**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow professional standards of practice for blood glucose monitoring as ordered by the physician, for 1 of 3 residents reviewed for blood glucose monitoring, of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included pneumonia, acute respiratory failure, type 2 diabetes mellitus, chronic kidney disease, and atrial fibrillation. Review of the Hospital Medical Certification for Medicaid Long-Term Care Services and Patient Transfer form dated 6/04/24 revealed resident #1 was alert, oriented, followed instructions and capable to make her own healthcare decisions. Resident #1 had a care plan for Diabetes Mellitus dated 6/05/24. The goal was to minimize the risk of complications related to low or high blood glucose through the review date. Interventions included staff to administer diabetes medication as ordered by the physician and to monitor side effects and effectiveness of the medications. Additional interventions included staff to monitor and report low or high blood glucose signs or symptoms. An Order Summary Report dated 6/13/24 revealed a physician order dated 6/05/24 for accu-checks AC (before meals), HS (at bedtime), and as needed for anti-diabetics. The order directed nurses to call the physician if results were less than 70 or greater than 300. Review of the Medication Administration Record (MAR) for June 2024 and the medical record revealed 12 omissions of documentation of accu-check performed from 6/05/24 to 6/12/24, when the resident was transferred to the hospital. On 8/29/24 at approximately 9:00 AM, the Director of Nursing (DON) confirmed resident #1's MAR was missing documentation on 12 occasions from the period of 6/05/24 to 6/12/24 to show accu-checks were performed as ordered. She stated her expectation was nurses would follow the physician orders and document the accu-check results in the chart. The DON was unable to provide any additional evidence the missing accu-checks were performed for resident #1 in accordance with physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment was accurate for Functional Range Of Motion (ROM) for 1 of 2 residents reviewed for Limited ROM of a total sample of 48 residents, (#84). Findings: Resident #84, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses which included nontraumatic subdural hemorrhage, hemiplegia and hemiparesis affecting the right dominant side, dementia, and chronic diastolic (congestive) heart failure. Review of the resident's quarterly MDS assessment with Assessment Reference Date of 2/04/24 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8 out of 15. Section GG 0115 for functional limitation in range of motion was coded 0 for the resident's upper extremity, indicating the resident had no impairment in functional limitation in ROM to his upper extremity, and was coded 1 for the resident's lower extremity, indicating the resident had functional limitation in ROM to one side of his lower extremity. Review of the Occupational Therapy discharge summary with dates of services from 9/07/23 through 12/27/23 revealed the resident was referred to the facility's Restorative Nursing Program with diagnosis that included contracture of the right hand/wrist/shoulder. A care plan for self-care deficits related to stroke with right sided weakness, limited ROM to the right upper extremity, and the right lower extremity, was created on 3/21/20, with revision on 3/27/24. On 3/25/24, at 11:52 AM, and on 3/26/24 at 9:25 AM, resident #84 was sitting up in bed watching television, his right hand was contracted, and no splint was noted to the resident's right hand. On 3/27/24 at 9:59 AM, Licensed Practical Nurse (LPN) D, stated the resident's right hand was contracted. She said the resident was on therapy's caseload, and a right resting hand splint was placed and removed by therapy per therapy's schedule. On 3/27/24 at 11:57 AM, the LPN MDS Coordinator explained that MDS assessments were completed by conducting observation of the resident(s), interviews with staff, and by doing a 7 day look back review of the residents' clinical records. The LPN MDS Coordinator stated she completed resident #84's quarterly MDS assessment with ARD of 2/04/24. A review of the resident's quarterly MDS section GG0115 for Functional Limitation in Range of Motion was conducted with the LPN MDS Coordinator. She stated resident #84 had contracture of his right hand and verbalized that the assessment was inaccurate. The LPN MDS Coordinator said she coded for limitation in ROM for the resident's lower extremity but did not accurately assess/code ROM to the resident's upper extremity. The facility did not have a policy pertaining to accuracy of assessment, but stated they followed the directives of the Resident Assessment Instrument (RAI) Manual. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 GG0115 read The intent of GG0115 is to determine whether functional limitation in range of motion (ROM) interferes with the resident's activities of daily living or places them at risk of injury. The RAI defined functional limitation in range of motion as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. Coding instructions were, Code 0, no impairment, if resident has full functional range of motion on the right and left side of upper/lower extremities. Code 1, impairment on one side: if resident has an upper-and/or lower extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent a medication administration error rate of 5% or greater for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8). There were 3 medication errors in 25 opportunities for a medication error rate of 12%. Findings: Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, and anemia in chronic kidney disease. Resident #8's admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status which indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The admission MDS also noted that the resident did not exhibit behavioral symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's admission MDS assessment revealed the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed a care plan initiated on 2/21/24 that indicated the resident used psychotic medications related to schizophrenia and bipolar disorder. Interventions included staff to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM, Registered Nurse (RN) A prepared the scheduled medications for resident #8 and placed the pills into the medicine cup, totaling 14 pills. RN A then verified the count of pills in the cup, ensuring there were 14 pills present. She administered the medications to resident #8, who was in his room. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered Aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24. It also showed active orders for ferrous sulfate 325 milligrams (mg) by mouth one time a day for anemia and Proscar 5 mg by mouth one time a day for BPH. Ferrous sulfate and Proscar were scheduled to be administered daily at 9:00 AM. On 3/26/24 at 10:28 AM, RN A checked resident #8's medication administration record and discovered that Aripiprazole had been previously discontinued on 2/26/24. She acknowledged that she administered Aripiprazole during the medication administration observation at 9:41 AM. She stated she should not have administered Aripiprazole to the resident since it was discontinued. She also stated there were active orders on the MAR for Proscar and ferrous sulfate that she failed to administer as prescribed. RN A recalled there were 14 pills in the medication cup and confirmed that neither Proscar nor ferrous sulfate were included in the pills she administered to the resident. RN A conveyed she should have checked the MAR to ensure that resident #8's medications matched the physician orders before administering them. On 3/26/24 at 11:00 AM, The Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that Aripiprazole was discontinued on 2/26/24. She confirmed that Aripiprazole should not have been administered by RN A. She emphasized that nurses were required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that Aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident. The DON acknowledged that RN A should have checked the MAR before giving the medication. She also reiterated when a nurse verified medications, the nurse was expected to ensure the medications aligned with the physician orders on the MAR before administering them. The facility's medication orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The facility's preparation and general guidelines policy read, Medications are administered as prescribed in accordance with good nursing principles .The mediation administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident was free of a significant medication error regarding administration of a discontinued high risk antipsychotic medication for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8). Findings: Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease. Resident #8's admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status that indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The admission MDS also noted that the resident did not exhibit behavior symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's admission MDS assessment revealed that the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed that a care plan was initiated on 2/21/24 that indicated the resident used psychotic medications related to schizophrenia and bipolar disorder and the interventions included to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM Registered Nurse (RN) A administered Aripiprazole 20 milligrams (mg) tablet along with Vraylar 4.5 mg capsule to resident #8 during the medication administration observation. The pharmaceutical strip pack noted the resident's name, Aripiprazole 20 mg, Vraylar 4.5 mg, and the directions for administration on Tuesday, 3/26/24. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered Aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24 and the provider also prescribed Vraylar 4.5 mg by mouth once a day for antipsychotic to start on 2/27/24. Aripiprazole and Vraylar are antipsychotic medications that are used to treat schizophrenia. There are moderate interactions with using Aripiprazole and Vraylar together. Using Aripiprazole with Vraylar together may increase side effects such as drowsiness, blurred vision, dry mouth, heat intolerance, flushing, decreased sweating, difficulty urinating, abdominal cramping, constipation, irregular heartbeat, confusion, and memory problems. Side effects are more likely to occur in the elderly .The recommended maximum number of medicines in the 'antipsychotics' category to be taken concurrently is usually one, (Retrieved on 4/5/24 from www.Drugs.com.) On 3/26/24 at 10:28 AM, RN A checked resident #8's medication administration record and discovered that Aripiprazole had been discontinued on 2/26/24. She acknowledged she administered Aripiprazole during the medication administration observation at 9:41 AM and she also indicated she administered it the day before. She confirmed she should not have administered Aripiprazole to the resident since it was discontinued. RN A conveyed she should have checked the MAR to ensure the medication matched the physician order before administering it. RN A observed that Aripiprazole was also in the medication cart and was included in the resident's medication regimen for the next day. She reiterated that Aripiprazole should not be included in the pharmacy strip pack for the resident since it had been discontinued on 2/26/24. On 3/26/24 at 11:00 AM, the Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that Aripiprazole was discontinued on 2/26/24. She indicated the pharmacy delivered strip packs for resident #8 on Mondays, Wednesdays, and Fridays, each contained a two-day supply of medications. She stated that the most recent medication strip pack delivered by the pharmacy was on Monday 3/25/24 that contained Aripiprazole and Vraylar among others. She confirmed that aripiprazole should not have been administered by RN A on 3/26/24 and it should not have been included in the pharmacy strip pack that was scheduled to be administered on Tuesday, 3/26/24 and Wednesday, 3/27/24. She emphasized that nurses were required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that Aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident after that date. The DON acknowledged that RN A should have checked the MAR before giving the medication. She conveyed that prefilled medication strip packs were delivered in trays from the pharmacy on Mondays, Wednesdays, and Fridays that contain a two-day supply of medications and were placed in the medication cart by the pharmacy and the nurse on duty. She confirmed when a medication is discontinued, it would automatically interface with the pharmacy informing them of the discontinued medication. She stated that Aripiprazole should not have been delivered by the pharmacy. She also reiterated when a nurse verified a medication, the nurse was expected to ensure the medications align with the physician orders on the MAR before administering them. She mentioned if there was not a physician order for a medication that was included in the strip pack, the nurse must not administer the medication, should remove the medication from the strip pack, then notify the supervisor and the provider. On 3/27/24 at 2:13 PM, the Pharmacy Operations Manager stated that on 2/26/24 they received an order from the facility to discontinue Aripiprazole and on 2/27/24 received an order to start Vraylar. She conveyed that orders were entered into the operating system by a tech, then reviewed and verified by the pharmacist for accuracy. She also conveyed if a medication was discontinued, the pharmacy was to discontinue it from the resident's profile. She confirmed that Aripiprazole continued to be delivered on Mondays, Wednesdays, and Fridays for a month after it was discontinued and that it should not have been sent out after the discontinued date of 2/26/24. She acknowledged the discontinued Aripiprazole remained on resident #8's profile until 3/27/24 and both Aripiprazole and Vraylar were delivered to the resident in the pharmacy strip packs until 3/27/24. The Pharmacy Operations Manager acknowledged the potential adverse reactions for Aripiprazole would be drowsiness, leukopenia, neutropenia, hyperglycemia, and extrapyramidal symptoms such as Parkinsonism, dystonia, tardive dyskinesia. The pharmacy and facility's Medication orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The pharmacy and facility's Preparation and General guidelines policy read, The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule. Isolated Class III

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure accurate receiving and dispensing of a high-risk antipsychotic medication for 1 of 8 residents observed for medication administration, (#8) and failed to ensure medications were administered per physician's order prior to hemodialysis for 1 of 1 resident reviewed for dialysis, (#82), of a total sample of 48 residents. Findings: 1. Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease. Resident #8's admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status which indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The admission MDS also noted the resident did not exhibit behavioral symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's admission MDS assessment revealed the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed that a care plan was initiated on 2/21/24 which indicated the resident used psychotic medications related to schizophrenia and bipolar disorder and the interventions included to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM, Registered Nurse (RN) A administered aripiprazole 20 milligrams (mg) tablet along with Vraylar 4.5 mg capsule to resident #8 during the medication administration observation. The pharmaceutical strip pack noted the resident's name, aripiprazole 20 mg and Vraylar 4.5 mg, to be administered on Tuesday, 3/26/24. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24 and the provider then prescribed Vraylar 4.5 mg by mouth once a day for antipsychotic to start on 2/27/24. Aripiprazole and Vraylar are antipsychotic medications that are used to treat schizophrenia. There are moderate interactions with using aripiprazole and Vraylar together. Using aripiprazole with Vraylar together may increase side effects such as drowsiness, blurred vision, dry mouth, heat intolerance, flushing, decreased sweating, difficulty urinating, abdominal cramping, constipation, irregular heartbeat, confusion, and memory problems. Side effects are more likely to occur in the elderly .The recommended maximum number of medicines in the 'antipsychotics' category to be taken concurrently is usually one, (Retrieved on 4/05/24 from www.Drugs.com). On 3/26/24 at 10:28 AM, RN A checked resident #8's MAR and discovered that aripiprazole had been discontinued on 2/26/24. She acknowledged that she administered aripiprazole during the medication administration observation at 9:41 AM and she also indicated that she administered it the day before. She confirmed that she should not have administered aripiprazole to the resident since it was discontinued. RN A conveyed she should have checked the MAR to ensure that the medication matched the physician order before administering it. RN A observed that aripiprazole was also in the medication cart and was included in the resident's medication regimen for the next day. She reiterated that aripiprazole should not be included in the pharmacy strip pack for the resident since it had been discontinued on 2/26/24. On 3/26/24 at 11:00 AM, the Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that aripiprazole was discontinued on 2/26/24. She indicated that the pharmacy delivered strip packs for resident #8 on Mondays, Wednesdays, and Fridays, each containing a two-day supply of medications. She stated that the most recent medication strip pack delivered by the pharmacy was on Monday 3/25/24 that contained aripiprazole and Vraylar among others. She confirmed that aripiprazole should not have been administered by RN A on 3/26/24 and that it should not have been included in the pharmacy strip pack that was scheduled to be administered on Tuesday, 3/26/24 and Wednesday, 3/27/24. She emphasized that nurses are required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident. The DON acknowledged that RN A should have checked the MAR before giving the medication. She conveyed that prefilled medication strip packs are delivered in trays from the pharmacy on Mondays, Wednesdays, and Fridays that contain a two-day supply of medications and were placed in the medication cart by the pharmacy and the nurse on duty. She confirmed when a medication was discontinued, it would automatically interface with the pharmacy informing them of the discontinued medication. She stated that aripiprazole should not have been delivered by the pharmacy. She also reiterated when a nurse verifies a medication, the nurse was expected to ensure the medications align with the physician orders on the MAR before administering them. She mentioned if there was not a physician order for a medication that was included in the strip pack, the nurse must not administer the medication, should remove the medication from the strip pack, and notify the supervisor and the provider. On 3/27/24 at 2:13 PM, the Pharmacy Operations Manager stated that on 2/26/24 they received an order from the facility to discontinue aripiprazole and on 2/27/24 received an order to start Vraylar. She conveyed that orders are entered into the operating system by a tech and then reviewed and verified by the pharmacist for accuracy. She also conveyed if a medication is discontinued, the pharmacy is to discontinue it from the resident's profile. She confirmed that aripiprazole continued to be delivered on Mondays, Wednesdays, and Fridays for a month after it was discontinued and that it should not have been sent out after the discontinued date of 2/26/24. She acknowledged that the discontinued aripiprazole remained on resident #8's profile until 3/27/24 and that both aripiprazole and Vraylar were delivered to the resident in the pharmacy strip packs until 3/27/24. The Pharmacy Operations Manager acknowledged the potential adverse reactions for aripiprazole would be drowsiness, leukopenia, neutropenia, hyperglycemia, and extrapyramidal systems such as Parkinsonism, dystonia, and tardive dyskinesia. The Pharmacy and Facility's Medication Orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The Pharmacy and Facility's Preparation and General Guidelines policy read, The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule. 2. Resident #82, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included end stage renal disease (ESRD), peripheral vascular disease, cardiomyopathy, hypertensive heart, chronic kidney disease with heart failure with stage 5 chronic kidney disease, chronic systolic (congestive) heart failure, and venous thrombosis and embolism. Hemodialysis is a procedure that uses a machine to do the job of your kidneys. The machine pumps your blood through a dialyzer, or artificial kidney. The dialyzer filters fluid, salts, and waste from your blood. Once they are removed, clean blood from the dialyzer returns to your body through a vein. (retrieved on 4/08/24 from drugs. com). Review of the quarterly MDS assessment dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status score of 9 out of 15, and the assessment noted the resident received dialysis. The resident's physician's orders dated 7/01/23, directed staff to give all medications at least 6 hours prior to hemodialysis (HD) or after returning, and on 8/04/23, revealed the resident's dialysis days were Monday/Wednesday/Friday, and chair time was 11:30 AM. Review of the resident's Medication Admin Audit Report for her dialysis days in March 2024, revealed the following medications were administered between 7:56 AM and 10:00 AM, approximately one to three hours prior to dialysis on March 1st, 4th, 6th, 8th, 11th, 13th, 15th, 18th, 20th, 22nd, 25th, and 27th. Liquid protein 30 milliliters, Sevelamer carbonate 800 milligram (mg) 2 tablets for chronic kidney disease, Carvedilol 12.5 mg, Losartan Potassium 25 mg for high blood pressure, and Levothyroxine 112 microgram (mcg) for hypothyroidism. The medications were not given at least 6 hours prior to dialysis as per the physician's order. On 3/27/24 at 2:40 PM, RN E stated the resident went out to dialysis three days per week, Monday, Wednesday, and Friday. RN E stated the resident received her medications between 8 AM to 9 AM, and her dialysis chair time was at 11:30 AM. The resident's physician orders were reviewed with RN E, and she acknowledged physician order dated 7/01/23 directed staff to give all medications at least 6 hours prior to Hemodialysis or after returning. RN E stated the order was a standard order, and she did not know what the facility's protocol was if the order was not carried out. On 3/27/24 at 2:58 PM, LPN B stated the physician order for medication to be given at least 6 hours prior to dialysis was a standing order for residents on dialysis, and the order populated to the resident(s) MAR. She said the order should be carried out, and if staff was unable to do so, the physician should be notified, so adjustments in the medication administration schedule could be made. On 3/28/24 at 11:04 AM, the resident's physician orders, and the Medication Admin Audit Report for the period 3/01/2024 through 3/27/2024 were reviewed with the DON. She acknowledged that the resident's medications were not administered as per physician order on the days the resident had dialysis. A care plan for ESRD with dialysis was created on 10/19/22 with revision on 8/02/23. An intervention initiated on 11/26/22 was give all medications at least 6 hours prior to HD or after returning. The policy Medication Administration -General Guidelines dated April 2018 read, Medications are administered in accordance with written orders of the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 48 residents, (#82). Findings: Resident #82, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on [DATE]. Her diagnoses included end stage renal disease, peripheral vascular disease, cardiomyopathy, hypertensive heart and chronic kidney disease with heart failure with stage 5 chronic kidney disease, chronic systolic (congestive) heart failure, venous thrombosis and embolism. A pharmacy recommendation dated 10/17/23 indicated the resident received levothyroxine at 9:00 AM, and the recommendation was to administer 112 micrograms (mcg) as a single dose on an empty stomach, and read, Consider dosing at 6 am. Levothyroxine is used in adults and children to treat hypothyroidism (underactive thyroid-a condition where the thyroid gland does not produce enough thyroid hormone). Directions included, Take levothyroxine tablets and capsules on an empty stomach, at least 30 to 60 minutes before breakfast with a full glass of water. Take the medicine at the same time each day. (retrieved on 4/08/24 from drugs.com). Review of the resident's physician's orders revealed an order dated 10/09/23 for levothyroxine 112 mg daily for hypothyroidism. Review of the resident's Medication Administration records for the period October 2023 through March 2024 revealed the medication levothyroxine was scheduled for administration at 9:00 AM. On 3/27/24 at 9:07 AM, the Director of Nursing (DON) stated the Consultant Pharmacist reviewed residents' medications, made recommendations, and sent a report via email to her. The DON stated that the recommendations were distributed to the Physician/Providers for review and response, and the expectation was that recommendations would be addressed within thirty (30) days of receipt. On 3/28/24 at 12:25 PM, resident #82's pharmacy recommendation dated 10/17/23, the resident's physician order and MARs were reviewed with the DON. She acknowledged the findings and said the recommendation should have been addressed within 30 days of receipt. The DON said that specific recommendation was a nursing task, and nurses could change the time of administration of the medication in the resident's electronic medical record. The policy Medication Regimen Review dated April 2018 read, Recommendations are acted upon and documented by the facility staff and/or prescriber .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was transmitted within the required 7 day time frame for 1 of 1 resident reviewed for assessments of a total sample of 46 residents, (#2). Findings: Review of resident #2's medical record documented she was admitted to the facility on [DATE] and was transferred to the hospital 11/04/21. Review of the Discharge Return Anticipated MDS assessment dated [DATE] revealed the assessment was completed but not transmitted to the National MDS database at Centers for Medicare and Medicaid Services (CMS). On 04/20/22 at 9:38 AM, MDS Supervisor D stated resident #2's MDS assessment had been completed but was not transmitted to CMS within the required 7 days. She said the assessment should have been transmitted to CMS on 11/11/21, it was our error. According to CMS.gov, The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps the nursing home staff identify health problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure respiratory therapy was administered as per physician orders for 1 of 3 residents reviewed for oxygen (O2) therapy of a total sample of 46 residents, (#29). Findings: Resident #29 was admitted to the facility on [DATE] with diagnoses to include dementia, Parkinson's disease, morbid obesity, and dependence on supplemental oxygen. Review of the resident's physician orders revealed an active order dated 2/28/22 for oxygen via nasal canula (n/c) at 2 liters/minute. On 4/19/22 at 1:43 PM, resident #29 was observed lying in bed without oxygen nasal canula nor any oxygen at the bedside. On 4/19/22 at 3:15, the Unit Manager (UM) acknowledged resident #29 was not receiving oxygen and the oxygen concentrator was across the room against the wall. She stated the oxygen was ordered as needed (PRN) and the concentrator was in the room in case the resident needed it. The UM reviewed the physician orders and acknowledged resident #29 should have been on oxygen at 2 liters via n/c continuously. She stated the resident was on hospice and continued to review the chart for a hospice order for prn oxygen . The UM was only able to find documentation in the hospice care plans and comprehensive assessment which indicated the resident was on 2 liters of oxygen prn. She stated, no, these are not orders. On 4/19/22 at 3:50 PM, the Director of Nursing (DON) reviewed resident #29's physician orders and reported an order dated 2/28/22 for oxygen at 2 liters n/c continuous. The DON stated the nurse probably forgot to add the continuous when the oxygen orders were ordered. Review of resident #29's care plans revealed a care plan for altered respiratory status/difficulty breathing related to shortness of breath. The goal noted the resident would not experience complication related to shortness of breath with an intervention to administer oxygen at 2 liters as ordered. Review of the Treatment Administration Record for April 2022, revealed an order for Oxygen via n/c at 2 liters/min every shift. The start date was 2/28/22, which the nurses signed every shift as being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent medication administration error rate of 5% or greater for 2 of 8 residents sampled for medication administration, (#279 and #84). There were 2 medication errors in 27 opportunities for a medication error rate of 7.41%. Findings: 1. On 4/18/22 at 9:17 AM, Licensed Practical Nurse (LPN) A prepared resident #279's scheduled medications. He removed 1 tablet Multivitamin (MTV) with Mineral from the cart stock medication bottle and placed it in a pill cup with the resident's other oral medications. He then proceeded to administer the medications to the resident who was in her room. Review of the medical record for resident #279 revealed she was admitted to the facility on [DATE]. A current physician order dated 4/14/22 was for MTV give 1 tablet by mouth one time a day for supplement. The order did not include Mineral to be given with MTV. On 4/18/22 at 11 AM, LPN A in the presence of the 7th floor Unit Manager (UM) showed his medication cart drawer only contained MTV with Mineral and no plain MTV. The UM acknowledged LPN A made a mediation error by giving the cart stock MTV that also contained mineral as the order was for plain MTV. LPN A indicated he was not aware there was difference between plain MTV and MTV with Mineral. 2. On 4/18/22 at 11:25 AM, Registered Nurse (RN) B was observed checking resident #84's blood sugar which was 312. RN B stated, since the resident's blood sugar is over 100 he can have insulin. RN B proceeded to prepare the insulin pen Admelog SoloStar 100 units/milliliter (ml) and dialed the dose to 10 units. RN B then administered 10 units of insulin subcutaneous (SQ) into the resident's left abdomen. Admelog is a fast-acting mealtime insulin that works to control blood sugar when you eat. (https://www.admelog.com) Review of the medical record for resident #84 revealed he was re-admitted to the facility on [DATE] with diagnosis including diabetes mellitus (DM) type 1. A current physician order dated 2/11/22 was for Admelog SoloStar Solution Pen-Injector 100 units/ml SQ one time a day at 1 PM for DM without complications. On 4/18/22 at 1:04 PM, the 7th floor UM reviewed resident #84's physician orders and stated, I do not know why the nurse gave 10 units prior to lunch as he is supposed to get 14 units of insulin after lunch at 1 PM. The UM validated the nurse gave the wrong dose of insulin at the wrong time. On 4/18/22 at 1:46 PM, RN B stated, I got confused because they just recently changed his insulin orders and we usually give insulin prior to meals not after. The UM added, the nurses should check the orders in the electronic medical record (EMR) and if not clear then double check the paper chart. On 4/21/22 at 10:50 AM, the Director of Nursing acknowledged the 2 medication errors regarding resident #279 and #84. She indicated the facility had plain MTV and MTV with Minerals on hand for medication cart stock and that nurses needed to triple check their medications to avoid errors. Review of the facility's policy and procedures for Medication Administration General Guidelines revised April 2018 read, Medications are administered as prescribed in accordance with good nursing principles and practice Five Rights- Right resident, right drug, right dose, right route and right time Medications are administered in accordance with written orders of the prescriber Medications are administered within 60 minutes of scheduled time, except before, with or after meals orders, which are administered based on mealtimes

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services for midline Intravenous (IV) catheters according to standards of practice and plan of care for 2 of 3 residents reviewed for IV catheters of a total sample of 46 residents, (#59 and #67). Findings: 1. Resident #59 was admitted to the facility on [DATE], and most recently re-admitted on [DATE] from an acute care hospital. His diagnoses included acquired end stage renal disease, lymphedema, history of Methicillin Resistant Staphylococcus Aureus infection, diabetes mellitus and diabetic peripheral angiopathy. Review of the Minimum Data Set Five-day assessment with assessment reference date [DATE] revealed resident #59 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. Additionally, the assessment revealed the resident did not reject care from staff and received dialysis. On [DATE] at 10:05 AM, resident #59 was seated in his wheelchair waiting for transportation to dialysis. A midline IV catheter was visible to his right upper arm. The clear adhesive dressing was not dated and unlabeled, with a piece of clear tape across the bottom holding the dressing down. The resident stated he had not received any medications in the IV for about a week and he didn't know why he still had the midline. His right hand was swollen, and the resident explained it had been like that for about a week. A midline catheter is put into a vein by the bend in your elbow or your upper arm . The midline tube ends in a vein below your armpit .midline catheter may allow you to receive long-term IV medicine or treatments .(retrieved [DATE] www.drugs.com). On [DATE] at 4:37 PM, resident #59 was awake and alert, sitting up in bed. He had the midline IV in his right upper arm with the clear dressing that was undated and unlabeled with clear tape on the bottom edge of the dressing. There was dark brown blood in the tubing. He explained the doctor told him the IV should be removed since it was not being used, and said, No one has done it. On [DATE] at 12:11 PM, resident #59's wife was at the bedside. He had the same midline IV catheter in his right arm with the clear dressing undated and dried blood still in the tubing. The resident reported the nurse hadn't looked at his IV at all today, and no one had changed the dressing for a while. Resident #59's wife stated she asked staff last week why he still had the IV, but they never gave her an answer. On [DATE] at 12:16 PM, the Assistant Director of Nursing (ADON) acknowledged the resident's unlabeled and undated midline IV catheter with the dark brown blood in the tubing underneath the dressing. She indicated the dressing should have been dated and initialed by the nurse and that nurses were responsible to assess the IV catheter site every shift. The ADON reviewed resident's physician orders and stated there were no active orders for midline IV. She conveyed there were no orders for flushes, dressing changes, or assessments. She noted resident #59's midline IV catheter was inserted at the beginning of April and the nurse who entered the order for the midline did not enter any orders for the care of the midline IV. The ADON explained orders to assess the midline catheter and IV site and dressing changes would normally be a part of the care nurses provided for a midline IV. She said the resident had orders for IV antibiotics and flushes but those orders expired after antibiotic therapy was completed. The ADON indicated the protocol was for the nurse to ask the physician for orders to discontinue the IV when the IV antibiotic medications were completed. She said if the IV was to be left in place, orders would be given for flushes, dressing changes and assessments. The ADON acknowledged midline IV catheters were an infection risk, especially for someone who received hemodialysis. They ADON confirmed there was no documentation in the resident's medical record to indicate the midline catheter dressing was changed or assessed since it was inserted on [DATE]. Review of resident'#59's Medication Administration Record (MAR) revealed an order completed for Have midline inserted every evening shift until [DATE] 23:59 which started on [DATE] at 3:00 PM. The MAR showed orders for antibiotic and flushes which the resident received via midline IV catheter on [DATE] through [DATE]. There were no other orders documented by nurses in April for midline IV catheter care including dressing changes, or for nurses to assess the midline catheter for infection or complications. Resident #59 had a care plan for intravenous lines, Receiving IV therapy and at risk for complications,the type of IV access was left blank. The goal was for resident #59's IV line to remain patent and have no complications. Interventions for resident #59's IV line were for staff to administer fluids as ordered, educate resident and family about central line associated bloodstream infection prevention, explain purpose of IV and procedure prior to start, observe for complications, dislodgment of IV catheter, swelling, redness, pain, separation of IV lines, shortness of breath, drainage or soiled IV dressing, phlebitis, infiltration, or bleeding. Further interventions included Provide IV site care as ordered. Review of the Nurse Progress Notes revealed no documentation of midline IV catheter dressing changes or assessments from the date the midline catheter was inserted on [DATE] until the line was discontinued on [DATE]. On [DATE] at 11:37 AM, Licensed Practical Nurse, (LPN) C said she had cared for resident #59 on the previous Monday and Tuesday shifts. She stated she knew to check the IV catheter based on the report she received from the previous nurse or based on the orders in the computer. She confirmed standard orders for midline IV catheters included flushes, and assessment of the IV catheter site usually every shift. LPN C explained when the IV medications were complete, she knew to call the physician and ask if midline was to be discontinued. She indicated she did not get report on the previous Monday or Tuesday about the IV catheter from the previous shift and there were no orders in the electronic record for the care of the IV. She that if the resident had an IV, that should be communicated by the nurses in the shift change report. She stated, That is something you would tell the next nurse, part of the information you would give and expect to get. On [DATE] at 12:04 PM, LPN D said she usually cared for resident #59 on her assignment. She reported he had the midline catheter inserted at the beginning of April to receive IV antibiotics for a urinary tract infection. LPN D explained she thought midline IV catheter dressings should be changed every seven days and the dressing needed to be labeled with a date and initialed. LPN D recalled the past Sunday that resident #59 still had the IV so she told the night nurse during report to call the doctor and get order to discontinue the IV but did not explain why she did not call the physician herself. LPN D noted the night nurse did not do it. LPN D stated the nurse should know to call the physician and get the IV discontinued when the IV medication order was completed. On [DATE] at 10:50 AM, the Director of Nursing (DON) stated the nurse should put in the orders for care of the midline IV catheter when it was inserted. She said for a clear dressing on a midline IV catheter such as resident #59's, the standard of care was to change the dressing every five to seven days or more often as needed. She conveyed a midline catheter was supposed to be flushed at least daily if no meds were going through it, and nurses should assess the site every shift for problems with the IV or the dressing. The DON explained if the nurse found a problem with the midline IV catheter such as patency, they would call the contracted IV team to come in and assess the line. She explained nurses should not use tape to hold down the IV dressing, instead the dressing should be changed, dated, initialed and documented in the medical record. She acknowledged that while the IV was not being used for medications, it would still need care from nurses such as flushing the line, changing the dressing, and assessing the IV for signs and symptoms of infection or other complications. She explained the IV team came on the evening of [DATE] to see resident #59's midline IV catheter once it had been brought to their attention by the surveyor. She stated the IV team was not able to salvage resident #5''s midline IV catheter because of dried blood in the line. Review of the Insertion of Peripheral IV Catheter dated 4/17 revealed general guidelines to, change dressing and perform site care if dressing becomes soiled, is no longer intact. The guidelines indicated the label on the dressing should include the date and time of dressing placement, initials, gauge size and length of catheter. The document directed that the IV catheter should be removed when there is suspected contamination, complication or when therapy is discontinued. Review of the document, Flushing Midline and Central Line IV Catheters dated 4/17 revealed the general guideline that midline IV catheters will be flushed at regular intervals to maintain patency. Review of the document Midline Dressing Changes dated 4/17 revealed general guidelines to change midline catheter dressing every five to seven days or more often it is wet, dirty, not intact or compromised in any way using sterile technique. The document also instructed staff to record the date and time the dressing was changed in the resident's medical record along with the signature and title of the person recording the data. 2. Resident #67 was admitted to the facility on [DATE] from an acute care hospital with diagnoses including recent sepsis, acute stress reaction and brain abscess. She had a Midline IV line inserted [DATE] in the right arm for administration of IV antibiotics and the line was re-inserted in the same location on [DATE] as it was not functioning properly. She received Merrem (IV antibiotic) every 6 hours for brain abscess through [DATE]. There was a prior order dated [DATE] to discontinue PICC (peripherally inserted central catheter) line but no new orders were entered post Midline IV insertion [DATE] or [DATE] regarding new IV type and care. There were prior orders in effect dated [DATE] for catheter site dressing changes every week and as needed that were not specific to the type of IV present nor the location. On [DATE] at 10:35 AM, resident #67 was observed sitting up in wheelchair at the bedside. She had a gauze dressing with transparent dressing over the right upper arm midline IV site. There was no visible date noted on the IV dressing. The resident was alert and oriented to person and place. She said, I was receiving IV antibiotics for brain infection. On [DATE] at 9:35 AM, resident #67 was observed sitting up in wheelchair and the midline IV in her right upper arm appeared same as yesterday's observation. There was no date on gauze dressing and the IV insertion site could not be visualized due to the presence of gauze. On [DATE] at 10:15 AM, Registered Nurse (RN) B was in the resident's room and observed the residents's midline dressing on right upper arm without a date. RN B validated observation of gauze dressing present without date and stated, when gauze is present dressing should be changed at minimum every 2 days. On [DATE] at 10:25 AM, the Unit Manager (UM) stated the resident had a midline inserted in her right arm on [DATE] and due to complications, she had another visit by the IV team on [DATE]. The UM added, the IV team would have applied new dressing on [DATE]. The UM indicated she could not find any evidence in the medical record to show the nurses changed IV site since [DATE]. The UM said she thought that if gauze was present then the IV site dressing needed to be changed every 2-3 days. On [DATE] at 10:45 AM the UM provided the facility policy for Midline Dressing Changes and validated the policy was to change dressing every 2 days/48 hours if gauze present. The UM added, the reason an IV site should be changed at least every 2 days as there was increased risk of infection due to moisture when gauze was present On [DATE] at 10:57 AM, the DON said the standard of practice was for nurses was to change gauze dressing every 48 hours and transparent film dressing every 5-7 days. The DON added, the nurses should have changed it 24 hours after the initial insertion and re-insertion of IV because there could be blood on the gauze which could lead to increased risk infection if not removed. According to the facility Midline Dressing Changes policy dated [DATE], Change midline catheter dressing 24 hours after insertion if placed with gauze .Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used cover with a TSM dressing and change the dressing every 48 hours .

Based on observation, interview and record review, the facility failed to ensure the high temperature dishwashers in 2 of 2 kitchens were monitored for sufficient pressure flow, (Main kitchen & Windsor Tower). Findings: On 11/02/20 at 9:39 AM, the main kitchen high temperature dishwasher was observed with the Director of Resident Services (RSD) and the Executive Chef (EC). The wash temperature was 160 °Fahrenheit (F) and the rinse temperature was 195 °F. There was no visual pressure gauge present to monitor the water pressure of the rinse water. Review of the daily monitoring log did not track the pressure during the rinse cycle. The RSD and the EC said they were not aware the pressure needed to be monitored. On 11/02/20 at 10:00 AM, the Windsor Tower's high temperature mechanical dishwasher was observed with the RSD, EC and the Windsor Towers Certified Dietary Manager (CDM). The wash temperature was 162°F, the rinse temperature was 195°F. There was no visual pressure gauge present to monitor the water pressure of the rinse water. The CDM was not aware the pressure of the rinse water needed to be monitored. Review of the monitoring logs for both dish washing machines for September 2020 to November 4, 2020 noted there was no documentation of the water pressure. Review of the manufacturer's specification sheet noted the water flow pressure should be 15-25 pounds per square inch (PSI). Review of Food and Drug Administration Food Code 2017 Chapter 4-501.113 Mechanical Ware Washing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 PSI) or more than 200 kilopascals (30 PSI).