1/28/2022] [MEDICATION(S)] Tablet 25 MG Give 25 mg by mouth two times daily for [CONDITION(S)] [Hypertension] .[MEDICATION(S)] Tablet [a medication used to treat high cholesterol] 20 MG Give 20 mg by mouth at bedtime related to Coronary Atherosclerosis .[MEDICATION(S)] [an antiplatelet, blood thinner] Tablet 75 MG Give 75 mg by mouth one time a day .[MEDICATION(S)] Sodium Tablet [a medication used to treat Gastroesophageal Reflux Disease] Delayed Release 40 MG Give 40 mg by mouth two times daily . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed the unit dose of [MEDICATION(S)] 40 mg scheduled 1/31/2022 at 4:00 PM and 7:00 PM, [MEDICATION(S)] 75 mg scheduled 2/3/2022 and 2/5/2022 at 9:00 AM, [MEDICATION(S)] 25 mg scheduled 2/2/2022 and 2/5/2022 at 7:00 AM and a unit dose dated 2/4/2022 and 2/5/2022 at 8:00 PM, and [MEDICATION(S)] scheduled 2/3/2022 at 8:00 PM, remained in the medication cart and had not been administered. There were 2 medication cards of [MEDICATION(S)] 600 mg scheduled for two times a day. There were 21 tablets remaining from the cards that were delivered on 1/29/2022. There should have been 7 tablets remaining after the medication was administered two times daily starting 1/29/2022. Observation of the 300 Hall Medication Cart on 2/13/2022 at 2:10 PM, revealed 13 tablets of [MEDICATION(S)] remained in the cart from the cards delivered on 1/29/2022. The order for the [MEDICATION(S)] 600 mg for 14 days should have been completed on 2/11/2022. Review of Resident #6's MAR dated 1/2022, revealed a check mark and nurse's initials indicating [MEDICATION(S)] 40 mg scheduled1/31/2022 at 4:00 PM and 7:00 PM had been administered. Review of Resident #6's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 75 mg scheduled 2/3/2022 and 2/5/2022 at 9:00 AM, [MEDICATION(S)] 20 mg scheduled 2/3/2022 at 8:00 PM, [MEDICATION(S)] 25 mg scheduled 2/2/2022 and 2/5/2022 at 7:00 AM and 2/5/2022 scheduled at 8:00 PM, had been administered. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. During an interview on 2/14/2022 at 2:16 PM, the DON confirmed the documentation on the January and February 2022 MAR was inaccurate. Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Active Orders report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAB 15MG [an antidepressant] Give 1 tablet by mouth at bedtime for appetite enhancement . Observation of the 300 Hall Medication cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 15 mg scheduled to be given on 2/2/2022 at 8:00 PM remained in the medication cart. Review of Resident #9's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 15 mg scheduled 2/2/2022 at 8:00 PM had been administered. Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Active Orders Report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAR TAB 25MG Give 1 tablet by mouth every 8 hours related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 25 mg scheduled 2/6/2022 at 6:00 AM, remained in the medication cart and had not been administered. Review of Resident #10's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 25 mg scheduled 2/6/2022 at 6:00 AM had been administered. Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Active Orders report dated 2/8/2022, revealed .[start date 7/20/2021] PANTROPRAZOLE TAB 40MG [a medication used to treat Gastroesophageal Reflux Disease] Give 1 tablet by mouth two times a day . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:30 PM, revealed [MEDICATION(S)] 40mg scheduled to be given on 2/2/2022 at 4:00 PM remained in the medication cart. Review of Resident #11's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 40mg scheduled 2/2/2022 at 4:00 PM had been administered. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's Active Orders report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] 40MG TABS Give 1 tablet by mouth two times a day related to Heart Failure .[MEDICATION(S)] TAB 80MG Give 1 tablet by mouth at bedtime related to [CONDITION(S)] .[MEDICATION(S)] TAB 25MG Give 1 tablet by mouth two times a date related to ESSENTIAL (PRIMARY) HYPERTENSION Hold for heart rate less than 55 .[MEDICATION(S)] 1000mg tabs Give 1 tablet by mouth two times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC [CONDITION(S)] . Observation of the 300 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 80 mg scheduled to be given on 2/5/2022 at 9:00 PM, [MEDICATION(S)] 25 mg scheduled 2/5/2022 at 5:00 PM, [MEDICATION(S)] 40 mg scheduled 2/5/2022 at 5:00 PM, and [MEDICATION(S)] HCL 1000 mg scheduled 2/5/2022 at 4:00 PM, remained in the medication cart and had not been administered. Review of Resident #12's MAR dated 2/2022, revealed a check mark and nurse's initials indicating [MEDICATION(S)] 80 mg scheduled 2/5/2022 at 9:00 PM, the [MEDICATION(S)] 40 mg and [MEDICATION(S)] 25 mg scheduled 2/5/2022 at 5:00 PM, and the [MEDICATION(S)] HCL 1000 mg scheduled 2/5/2022 at 4:00 PM had been administered. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's Active Orders Report dated 2/8/2022, revealed .[start date 7/20/2021] [MEDICATION(S)] tab 20 mg Give 1 tablet by mouth at bedtime related to MIXED [CONDITION(S)] .[start date 8/25/2021] [MEDICATION(S)] 5 MG TAB Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION hold if SBP [systolic blood pressure] less than 110 . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 5 mg with a scheduled date of 2/3/2022 at 8:00 AM and [MEDICATION(S)] 20 mg scheduled for 2/3/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of Resident #14's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 5mg scheduled 2/3/2022 at 8:00 AM and the [MEDICATION(S)] 20 mg scheduled 2/3/2022 at 8:00 PM, had been administered. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #15 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Active Orders report dated 2/8/2022, revealed .[start date 1/21/2022] [MEDICATION(S)] TAB 80 MG Give 1 tablet by mouth at bedtime related to [CONDITION(S)] .[MEDICATION(S)] 40 MG Give 1 tablet by mouth two times a day related to [CONDITION(S)] .[MEDICATION(S)] HCL Tablet 50 MG Give 50 mg by mouth three times a day related to ESSENTIAL (PRIMARY) HYPERTENSION . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] 40 mg scheduled 2/2/2022 at 5:00 PM, [MEDICATION(S)] 50 mg and [MEDICATION(S)] 80 mg scheduled 2/3/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of Resident #15's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 40 mg scheduled 2/2/2022 at 5:00 PM, the [MEDICATION(S)] 50 mg and [MEDICATION(S)] 80 mg scheduled 2/3/2022 at 8:00 PM, had been administered. Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Active Orders report dated 2/8/2022, revealed .[start date 10/27/2021] Famotidine Tablet Give 20 mg by mouth two times a day for GERD .[MEDICATION(S)] [MEDICATION(S)] Tablet 25 MG Give 25 mg by mouth two times a day for HYPERTENSION hold for SBP < [symbol for less than] 90, HR [Heart Rate] < 55 . Observation of the 400 Hall Medication Cart on 2/8/2022 at 2:00 PM, revealed Famotidine 20 mg with a scheduled date of 2/4/2022 and 2/7/2022 at 5:00 PM, and [MEDICATION(S)] 2.5 mg scheduled 2/6/2022 at 8:00 PM, remained in the medication cart and had not been administered. Review of Resident #16's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the Famotidine 20 mg scheduled 2/4/2022 and 2/7/2022 at 5:00 PM had been administered. [MEDICATION(S)] 25 mg had a code of 4 indicating a pulse was below 60. There was no documentation Resident #16's pulse had been assessed or documented at 8:00 PM. During an interview on 2/8/2022 at 2:30 PM, the Admissions Nurse stated, .Not in the program for the nurse to auto document a pulse . The Admissions Nurse confirmed there was no documentation Resident #16's pulse had been assessed. Review of the medical record, revealed Resident #17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Active Orders report dated 2/8/2022, revealed .[start date 7/21/2021] POT [Potassium] CL [Chloride] MICRO TAB 20 MEQ [milliequivalent] Give 1 tablet by mouth one time a day related to [CONDITION(S)] .[start date 12/22/2021] [MEDICATION(S)] HCL Capsule Delayed Release Sprinkle 20 MG Give 1 capsule by mouth one time a day related to Major Depressive Disorder . Observation of the 300 Hall Mediation Cart on 2/8/2022 at 2:00 PM, revealed [MEDICATION(S)] HCL 20 mg with a scheduled date of 2/6/2022 at 9:00 AM and Potassium Chloride 20 meq scheduled 2/6/2022 at 9:00 AM, remained in the medication cart and had not been administered. Review of Resident #17's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 20 mg scheduled 2/6/2022 at 9:00 AM and the Potassium Chloride 20 meq scheduled 2/6/2022 at 9:00 AM, had been administered. During an interview on 2/8/2022 at 2:00 PM, the Admission Nurse confirmed the documentation on the MAR was inaccurate. Review of the medical record, revealed Resident #18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Active Orders report dated 2/8/2022, revealed .[start date 7/21/2021] [MEDICATION(S)] TAB 5 MG Give 1 tablet by mouth two times a day for muscle spasm .[MEDICATION(S)] TAB HCL 5 MG Give 1 tablet by mouth two times a day related to Unspecified Dementia .[start date 9/14/2021] [MEDICATION(S)] TAB 3.125 MG Give 1 tablet by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION HOLD FOR HEART RATE LESS THAN 60. HOLD FOR BLOOD PRESSURE LESS THAN 110/80 . Observation of the 300 Hall Mediation Cart on 2/8/2022 at 2:00 PM, revealed the [MEDICATION(S)] 5 mg and [MEDICATION(S)] HCL 5 mg scheduled 2/7/2022 at 4:00 PM and the [MEDICATION(S)] 3.125 mg scheduled 2/7/2022 at 5:00 PM, remained in the medication cart and had not been administered. Review of Resident #18's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 5 mg and [MEDICATION(S)] HCL 5 mg scheduled 2/7/2022 at 4:00 PM and the [MEDICATION(S)] 3.125 mg scheduled 2/7/2022 at 5:00 PM had been administered. During an interview on 2/8/2022 at 2:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #19's Active Orders Report dated 2/8/2022, revealed .[start date 2/4/2022] [MEDICATION(S)] Calcium tablet 40 mg by mouth at bedtime for [CONDITION(S)] .Tamsulosin [[MEDICATION(S)]] HCL capsule 0.4 mg give 1 capsule by mouth at bedtime for [CONDITION(S)] .[MEDICATION(S)] Sodium Tablet 100 mcg give 1 tablet by mouth one time a day for Low [CONDITION(S)] .Omeprazole capsule delayed release 40 mg give 1 capsule by mouth one time a day for GERD [gastroesophageal reflux disease] .[MEDICATION(S)] [MEDICATION(S)] tablet 5 mg give 5 mg by mouth one time a day for [CONDITION(S)] [hypertension] .[MEDICATION(S)] 20 mg give 20 mg by mouth one time a day for [CONDITION(S)] .Potassium Chloride ER tablet extended release 20 meq give 1 tablet by mouth one time a day for [CONDITION(S)] .Hydrocortisone Tablet 5 mg give 15 mg by mouth one time a day for Allergy 3 tabs to equal 15 mg before breakfast .Hydrocortisone Tablet 5 mg give 5 mg by mouth one time a day for Allergy give 5 mg before supper .[MEDICATION(S)] Tablet 25 mg give 25 mg by mouth one time a day for [CONDITION(S)] . Observation of the 200 Hall Medication Cart on 2/8/2022 at 1:30 PM, revealed the unit dose of [MEDICATION(S)] Calcium 40 mg and Tamsulosin HCL 0.4 mg with a scheduled date of 2/5/2022 at 8:00 PM, [MEDICATION(S)] Sodium 100 mcg and Omeprazole 40 mg scheduled 2/6/2022 at 6:00 AM, [MEDICATION(S)] [MEDICATION(S)] 5 mg, [MEDICATION(S)] 20 mg and Potassium Chloride 20 [milliequivalents] meq scheduled 2/6/2022 at 9:00 AM, remained in the medication cart and had not been administered. Observation on the 200 Hall Medication Cart on 2/8/2022 at 1:30 PM, revealed the medication card [MEDICATION(S)] 25 mg had 29 of 30 pills left in the card which reflected one pill had been administered since 2/5/2022, and Hydrocortisone 5 mg had 21 pills of 24 left in the card which reflected 3 pills had been administered since 2/5/2022. Review of Resident #19's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the Hydrocortisone Tablet 5 mg was administered on 2/5/2022 at 4:00 PM, the [MEDICATION(S)] 25 mg was administered on 2/5/2022 and 2/6/2022 at 9:00 AM, the [MEDICATION(S)] Sodium 100 mcg and Omeprazole 40 mg 2/6/2022 had been administered at 6:00 AM, [MEDICATION(S)] [MEDICATION(S)] 5 mg, [MEDICATION(S)] 20 mg and the Potassium Chloride 2/6/2022 had been administered at 9:00 AM. The MAR revealed [MEDICATION(S)] Calcium tablet 40 mg and Tamsulosin 0.4 mg scheduled for 2/5/2022 at 8:00 PM was not given because the medication was not in the facility. The medication cart contained the 2 medication unit doses scheduled 2/5/2022 at 8:00 PM. During an interview on 2/8/2022 at 1:30 PM the ADON confirmed the medications were in the medication cart and had not been administered to Resident #19 as ordered by the Physician. She stated, .Yeah, I see it .I have no explanation . During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record revealed, Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #20's Active Orders report dated 2/8/2022, revealed .[start date 9/22/2021] [MEDICATION(S)] HCL 200 mg Give 1 tablet by mouth in the morning for Cardiovascular, [MEDICATION(S)] [MEDICATION(S)] Give 12.5 mg by mouth two times a day for Hypertension . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 200 mg scheduled 2/1/2022 and 2/8/2022 at 8:00 PM, and [MEDICATION(S)] 25 mg ½ tablet (12.5 mg) scheduled 2/8/2022 at 9:00 AM, remained in the medication cart and had not been administered. Review of Resident #20's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 200 mg scheduled 2/1/2022 and 2/8/2022 at 8:00 AM and [MEDICATION(S)] 25 mg ½ tablet scheduled 2/8/2022 at 9:00 AM, had been administered. During an interview on 2/8/2022 at 1:00 PM the ADON confirmed the medications remained in the medication cart and had not been administered to Resident #20 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Active Orders Report dated 2/8/2022, revealed .[start date 12/3/2021] [MEDICATION(S)] Sodium 40 mg give 1 tablet by mouth one time a day for Gastro-[CONDITION(S)] Reflux Disease .Tamsulosin HCL [[MEDICATION(S)] Acid] 0.4 mg [a medication used to treat an enlarged prostate] give 2 capsules by mouth at bedtime for Urine Retention . Observations of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 40 mg scheduled 2/8/2022 at 6:00 AM and Tamsulosin 0.4 mg scheduled 2/4/2022 at 8:00 PM remained in the medication cart. Review of Resident #23's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the Tamsulosin 0.4 mg scheduled 2/4/2022 at 8:00 PM and the [MEDICATION(S)] 40 mg scheduled 2/8/2022 at 6:00 AM had been administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #23 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record revealed, Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #24's Active Orders report dated 2/8/2022 revealed, .[start date 1/17/2022] [MEDICATION(S)] tablet Give 100 mg by mouth two times a day for Gout .Losartan Potassium tablet 25 mg give 25 mg by mouth two times a day for Hypertension .[MEDICATION(S)] HCL tablet 100 mg give 100 mg by mouth three times a day for Hypertension . Observation of the 100 Hall Medication Cart on 2/11/2022 at 3:20 PM, revealed the unit dose of [MEDICATION(S)] HCL 100 mg scheduled 2/10/2022 at 2:00 PM, the Losartan Potassium 25 mg scheduled 2/10/2022 and at 2:00 PM, and [MEDICATION(S)] 100 mg scheduled 2/10/2022 at 5:00 PM, remained in the medication cart and had not been administered. Review of Resident #24's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] HCL 100 mg and Losartan Potassium 25 mg scheduled 2/10/2022 at 2:00 PM and [MEDICATION(S)] 100 mg scheduled 2/10/2022 at 5:00 PM, had been administered. Review of the medical record, revealed Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's Active Orders report dated 2/8/2022, revealed .[start date 9/4/2021] [MEDICATION(S)] tablet 80 mg Give 1 tablet by mouth one time a day for Elevated Cholesterol . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] 80 mg scheduled 2/7/2022 at 5:00 PM, remained in the medication cart and had not been administered. Review of Resident #25's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] 80 mg scheduled 2/7/2022 at 5:00 PM, had been administered. During an interview on 2/8/2022 at 1:00 PM, the ADON confirmed the medications were in the medication cart and had not been administered to Resident #25 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM, the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's Active Orders Report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] HCL 20 mg [an antidepressant] Give 1 tablet by mouth one time a day for Depression . Observation of the 100 Hall Medication Cart on 2/8/2022 at 1:00 PM, revealed the unit dose of [MEDICATION(S)] HCL 20 mg scheduled 2/4/2022 at 9:00 AM remained in the medication cart. Review of Resident #26's MAR dated 2/2022, revealed a check mark and nurse's initials indicating the [MEDICATION(S)] HCL 20 mg scheduled 2/4/2022 at 9:00 AM, had been administered. During an interview on 2/8/2022 at 1:00 PM the ADON confirmed the [MEDICATION(S)] was in the medication cart and had not been administered to Resident #26 as ordered by the Physician. During an interview on 2/8/2022 at 4:00 PM the Admission Nurse confirmed the documentation on the 2/2022 MAR was inaccurate. Review of the medical record, revealed Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #27's Active Orders report dated 2/8/2022, revealed .[start date 12/27/2021] [MEDICATION(S)] Tablet

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by undated food items, a dirty deep fryer, meat slicer, and mixer, inappropriate tray line serving temperatures, and 2 of 13 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to distribute and serve food in a sanitary manner during dining. This had the potential to affect the 73 of the 78 residents who had received a tray from the Kitchen. The findings include: Review of the facility's policy titled,Table Top Mixer, dated 3/26/2012, revealed .The mixer will be cleaned and sanitized after each use . Review of the facility's policy titled,Food Slicer, dated 3/26/2012, revealed .This machine must be thoroughly cleaned and sanitized after each use . Review of the facility's policy titled, Deep Fryer, dated 3/26/2012, revealed .The deep fryer will be cleaned as needed .to ensure food safety. To produce evenly cooked, perfectly browned fried products keep the oil in the deep fryer clean and clear . Observation in the resident's room on 7/12/2021 at 1:37 PM, revealed CNA #1 delivered a lunch tray to Resident #9, placed the tray on the bedside table, repositioned the resident, and adjusted the bed controls. CNA #1 picked up and opened a plastic bag containing Resident #9's sandwich and removed the sandwich with her bare hands. CNA #1 did not perform hand hygiene. Observation in the resident's room on 7/12/2021 at 1:43 PM, revealed CNA#1 delivered a lunch tray to Resident #38, placed the tray on the bedside table, touched wheelchair handles, and repositioned the bedside table, knocking off a roll of toilet paper and a bottle of lotion onto the floor. CNA #1 picked up the items off of the floor and continued to set up the resident's meal tray without performing hand hygiene. Observation in the resident's room on 7/12/2021 at 1:49 PM, revealed of CNA #1 delivered a lunch tray to Resident #167, placed the tray on the bedside table, touched the bed controls to elevate the head of the bed, then opened the Styrofoam food container, removed the lids from the cups, and handled the plastic eating utensils without performing hand hygiene. Observation in the resident's room on 7/12/2021 at 1:52 PM, revealed CNA #1 delivered a lunch tray to Resident #37, placed the tray on the bedside table, picked up and opened a plastic bag containing a peanut butter and jelly sandwich. CNA #1 then removed Resident #37's sandwich from the plastic bag with her bare hands without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:11 AM, revealed CNA #1 delivered a breakfast tray to Resident #38, placed the tray on the bedside table and knocked a plastic knife off onto the floor. CNA #1 then picked up the knife, touched the bedside table, turned on the light switch, and assisted the resident to reposition in the bed. CNA #1 picked up Resident #38's toast bare handed, spread jelly, and placed the toast back onto resident's plate without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:17 AM, revealed CNA #1 delivered a breakfast tray to Resident #55, placed the tray on the bedside table, picked up the bed controls, touched the bedside table to reposition the table across the bed. CNA #1 proceeded to open all food containers, picked up 3 pieces of toast, individually spreading butter and jelly on each piece and placed the toast back onto resident's plate without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:21 AM, revealed CNA #1 delivered a breakfast tray to Resident #42, placed the tray on the bedside table, touched the bed controls and the bedside table, and removed all the lids on the tray and the food containers without performing hand hygiene. CNA #1 picked up Resident #42's toast bare handed, buttered toast, and placed it back on the resident's plate. Observation in the 100 hall on 7/13/2021 beginning at 8:26 AM, revealed CNA #2 removed a breakfast tray from the meal cart, delivered and set up breakfast trays to Resident #168's, #219's, #45's, #57's, #121's, #169's, and #118's rooms. CNA #2 then prepared a cup of coffee and delivered the coffee to Resident #57 and #121. CNA #2 then went to Resident #118's room and fed her breakfast. CNA #2 did not perform hand hygiene during this meal delivery. Observation in the resident's room on 7/13/2021 at 8:28 AM, revealed CNA #1 delivered a breakfast tray to Resident #167, CNA #1 peeled Resident #167's banana and removed the banana from the banana peel with her bare hands and placed it on the resident's plate without performing hand hygiene. Observation in the resident's room on 7/13/2021 at 8:31 AM, revealed CNA #1 delivered a breakfast tray to Resident #61, placed the tray on the bedside table, touched the resident, bed controls, blanket, pillow, and the bedside table. CNA #1 then touched Resident #61's bacon and toast with bare hands to straighten it on the plate. CNA #1 continued to set up the resident's meal tray without performing hand hygiene. During an interview on 7/13/2021 at 9:13 AM, CNA #2 was asked what should be done before serving each resident their meal tray and assisting to feed residents. CNA #2 stated, Wash my hands .I washed them when I first got here . During an interview on 7/14/2021 at 6:05 PM, the Director of Nursing (DON) was asked what would be expected of staff when passing meal trays to residents. The DON stated, I expect them to wash their hands first The DON was asked what should staff do when they leave a resident's room to get another resident tray. The DON confirmed staff should sanitize their hands before and after delivering a meal tray to residents and before serving a meal to a resident. Observation in the Kitchen on 7/13/2021 at 12:15 PM, revealed the following items stored in the freezer: a. 2 undated bags of corn nuggets b. 1 open and undated bag of potato tots Observation in the Kitchen on 7/13/2021 at 12:20 PM, revealed brown sediment floating in the dark grease with thick build up around the pan of the deep fryer. Observation in the Kitchen on 7/13/2021 at 12:22 PM, revealed dried food particles on the meat slicer. Observation in the Kitchen on 7/13/2021 at 12:24 PM, revealed a dried unknown substance on the mixer. Observation in the Kitchen on 7/13/2021 at 12:28 PM, revealed Dietary Staff #3 took temperatures on the serving line. The alternate meat was turkey and the holding temperature was 80 degrees Fahrenheit (F). The first meal cart had left the Kitchen. During an interview on 7/14/2021 at 2:58 PM, the Dietary Manager (DM) confirmed the two bags of corn nuggets and one bag of potato tots should have been dated or left in the box. The DM was asked about the build up on and the dark grease in the deep fryer. The DM stated, It needed to be cleaned . The DM was asked what the dried particles were on the meat slicer. The DM stated, .it was dried chipped meat . The DM was asked how often should the meat slicer be cleaned. The DM stated, After every use. The DM was asked what was the dry substance on the mixer. The DM stated, .I don't know what that was .I'm going to say it was dry pudding. The DM was asked what should the temperature of the turkey have been. The DM stated,165. The DM was asked should it had been served to the residents. The DM stated, Absolutely not .

Based on policy review, observation, and interview, the facility failed to deliver meal trays to residents in a timely manner resulting in late meals. This had the potential to affect the 73 of the 78 residents who had received a tray from the Kitchen. The findings included: Review of the facility's policy titled, Resident Dining Services dated 12/6/2016, revealed .The Food and Nutrition Services department will have a process in place to assure residents receive meals in a timely manner with appropriate assistance and supervision . Observation of the halls on 7/12/2021 revealed lunch meal trays were scheduled to be delivered on the 300 Hall at 12:45 PM, on the 400 Hall at 12:50 PM, on the 100 Hall at 1:00 PM, and on the 200 Hall at 1:15 PM. Observation on 7/12/2021 revealed the first meal was delivered on the 300 Hall to a resident at 1:38 PM. The meal was 53 minutes late. Observation on the 100 Hall revealed the first meal was delivered to a resident at 2:08 PM. The meal was 1 hour and 8 minutes late. The first meal tray was delivered on the 200 Hall at 2:28 PM. The meal was 1 hour and 13 minutes late. During an interview on 7/13/2021 at 8:05 AM, Resident #51 stated that she had failed to receive a breakfast tray Sunday (7/11/2021) morning and her first meal that day was at 12:15 PM. She also confirmed she didn't receive her supper tray until 8:15 PM. During an interview on 7/13/2021 at 9:03 AM, Resident #121 confirmed that on 7/11/2021 he did not receive a breakfast tray and his first meal that day was between 1:00 or 2:00 PM and stated, .didn't get supper till 8o'clock [8:00 PM] .ever since I've been here all the meals are late . During an interview on 7/14/2021 at 9:15 AM, Dietary Staff #3 confirmed she worked Sunday and stated, .the young man that was supposed to be here didn't show up .he was new .no one stays .I was by myself .I didn't understand the tickets, they were a mess .breakfast trays are supposed to go out 7:00-7:30 [AM] . Dietary Staff #3 was asked if the breakfast trays were served. Dietary Staff #3 stated, .I didn't serve them breakfast .it didn't make any sense to serve them breakfast it was lunch time, I gave them a little extra . Dietary Staff #3 was asked if the Kitchen had been short staffed. Dietary #3 stated, Yes . Dietary Staff #3 was asked why meals were being on Styrofoam. Dietary Staff #3 stated, Because we are short staffed . Dietary Staff #3 was asked why were the lunch trays late being delivered. Dietary Staff #3 stated, .don't get out on time .we don't have that many people . During an interview on 7/14/2021 at 1:48 PM, Dietary Staff #1 was asked if the residents' meals have been late. Dietary Staff #1 stated, .they are always late .get breakfast at 9:00 or 10 o'clock [10:00 AM] .lunch at 2:00 or 3 o'clock [3:00 PM] . During an interview on 7/14/2021 at 2:02 PM, Dietary Staff #2 was asked what had happened on Sunday (7/11/2021). Dietary Staff #2 stated, .received a text .asked if I could come in and help Sunday morning .new guy didn't show up and [Named Dietary Staff #3] was working by herself .I think I made it here at 1 to 1:15 [PM] .serving lunch by the time I got here . During an interview on 7/14/2021 at 2:26 PM, Dietary Staff #4 was asked if she worked Sunday (7/11/2021). Dietary Staff #4 stated, .I was called to come in because [Named Dietary Manger] called and said [Named Previous Dietary Staff] didn't come in .breakfast was still on the steamer .hadn't been served .did have everything ready .when I got here I worked .long story short breakfast did not get served .I didn't even know how to read the tickets .she decided to go serve lunch .her lunch was done she just needed to move breakfast so lunch wouldn't get cold .she was the only one here .said she had asked the CNA [Certified Nursing Assistant]s and they said no .we did roll out lunch about 12 [PM] . Dietary Staff #4 was asked why were meals being served in Styrofoam. Dietary #4 stated, Because they are short staffed no one wants to be here at 10 o'clock at night washing dishes . During an interview on 7/14/2021 at 2:26 PM, the Dietary Manager (DM) was asked what happened Sunday (7/11/2021) in the Kitchen. The DM stated, .I received a phone call from [Dietary Staff #3] told me that the guy didn't show up .I then called [Named Dietary Staff #2] .to see if she could go ahead and come in .I then called [Dietary Staff #3] didn't have anybody to bring in if she could get someone .to pass the trays she said she had the whole meal fixed .breakfast supposed to go out between 7:00 - 7:30 [AM] .not feeding them is not option . The DM was asked if the residents received breakfast on Sunday. The DM stated, according to what I was told, no . The DM was asked why lunch was so late Monday (7/12/2021). The DM stated,We were down a dietary aide so I had to come in and cover his shift .just me and Dietary #3 in the Kitchen .I didn't realize it was that late .there is only so much one person can do. The DM confirmed the trays were late and stated, .the responsibility, it's all mine .I'm supposed to be here 24/7 .I've been dietary aide .cook .and management .on repeated basis .nearly everyday . During an interview on 7/14/2021 at 3:46 PM, the Registered Dietician (RD) was asked who was responsible for the Kitchen. The RD stated, The Dietary Manager . The RD was asked if the kitchen was short staffed. The RD stated, It has been this last month .they have had a tremendous turn over . The RD was asked if she was aware the residents didn't receive breakfast on Sunday (7/11/2021). The RD stated. I heard about it Monday .they said they served an early lunch . The RD was asked if an early lunch would take the place of breakfast. The RD confirmed she was at the facility Monday and was asked if she was aware the Kitchen was short staffed on Monday. The RD stated, No .but one day she [Named the DM] worked as an aide .worked as a cook .it might have been Monday .it's hard to keep up with them .so the Administrator asked me to come in Tuesday and make sure that the meals got out on time. The RD confirmed the meals had been late and stated, Yes .for the last month .I'm telling you the truth .they have been late .not everyday .but 50 percent The RD was asked if she offered to help the staff when they are short. The RD stated,No .I'm on limited hours here .I don't work the tray line .I don't actually go back there and work with them .I do oversight .I see the trays are late and try to figure out what was going on .we are short staffed .and need people that know what is going on .

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when dietary staff did not properly restrain hair and when food items were stored in the refrigerator and freezer uncovered, unlabeled, and undated. The facility had a census of 82 residents, with 80 of those residents receiving a tray from the kitchen. The findings include: The facility's .Dress Code policy dated 3/27/12 documented, .Food employees wear a hair covering which covers all hair completely.longuards must be used for employees with facial hair . The facility's .Cold Storage Areas policy dated 3/26/12 documented, .Date, label and properly secure all products removed from original containers . Observations in the kitchen on 6/17/19 beginning at 5:50 AM, revealed: a. Dietary Staff #1 was in the kitchen during breakfast preparation with no beard cover over his facial hair. b. Ice filled glasses stored in the freezer uncovered, unlabeled, and undated. c. Trays of pancakes, turkey sausage, and bacon uncovered, unlabeled, and undated in the refrigerator. d. Bags of carrots and corn were stored in the freezer, under the fan, opened to air. Observations on 6/17/19 at 7:53 AM and 8:06 AM, revealed Dietary Staff #1 coming out of the kitchen pushing a meal cart with his beard cover pulled down exposing, facial hair. Observations in the kitchen on 6/18/19 at 11:30 AM, revealed Dietary Staff #2 was serving lunch plates with no beard cover over his facial hair. Interview with the Dietary Manager on 6/19/19 at 7:50 AM, in the Conference Room, the Dietary Manager was asked if dietary employees with facial hair should wear a beard guard while in the kitchen. The Dietary Manager stated, Yes. The Dietary Manager was asked if food and ice should be stored in the refrigerator and freezer open, uncovered, and unlabeled. The Dietary Manager stated, No, ma'am .

Based on medical record review and interview, the facility failed to send the Ombudsman a notice of transfer for 2 of 4 (Resident #80 and 233) sampled residents reviewed for transfer/discharge requirements. The findings included: 1. Medical record review revealed Resident #80 was admitted to the facility on [DATE], readmitted [DATE], and 7/18/18 with [DIAGNOSES REDACTED]. The telephone orders dated 5/15/18 documented, .Send to (Named Hospital) ER (emergency room ) . The nurses' notes dated 5/15/18 documented, .Resident has critical lab .Order to start O2 (oxygen) @ (at) 2L (liters)NC (nasal cannula) & (and) send to ER .Resident picked up via ambulance service at 8:00pm (8:00 PM), resident's daughter notified and in route to meet pt (patient) at hospital . Medical record review revealed the resident returned from the hospital on [DATE]. The facility was unable to provide documentation that the Ombudsman had been notified of the transfer to the hospital on [DATE]. 2. Medical record review revealed Resident #233 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The telephone orders dated 5/12/18 documented, .Discharge to ER . The nurses' notes dated 5/13/18 documented, .LATE ENTRY FOR 05/12/2018 .Resident sent to (Named Hospital) per order at approximately 1500 (3:00 PM) via stretcher with two EMTs (Emergency Medical Technicians) . Medical record review revealed this resident returned from the hospital on [DATE]. Interview with the Administrator on 7/24/18 at 7:00 PM, in the conference room, the Administrator confirmed the Ombudsman was not notified of transfers and stated .we had not been notifying the Ombudsman, we just started last month, he came by and said we were not doing it, brought the form, and said needed to get in compliance. We sent last month and Ombudsman has given us feedback on that form .

Based on review of the National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Prevention quick reference guide, policy review, medical record review, and interview, it was determined the facility failed to identify a pressure ulcer before it was identified at a Stage 3 for 1 of 5 (Resident #45) sampled residents reviewed of the 5 residents with pressure ulcers. The failure to identify a pressure ulcer before it became a Stage 3 resulted in an actual harm for Resident #45. The findings included: Review of the NPUAP Pressure Ulcer Prevention quick reference guide documented, (page) 12 . Category/Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss .(page) 34 .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer. An initial assessment includes: .A focused physical examination .2 .Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected .(page) 351. Assess the pressure ulcer initially and re-assess it at least weekly .1.1 Document the results of all wound assessments .3. assess and document physical characteristics including .location .size . Review of the facility policy, Weekly Skin Assessment-New Site Identification dated 2/2017 revealed, Weekly skin assessment and new skin issues are identified and communicated to the team by completion of the user defined assessment Skin 01. Weekly Skin Check. The procedure was to open a new Weekly Skin Check and document the assessment date. 3. If new skin conditions exist: a. Fully document the findings in the additional assessment fields. b. Notify physician of assessment and request orders. c. Add any new orders to resident orders. The computer system will notify the treatment nurse by e-assignment message. Closed medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Braden Pressure Ulcer Risk assessment dated [DATE] revealed a score of 13 indicating Resident #45 was at moderate risk for development of a pressure sore. The Wound Evaluation Flow Sheet completed on 3/9/17 revealed Resident #45 had a pressure ulcer to her left buttock, coccyx and right buttock. There was no documentation of a pressure ulcer on her left calf. Review of the the admission comprehensive Minimum Data Set ((MDS) dated [DATE] revealed Resident #45 had 1 Stage 1 pressure ulcer and 2 Stage 2 pressure ulcers. The MDS further indicated Resident #45 required extensive assistance of one staff member for bed mobility and extensive assistance of 2 staff members for transferring. The Brief Interview for Mental Status score was a 7, indicating severe cognitive impairment. The care plan for potential skin breakdown dated 3/16/17 had interventions including a weekly skin assessment. Review of a Physician Order dated 5/15/17 revealed a physician's order to apply Santyl cream ([MEDICATION NAME] ointment to break down dead skin) to Resident #45's left calf. Review of the Nurses' Notes dated 5/15/17 at 3:35 PM documented an assessment note of the pressure ulcer on the left calf of the resident but there was no documentation of the description, size, or stage of the pressure ulcer or that the the physician had been notified. The Wound Care Specialist Evaluation form dated 5/17/17 documented the coccyx wound but there was no documentation of the pressure ulcer to the left calf. Review of the medical record revealed there was no documentation in LPN #2's nurse's notes from 5/17 to 5/20/17 and on 5/22/17 of the left calf pressure ulcer. There was no documentation the Weekly Skin Checks were completed in accordance with the facility policy to determine identified changes (improvement or decline) of the pressure ulcer as well as the effectiveness of the Santyl treatment. Review of the Wound Evaluation Flow Sheet dated 5/31/2017, documented a pressure ulcer on the left calf that measured 7.5 centimeters (cm) by 1 cm by .3 cm deep. Review of the Wound Evaluation Flow Sheet dated 6/2/17 documented a Stage 3 pressure ulcer on the left calf that measured 7.5 cm, 16 days after identification. A review of the Wound Care Specialist Evaluation form dated 6/7/17 revealed the wound care physician evaluated Resident #45 and the left calf pressure ulcer was debrided and measured 8.7 cm x 1.1 cm x 0.1cm. Interview with LPN #1 on 7/11/17 at 8:43 AM, in the conference room, LPN #1 stated she was the wound nurse. She stated, We measure wounds weekly. I don't see any notes of the calf before 5/31 (2017). (Consultant #1) filled out the form on 6/2 (2017) noting the wound was evaluated on 5/31, but (the wound on the left calf) was found on 5/15. The wound care doctor did not see the calf wound until 6/07 (2017). Interview with Nurse Consultant #1 on 7/11/17 8:52 AM in the conference room, Nurse Consultant #1 stated, The nurse found the wound on 5/15 and put a treatment in place, but didn't do a new skin assessment so it didn't trigger a new area that would have triggered us to measure the wound. The skin assessment was done and the wound was measured on 5/31/17 and I entered the measurement on 6/2/17. There isn't a nurse's note that I can find about the calf wound when it was found. I don't remember how we found out about it to do the new skin assessment. Interview with LPN #2 on 7/11/17 at 9:28 AM in the conference room, Licensed Practical Nurse (LPN) #2 stated I usually try to always document if I find a wound. I would have taken care of (Resident #45) that day (5/15/17). The computer system is still new to me and I'm not sure all the places to document everything. Interview with LPN #2 on 7/11/17 6:55 PM in the conference room, LPN #2 stated, I really don't remember what the wound looked like or even writing the order. I wouldn't write an order for [REDACTED]. Telephone interview with Nurse Practitioner #1 (NP#1) on 7/11/17 at 7:10 PM in the conference room, NP #1 stated she was familiar with Resident #45. She stated, I did see the wound. I may have looked at it and I may not have made a note if I wasn't seeing her. I'm not sure why they called me and not (wound care physician). I remember it had slough in the wound bed. I don't do the sizing. I would expect that someone would have shown (wound care physician) since they make rounds with her every week. It is possible that it could have gotten to a Stage 3 in one week from the prior skin assessment. The failure of the facility to identify a pressure ulcer before it became a Stage 3 resulted in an actual harm for Resident #45.