Every finding on record at Woodlawn Healthcare Center LLC

Based on interview, observation, and record review, the facility's water management plan failed to have an assessment documenting where Legionella or other opportunistic waterborne pathogens could grow and spread or to include interventions for when control limits were not met. This deficiency has the potential to affect the facility's census of 51 residents. Findings include:Review on 2/18/26 of facility policy titled Woodlawn Care Center Legionella Management Plan Policy and Procedure, revealed that there was no assessment identifying areas within the facility where Legionella or other opportunistic waterborne pathogens could grow and spread. Further review revealed that there were no established interventions for situations in which control limits were not met. The review also revealed under control measures, hot water temperatures were required to be maintained at a level high enough to discourage the growth of Legionella, between 116-120 degrees Fahrenheit. Interview on 2/19/26 at approximately 2:20 p.m. with Staff B (Director of Maintenance) confirmed the above findings. Review on 2/18/26 of the CDC's Controlling Legionella dated January 3, 2025 revealed Store hot water above 140 F (60 C). Maintain circulating hot water above 120 F (49 C). Review on 2/18/26 of the CDC's Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings dated September 30, 2025 revealed, .3. Identify Areas Where Legionella Could Grow & Spread .Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in you building water systems . Each potentially hazardous condition should be addressed individually with a control point, measure, and limit . 5. Establish Ways to Intervene When Control Limits Are Not Met . You should plan for your monitoring results to vary over time and be prepared to apply corrective actions. Corrective actions are taken in response to systems performing outside of control limits .

Based on interview and record review, the facility failed to provide notifications of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 2 of 3 residents reviewed for Beneficiary Notification (Resident identifiers are #4 and #14).Findings include: Resident #4Review on 2/18/26 of the SNF Beneficiary Notification for residents who received Medicare Part A services (Form CMS-20052) revealed that the facility/provider initiated a discharge from Medicare Part A services for Resident #4 before the resident's benefit days were exhausted. Further review revealed that Resident #4 remained in the facility and that the last covered skilled services was 10/10/25. Resident #4 or Resident #4's representative was not provided the SNF ABN. Resident #14Review on 2/18/26 of SNF Beneficiary Notification for residents who received Medicare Part A Services (FORM CMS-20052) revealed that the facility/provider initiated a discharge from Medicare Part A services for Resident #14 before the resident's benefit days were exhausted. Further review revealed that Resident #14 remained at the facility and that his/her last covered skilled services was 10/16/25. Resident #14 or Resident #14's representative was not provided the SNF ABN.Interview on 2/18/2026 at approximately 9:00 a.m. with Staff D (Business Office Manager) confirmed the above findings.

Based on observation, interview, and record review, the facility failed to ensure that residents have the appropriate equipment to prevent a decrease in Range of Motion (ROM) for 1 of 1 resident reviewed for limited range of motion in a final sample of 13 residents (Resident identifier is #21).Findings include:Review on 2/18/26 of Resident #21's physician's orders revealed an order for OT [Occupational Therapy] Recommendation: B palm protectors [orthotic device] should be worn daily as tolerated to reduce contractures and skin breakdown. B palms should be cleaned and thoroughly dried before donning. The order had a start date of 12/30/25, and an end date of 3/24/26. Observation on 2/17/26 at 2:06 p.m. of Resident #21 revealed Resident #21 was sleeping in bed, both hands clenched. Resident #21 was not wearing palm protectors. Further observation revealed that the palm protectors were stored in the drawer of the resident's bedside table.Interview on 2/17/26 at 2:07 p.m. with Staff C (Licensed Nursing Assistant (LNA)) confirmed the above findings. Staff C stated that he/she was Resident #21's assigned LNA and had not applied the palm protectors for Resident #21.Observation on 2/18/26 at 8:30 a.m. and 12:29 p.m. revealed Resident #21 was in the main dining room being assisted with his/her meal. Resident #21's hands were resting on his/her lap and were clenched shut. Resident #21 was not wearing palm protectors on either hand.Review of 2/18/26 of Resident #21's Treatment Administration Records for January 2026 and February 2026 revealed that there was no documentation that the palm protectors were being applied daily.Interview on 2/18/26 at 1:06 p.m. with Staff A (Assistant Director of Nursing) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for 1 of 3 residents reviewed for beneficiary notices (Resident identifier is #148.) Findings include: Review on 1/14/25 of the Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #148 was discharged from Medicare Services on 9/2/24 to home or lesser care. Review on 1/14/25 of Resident #148's SNF Beneficiary Notification Review form revealed that Resident #148 was not provided a Notice of Medicare Non - Coverage (NOMNC) Form CMS - 10123 notice prior to discharge from Medicare Part A services. Interview on 1/14/25 at approximately 11:10 a.m. with Staff A (Business Office Manager) confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that the activities program was directed by a qualified professional for a facility census of 44 residents. Findings include: Interview on 1/13/24 at approximately 8:30 a.m. with Staff C (Activities Director) revealed that he/she started working at the facility as the Activities Director in April 2024. Interview on 1/14/24 at approximately 2:40 p.m. with Staff B (Administrator) confirmed Staff C had not completed a certification as a therapeutic recreation specialist and did not have 2 years of experience in a social or recreational program.

Based on observation, interview and record review, it was determined that the facility failed to properly sanitize dishes according to manufacturer's instructions for a facility census of 44 residents. Findings include: Observation on 1/13/25 at approximately 8:30 a.m. of Staff C (Dietary Manager) run a load of dishes through the dishwasher. Staff C dipped a test strip for the sanitizer into a bucket that was attached to the outside of the dishwasher. Staff C reported a result of 0 PPM (parts per million). Staff C then ran the dishwasher for a second time and tested the fliud in the bucket two more times. Staff C reported results of 0 PPM on both testing strips. Interview on 1/13/25 at approximately 8:30 a.m. with Staff C revealed the manufacturer requires the sanitizer to register on the test strips in a range of 50- 100 PPM's. Observation on 1/13/25 at approximately 8:35 a.m. revealed a sign posted on the wall near the dishwasher. The sign posted was titled, Sanitizer Test Strips. Further review of the sign revealed: .Please notify the Dietary Manager if the results of the Test Strip are not in the 50-100 PPM range . Review on 1/14/25 of the January 2025 Sanitizer PPM Daily Logs, revealed that there were no recorded sanitizer testing on 1/4/25 and 1/11/25 at breakfast. Interview on 1/15/25 at approximately 2:30 p.m. with Staff E (Dietary Aide) confirmed the above findings. Further interview with Staff E revealed that he/she does the PPM testing frequently and follows the same process for testing as Staff C was observed doing on 1/13/25. Review on 1/14/25 of the manufacturers instructions for the Chlorine Sanitizer Test Procedures for Low-Temperature Dishmachines, Dated 2015, revealed: .For conveyor dishmachines: When the rack activates rinse, use proper PPE (Personal Protective Equipment) to collect a rinse sample directly from the rinse nozzle .

Based on interview and record review, it was determined that the facility failed to ensure that the required committee members attended meetings at least quarterly for 4 of the 4 quarterly meetings reviewed. Findings include: Review on 1/14/25 of the Quality Assurance Improvement QAPI meeting attendance sheets from 2024 revealed the following required members were not in attendance: Quarter 1 - Infection Preventionist Quarter 2 - Infection Preventionist Quarter 3 - Infection Preventionist Quarter 4 - Administrator Interview on 1/14/25 at approximately 1:30 p.m. with Staff B (Administrator) confirmed the above findings. Review on 1/14/25 of the facility's police titled Quality Performance and Performance Improvement (QAPI) Program - Governance and Leadership, revised 10/14/24, revealed .The following individuals serve on the committee: Administrator, or a designee who is in a leadership role, Director of nursing services, Medical director, Infection preventionist .

Based on observation, interview, and record review, it was determined that the facility failed to implement a resident's care plan for 1 of 2 residents reviewed for indwelling catheter in a final sample of 21 residents (Resident Identifier #16). Findings include: Observation on 2/20/24 at approximately 6:30 p.m. revealed that Resident #16 had a urinary drainage bag hanging on his/her walker below his/her bladder. Review on 2/22/24 of Resident #16's Foley Catheter Care Plan dated 1/7/21, revealed a care plan intervention to record urinary output. Review on 2/22/24 of Resident #16's medical records revealed no documentation of urinary output. Interview on 2/22/24 at approximately 2:25 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B stated that the nursing staff does not record urine output for residents with indwelling catheters.

Based on interview and record review, it was determined that the facility failed to update resident care plans with new or revised interventions after a fall for 2 of 6 residents reviewed for falls in a final sample of 21 residents (Resident Identifiers #14 and #29). Findings include: Resident #29 Review on 2/22/24 of the Facility Incident/Accident report dated 2/10/24, indicated that Resident #29 had a fall on 2/10/24 with no apparent injuries. Review on 2/22/24 of the Facility Incident/Accident report dated 2/12/24, indicated that Resident #29 had a fall on 2/12/24 with no apparent injuries Review on 2/22/24 of the Facility Incident/Accident report dated 2/15/24, indicated that Resident #29 had a fall on 2/15/24 resulting in a right femoral fracture. Review on 2/22/24 of Resident #29's Falls Care Plan dated 1/30/24, revealed no new interventions after falls on 2/10/24, 2/12/24, or 2/15/24. Interview on 2/22/24 at approximately 1:45 p.m. with Staff B (Director of Nurses) confirmed that no new interventions were added to Resident #29's Falls Care Plan after the above falls. Review on 2/22/24 of the facility's policy Falls and Fall Risk, Managing, dated 3/2018, revealed the following: .1. the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s)of falls for each resident at risk or with a history of falls .5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . 40522 Resident #14 Review on 2/23/24 of Resident #14's nurse's notes, dated 9/29/23, revealed that Resident #14 stood up without a walker, was backing up, and fell on his/her left shoulder. The staff was trying to get to Resident #14 and were not able to reach him/her. Resident #14 moved his/her left arm and it ached. The nurse practitioner was notified. Review on 2/23/24 of Resident #14's Incident/Accident Report dated 9/29/23, revealed that at 6:00 p.m. in Resident #14's room Resident #14 stood up without walker, backed up, and fell on his/her left shoulder. Resident #14 left shoulder ached. Further review revealed fall prevention/investigation recommendation indicated that Resident #14 was off therapy. Resident #14 remained unsteady, await doctor approval for a X-ray, continue to monitor, await doctor visit, and X-ray showed fracture to left clavicle. There were no recommendations to prevent falls documented in relation to this fall. Review on 2/23/24 of Resident #14's nurse's note, dated 10/16/23, revealed that Resident#14 was found sitting on the floor in an upright position with his/her back to the bed. Resident #14 did not respond to questions. Resident #14 grimaced with any touch to the left side of his/her body. Resident #14 had a left clavicle fracture from a fall on 9/29/23. Mobile X-ray ordered and as needed pain medication was administered. Review on 2/23/24 of Resident #14's Fall Care Plan which was not in the facility care plan binder, revealed the following interventions: 6/15/23 Occupational Therapy/Physical Therapy screen as needed, keep call bell within reach, proper footwear, keep environment free of clutter, ensure well-lit environment, fall assessment quarterly and as needed, and use transfer aid. 6/17/23 Reorient resident to environment, encourage to ask for help, keep environment free from clutter, and offer activities of choice. 8/16/23 Education to staff to remove resident out of dining room after meals 9/8/23 Reminder to staff to be sure resident is out of dining room after meals 9/29/23 awaiting X-ray, and no interventions modified to prevent falls for this date. 9/30/23 Found lying on the floor complaining of shoulder pain, X-ray showed left clavicle fracture, on comfort measures as of now, and no interventions modified to prevent falls. 11/5/23 slid out of wheelchair times 2 by nurse's cart, witnessed, and no injury. Further review of the Fall Care Plan revealed no modified interventions documented as mentioned in the above 10/16/23 fall incident report. Interview on 2/23/24 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B was unable to provide documentation of a fall investigation and a modified/updated fall care plan with interventions for Resident #14's fall on 10/16/23. Review on 2/26/24 of Resident #14's Incident/Accident Report dated 10/16/23, revealed that at 7:30 a.m. in Resident #14's room, Resident #14 was sitting on the floor in an upright position with back to his/her bed. Fall Prevention/Investigation Committee recommendations indicated that Resident #14 had increased intermittent confusion and bouts of deep somnolence, recently on comfort care measures. Continue to keep the bed in low position, continuous rounding, fall mat to be in place, and resident in high visibility areas while out of bed.

Based on record review, interview, and facility assessment it was determined that the facility failed to provide sufficient nursing staff in accordance with their facility assessment. Findings Include: Review on 2/21/24 at 9:00 am of 30 days (1/20/24 to 2/19/24) of the nursing staffing schedule revealed that on the following weekend days the facility had one nurse working from the hours of 6:00 pm until 10:00 pm: 1/20/24 and 1/21/24 1/21/24 and 1/22/24 1/27/24 and 1/28/24 2/3/24 and 2/4/24 2/10/24 and 2/11/24 2/17/24 and 2/18/24 Review on 2/21/24 of the Facility Assessment with a revised date of 1/20/24 revealed: .page 3 Woodlawn has 3 shifts 6 am to 2 pm, 2 pm to 10 pm, and 10 pm to 6 am. Minimum staff is as follows: 1st. shift has two nurses and 5 aides [Licensed Nursing Assistant], 2nd shift has two nurses and four aides, and 3rd shift has one nurse and 2 aides. Interview on 2/23/24 at 3:30 pm with Staff B (Director of Nursing) confirmed the above findings.

Based on observation, interview, and policy review it was determined that the facility failed to store food and prepare food in accordance with professional standards for food service safety to prevent food-borne illness for one main kitchen and one kitchenette observed. Findings Include: Observation on 2/20/24 at 6:30 pm of the main kitchen revealed a zip-lock bag containing cut-up celery, dated 2/19, the edges of the celery were brown and soft. A blue container, with no date, containing cut-up mushrooms, the mushrooms in the container had an odor and were dark brown, soft, and sitting in a small amount of liquid. Interview 2/20/24 during the above observation with Staff F (Cook) confirmed the above findings.

Based on review and interview it was determined that the facility failed to complete the facility assessment related to staff competencies necessary to provide the level and types of care needed for the resident population. Findings include: Review on 3/1/24 of the facility assessment revealed that the required list of staff competencies necessary to provide the level and type of care needed for the resident population was not included in the facility assessment. Interview on 3/1/24 with Staff E (Administrator) confirmed the above finding.

Based on record review and interview it was determined that the facility failed to provide notification of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) and timely Notice of Medicare Non-Coverage (NOMNC) for 2 out of 3 residents reviewed for beneficiary notifications (Resident Identifiers #7 and #12). Findings include: Resident #7 Review on 2/21/24 of Resident #7's SNF Beneficiary Protection Notification Review, for residents who received Medicare Part A services, revealed that the facility/provider initiated discharge from Medicare Part A Services when benefit days were not exhausted (he/she stayed at the facility) and that his/her last covered skilled day was 9/12/23. A SNF ABN was not provided by the facility. The NOMNC provided by the facility revealed .services will end 9/12/23 . The resident representative was notified by email on 9/11/23. Resident #12 Review on 2/21/24 of Resident #12's SNF Beneficiary Protection Notification Review, for residents who received Medicare Part A services, revealed that the facility/provider initiated discharge from Medicare Part A Services when benefit days were not exhausted (he/she stayed at the facility) and that his/her last covered skilled day was 11/15/23. A SNF ABN was not provided by the facility. The NOMNC provided by the facility revealed . services will end 11/15/23 . The resident was notified and signed the NOMNC on 11/15/23. Interview on 2/21/24 at approximately 10:20 a.m. with Staff D (Business Office Manager) confirmed SNF ABNs were not provided to Residents #7 and #12, as well as NOMNCs not provided 48 hours in advance to both residents per the regulation.

Based on interview and record review, it was determined that the facility failed to put measures in place to ensure that further potential abuse did not occur while an investigation was in process for 1 out of 1 resident reviewed for abuse (Resident Identifier is #1). Findings include: Interview on 12/19/23 at 10:20 a.m. with Staff B (Administrator) revealed that on the evening of 11/28/23, he/she received a phone call at approximately 7:00 p.m. from Staff G (Charge Nurse) regarding concerns about rough care or rough handling of Resident #1 during care by Staff F (Licensed Nursing Assistant (LNA)). Staff G told Staff B that Staff F would not be providing care for Resident #1 for the rest of Staff F's shift. Review on 12/19/23 at 10:30 a.m. of the facility's Weekly Day Schedule revealed that Staff F had worked a double shift from 6:00 a.m. to 10:00 p.m. on 11/28/23. Interview on 12/19/23 at 10:45 a.m. with Staff B confirmed the above. Staff B stated that Staff F finished his/her shift on 11/28/23 and continued to work after the concern of abuse was reported. Review on 12/15/23 of the facility's policy titled, Abuse and/or Neglect Investigation, last revised dated 10/26/23, revealed .4. Employees of this facility that have been accused of resident abuse will be placed on administrative leave pending results of the investigation .

Based on interview and record review, it was determined that the facility failed to follow the Centers for Disease Control and Prevention (CDC) return to work guidelines for Health Care Personnel (HCP) who were positive for COVID-19 for 3 of 24 HCPs reviewed (Staff identifiers are C, D, and E). Findings Include: Review on 9/6/23 of the CDC's Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 [Severe acute respiratory syndrome coronavirus 2] Infection or Exposure to SARS-CoV-2, updated September 23, 2022, revealed, . Return to Work Criteria for HCP with SARS-CoV-2 Infection. HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: at least 7 days have passed since symptoms first appeared if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g. [for example], cough, shortness of breath) have improved.*Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: at least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). *Either a NAAT (molecular) or antigen test may be used. If using an antigen test, HCP should have a negative test obtained on day 5 and again 48 hours later . Review on 9/6/23 of the CDC's Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated September 23, 2022, revealed, .Contingency Capacity Strategies to Mitigate Staffing Shortages . Allowing HCP with SARS-CoV-2 infection who are well enough and willing to work to return to work as follows: HCP with mild to moderate illness who are not moderately to severely immunocompromised: at least 5 days have passed since symptoms first appeared (day 0), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Healthcare facilities may choose to confirm resolution of infection with a negative nucleic acid amplification test (NAAT) or a series of 2 negative antigen tests taken 48 hours apart*. HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised: at least 5 days have passed since the date of their first positive viral test (day 0). Healthcare facilities may choose to confirm resolution of infection with a negative NAAT (molecular) or a series of 2 negative antigen tests taken 48 hours apart*. * Some people may be beyond the period of expected infectiousness but remain NAAT positive for an extended period. Antigen tests typically have a more rapid turnaround time but are often less sensitive than NAAT. Antigen testing is preferred if testing asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days. Staff C Review on 12/19/23 of the COVID-19 Line List revealed that Staff C (Licensed Practical Nurse LPN)) tested positive for COVID-19 via home testing on 11/21/23. Review on 12/19/23 of the Return to work List revealed that Staff C returned to work on 11/25/23, day 4 from their positive COVID-19 home test, after a negative COVID-19 test via home testing. Interview on 12/19/23 at approximately 11:00 a.m. with Staff A (Director of Nursing) confirmed the above findings. Staff D Review on 12/19/23 of the COVID-19 Line List revealed that Staff D (Licensed Nursing Assistant (LNA)) tested positive for COVID-19 via home testing on 11/22/23. Review on 12/19/23 of the Return to work List revealed that Staff D returned to work on 11/25/23, day 4 from their positive COVID-19 home test, after a negative COVID-19 test via home testing. Interview on 12/19/23 at approximately 11:10 a.m. with Staff A confirmed the above findings. Staff E Review on 12/19/23 of the COVID-19 Line List revealed that Staff E (Housekeeper) tested positive for COVID-19 via home testing on 11/25/23. Review on 12/19/23 of the Return to work List revealed that Staff E returned to work on 11/29/23, day 4 from their positive COVID-19 test, after a negative COVID-19 test via home testing. Interview on 12/19/23 at approximately 11:15 a.m. with Staff A confirmed the above findings. Interview on 12/19/23 at approximately 11:30 a.m. with Staff A and Staff B (Administrator) revealed that the facility did not have a policy for returning to work after a COVID-19 infection or when to use contingency staffing protocols. Interview further revealed the facility did not have a policy and/or a facility assessment that defined the sufficient number of qualified staff necessary to meet residents' needs. Interview on 12/19/23 at approximately 12:30 p.m. with Staff A and Staff B revealed that they were not counting the day staff became symptomatic or the day staff tested positive as day 0 when determining when staff could return to work. Review on 12/19/23 of facility policy titled Coronavirus Disease (COVID-19)-Testing Guidelines .Staff with signs or symptoms of COVID-19, regardless of vaccination status, must be tested as soon as possible and are expected to be restricted from the facility pending the results of COVID-19 testing. If COVID-19 is confirmed, staff should follow the CDC's guidance .

Based on interview and record review, it was determined that the facility failed to employ, at least on a part-time basis, an Infection Preventionist who had completed specialized training in infection prevention and control. Findings include: Interview on 12/19/23 at 10:00 a.m. with Staff A (Director of Nursing) revealed that Staff A was acting as the Infection Preventionist (IP) as well as full-time Director of Nursing. Interview on 12/19/23 at approximately 10:15 a.m. with Staff B (Administrator) confirmed that Staff A was filling the role of both Infection Preventionist and full-time Director of Nursing. Further interview with Staff B revealed that Staff B also assisted with Infection Prevention but was not qualified by education, training, experience, or certification.

Based on record review and interview, it was determined that the facility failed to document advanced directives accurately for 1 out of 25 resident reviewed for advanced directives (Resident identifier is #7). Findings include: Interview on 12/28/22 at approximately 12:12 p.m. with Staff F (Licensed Practical Nurse) revealed that he/she would identify a resident's code status by looking at the label on the binder of the paper medical record. A blue dot would identify the resident as a full code, absence of a blue dot would indicate do not resuscitate. Staff F confirmed that Resident #7 did not have a blue dot on one of his/her paper medical record. Review on 12/30/22 of Resident #7's chart revealed that he/she had a Resuscitation Designation signed on 4/11/2017 indicating that Resident #7 did want cardiopulmonary resuscitation to be performed. Interview on 12/30/22 at approximately 11:12 a.m. with Staff D (Minimum Date Set (MDS) Coordinator) revealed that Resident #7 should have had a blue dot on their paper medical record(s) to indicate full code.

Based on interview and record review, it was determined that the facility failed to consult with residents' physician when there was a need to alter treatment for 1 out of 1 resident reviewed for notification of changes in a final sample of 18 residents (Resident identifier is #23). Findings include: Review on 12/27/22 of Resident #23's medical record revealed the following nursing notes: 1. 12/26/22, Res [resident] c/o [complained of] swollen feet both were puffy, placed in bed with feet elevated, scheduled meds [medication] given, will monitor, written by Staff B (Licensed Practical Nurse). 2. 12/27/22 Res c/o cramp in Right foot, says it's the worst pain [pronoun omitted] ever had. Too soon for more Tylenol, repositioned feet, still elevated. No further c/o, written by Staff B. Interview on 12/29/22 at approximately 9:40 a.m. with Staff B confirmed that the physician was not notified of Resident #23's condition changes on 12/26/22 and 12/27/22. Interview on 12/29/22 at approximately 9:45 a.m. with Staff A (Registered Nurse) revealed that the resident's physician was in the facility on 12/28/22 and there was no evidence of the physician being notified of Resident #23's concerns on 12/26/22 and 12/27/22. Staff A stated he/she would call Resident #23's physician and feels it may be a side effect of the new medication the resident has started.

Based on interview and record review, it was determined that the facility failed to ensure that medication parameters were followed according to physician orders for 2 out of 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident identifiers are #7 and #22). Findings include: Standards: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #7 Review on 12/30/22 of Resident #7's Medication Administration Record (MAR) revealed the following physician's orders for pain medications: Ibuprofen 600 milligrams (mg) tab. Give 1 tablet by mouth 3 times daily as needed for pain. Acetaminophen 325 mg. Give 2 tablets (650 mg) by mouth every 4 hours as needed for pain. Interview on 12/30/22 at approximately 10:06 a.m. with Staff F (Licensed Practical Nurse) revealed that there were no parameters being followed for the administration of Resident #7's pain medications. Staff F confirmed that there were no numerical parameters for the administration of the Ibuprofen and Acetaminophen. Resident #22 Review on 12/29/22 of Resident #22's MAR revealed the following physician's orders for pain medications: Oxycodone 5 mg take 0.5 tablets (2.5 mg) by mouth every 4 hours as needed for pain. Tylenol 500 mg take 2 tablets (1,000 mg) by mouth every 8 hours as needed for pain. Interview on 12/30/22 at approximately 10:10 a.m. with Staff E (Registered Nurse) revealed that there were no pain parameters being followed for the administration of Resident #22's pain medications. Staff E confirmed that there were no numerical parameters for the administration of the Oxycodone and Tylenol.

Based on record review and interview, it was determined that the facility failed to ensure that drug regimen reviews were reviewed and addressed by the provider for 2 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident identifier are #7 and #20). Findings include: Resident #20 Review on 12/30/22 of Resident #20's monthly pharmacy reviews revealed: June 2022 no pharmacy review was done of Resident #20's medications. Interview on 12/30/22 at approximately 10:30 a.m. with Staff D (Licensed Practical Nurse) revealed that he/she confirmed with the pharmacist that there was no pharmacy review done in June 2022 for Resident #20. 46510 Resident #7 Review on 12/30/22 of the Consultant Pharmacist's Medication Record Review revealed that Resident #7 had no documentation of a licensed pharmacist review of their drug regimen review for April 2022 and June 2022. Interview on 12/30/22 at approximately 10:32 a.m. with Staff D (Minimum Data Set (MDS) Coordinator) confirmed that Medication Record Reviews for Resident #7 were missing for April 2022 and June of 2022. Review on 12/30/22 of the facility policy titled, IA1: Provider Pharmacy Requirements, dated August 2020 revealed: Procedures .C. The provider pharmacy is responsible for rendering the required service in accordance with local, state and federal laws and regulations; facility policies and procedures; community standards of practice; and professional standard of practice. .11) Screening each new medication order for an appropriate indication or diagnosis; for medication interactions; for duplication of therapy with other drugs in the same therapeutic class ordered for the resident; and for appropriate drug dose, dosing interval, and route of administration, based on resident specific information and other pertinent variables. If diagnosis or indication is not available, notifying the nursing staff of the need to obtain the information from the prescriber prior to administering the drug. 12) Providing medication information and consultation to the facility's nursing staff. .