Based on observation, record review, staff interview, and policy and procedure review, the facility failed to maintain accurately documented medical records for one (Resident #13) of one resident reviewed for non-pressure related skin conditions. The findings include: An observation was made of Resident #13 on 6/18/24 at 10:00 AM. He had a large, tan colored, adhesive dressing on his left leg, dated 6/14/24. A review of the electronic medical record (EMR) revealed a physician's order dated 6/12/24, instructing nursing staff to cleanse the left leg below the knee skin tear with normal saline, apply antibiotic ointment, and cover with a Band-Aid once a day, every other day until healed. A review of the June 2024 treatment administration record (TAR) revealed that Registered Nurse (RN) A signed the treatment as having been completed per the physician's order on 6/16/24. An interview was conducted with RN A on 6/20/24 at 10:41 AM. She stated she worked on 6/16/24, and was assigned tasks including the completion of residents' ordered skin treatments. She reviewed the TAR and confirmed that her initials were signed for the 6/16/24 skin treatment for Resident #13. She stated placing her initials in the TAR meant the treatment was completed as ordered. She was not sure why the date on the dressing would have read 6/14/24 during the observation on 6/18/24. She stated she thought 6/16/24 was the day the resident's wife took him out, and he did not want the bandage changed before he left with his wife. RN A stated she was off duty by the time they returned. She further stated she should have gone back and documented that the treatment was not administered on 6/16/24. She stated the area was a scratch from a skin lesion. A review of the facility's policy for Charting and Documentation (revised 1/2018), revealed that all services provided to the resident, or any changes in the resident's medical or mental condition, would be documented in the resident's medical record. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: e. whether the resident refused the procedure/treatment. .

Based on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less, based on three errors out of 31 opportunities for error, resulting in an error rate of 9.68%. This involved three (Residents #31 and #6 & #13) of five residents observed during medication administration, from a total sample of 18 residents. The findings include: During a medication administration observation for Resident #31 on 09/14/22 at 9:37 a.m., Licensed Practical Nurse (LPN) A obtained Amlodipine 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the resident's blood pressure (BP) was less than 120/80. LPN A popped the medications into the medication cup, performed hand hygiene and went into Resident #31's room. Before administering the medication, the nurse was asked for the resident's blood pressure. she stated it was 125/62 millimeters of mercury (mmHg). She was asked to verify the resident's blood pressure again before administering the medication. She again stated, The blood pressure is 125/62 mmHg and proceeded to administer the medication. (Copy of the medication administration record (MAR) obtained) During another observation on 09/14/22 at 9:48 a.m., LPN A was observed preparing medication for Resident #6. She obtained Aspirin 81 mg, Ativan 1 mg, Buspirone 15 mg, Ferrous sulfate 325 mg, and lisinopril 40 mg. All of the medications were popped into a medication cup. LPN A also obtained four ounces of Ensure (nutritional supplement), then proceeded into Resident #6's room. After performing hand hygiene, LPN A assisted the resident in taking the medication by pouring all of the pills into the resident's mouth. She then gave the resident the Ensure. After Resident #6 was finished drinking the Ensure, LPN A performed hand hygiene before administering eye drops. While she was performing hand hygiene, Resident#6 was observed taking a pill out of her mouth and dropping it on the floor. LPN A was made aware of the resident's behavior, and she picked the pill up from the floor. She then asked Resident #6 if she had additional pills in her mouth, and the resident spit out two additional pills. LPN A stated the medications spit out were Buspirone, Aspirin and ferrous sulfate. (Photographic evidence obtained) LPN A discarded the medication and notified the Director of Nursing (DON). The DON arrived and could be heard explaining to LPN A her next steps to take. In an interview on 09/14/22 at 9:49 a.m., LPN A was asked to review the physician's orders, which revealed the orders for Amlodipine 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the if the resident's blood pressure (BP) was less then 120/80. When asked if the medication should have been administered, she stated she went by the top number (systolic - 120) and not the bottom number (diastolic - 62). She stated she was not sure what the facility's policy said about that. When asked about Resident #6's behavior of pocketing her medication, LPN A confirmed that she should have checked the resident's mouth to ensure she had swallowed the medication. On 09/15/22 at 9:25 a.m., Registered Nurse (RN) B was observed preparing medications for Resident #13. After obtaining all the medication, she stated she needed to remove the lidocaine patch from Resident #13's right upper extremity. She performed hand hygiene, administered the medication to the resident, and walked out of the resident's room without removing the lidocaine patch. RN B proceeded to administer medication to the next resident. In an interview on 09/15/22 at 10:00 a.m., RN B was asked to review Resident #13's physician's orders, which showed an order for a lidocaine adhesive patch, 4%, apply one patch for approximately 12 hours to the right upper extremity (RUE) for pain/discomfort at 8:00 p.m., and remove the patch from the RUE in the morning at 10:00 a.m. RN B had already marked the Medication Administration Record (MAR) indicating the patch had been removed. (Copy of the MAR obtained) RN B was reminded by the clinical educator who was accompanying her during medication pass that she forgot to remove the patch. RN B walked back to the resident's room and removed the patch. In an interview on 09/15/22 at 11:45 a.m., the Director of Nursing (DON) and the Administrator were informed of the medication errors. They both verbalized understanding and stated education would be initiated. A review of the facility's policy and procedure titled, Medication Administration (revised August 2014), revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration. The administration procedure revealed that medications are to be administered in accordance with the written orders from the prescriber and administered without unnecessary interruptions. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted in the MAR and action is taken as appropriate. The individual who administers the medication dose should record the administration on the resident's MAR directly after the medication is given. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to adhere to the parameters ordered by the physician for the administration of blood pressure medication for one (Resident # 31) of five residents observed during medication administration, from a total of 18 residents in the sample. The findings include: During a medication administration observation for Resident #31 on 09/14/22 at 9:37 a.m., Licensed Practical Nurse (LPN) A obtained Amlodipine 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the resident's blood pressure (BP) was less than 120/80. LPN A popped the medications into the medication cup, performed hand hygiene and went into Resident #31's room. Before administering the medication, the nurse was asked for the resident's blood pressure. She stated it was 125/62 millimeters of mercury (mmHg). She was asked to verify the resident's blood pressure again before administering the medication. She again stated, The blood pressure is 125/62 mmHg and proceeded to administer the medication. (Copy of the medication administration record (MAR) obtained) In an interview on 09/14/22 at 9:49 a.m., LPN A was asked to review the physician's orders, which revealed the orders for Amlodipine 10 milligrams (mg) and Losartan 100 mg. Both medications had special instructions to hold the medications if the if the resident's blood pressure (BP) was less then 120/80. When asked if the medication should have been administered, she stated she went by the top number (systolic - 120) and not the bottom number (diastolic - 62). She stated she was not sure what the facility's policy said about that. A review of Resident #31's medical record revealed that he was admitted to the facility on [DATE]. His diagnoses included hypertension (HTN), muscle weakness, repeated falls, and weakness. A review of his Care Plan, initiated on 8/13/21 and revised on 9/09/22, revealed that he was at Risk for Falls due to recent hospitalization, adapting to new surroundings, right lower extremity weakness, polyneuropathy, HTN and edema. The Care Plan further revealed that Resident #31 had falls on 8/23/21, 11/7/21, 12/16/21, 5/25/22, 6/11/22, and on 9/09/22. A review of the Physician's Orders, revealed an order dated 9/14/22 for Amlodipine 10 mg (milligrams) orally once a day: Hold if BP (blood pressure) is less than (<) 120/80. Another order, dated 9/14/22, was written for Losartan tablet 100 mg, 1 tablet orally once a day: Hold if BP<120/80. (Copy obtained) A review of the August 2022 and September 2022 MARs revealed that Resident #31 received Amlodipine and Losartan on 8/19/22 (BP 131/68), 8/25/22 (BP 139/79), 9/4/22 (BP 131/69), 9/13/22 (BP 166/77) and 9/14/22 (BP 125/62). (Copies of the MARs were obtained) In an interview on 09/15/22 at 11:45 a.m., the Director of Nursing (DON) and the Administrator were informed of the medication errors. They both verbalized understanding and stated education would be initiated. A review of the facility's policy and procedure titled Medication Administration (revised August 2014), revealed that medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration. The administration procedure revealed that medications are to be administered in accordance with the written orders from the prescriber and administered without unnecessary interruptions. According to the National Heart, Lung, and Blood Institute at https://www.nhlbi.nih.gov/health/low-blood-pressure#:~:text=If%20your%20blood%20pressure%20drops,a%20weak%20and%20rapid%20pulse (Accessed on 9/27/22 at 4:05 p.m.), If your blood pressure drops too low, your body ' s vital organs do not get enough oxygen and nutrients. When this happens, low blood pressure can lead to shock, which requires immediate medical attention. .

Based on observations, staff interviews, and facility document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The findings include: A tour of the kitchen began at 11:51am on 4/5/2021. A microwave and juice machine fountain, both located next to the entrance of the kitchen, were not clean. Dried food particles and miscellaneous stains were observed on the door, sides, base, and internal hood of the microwave, above the area where food is placed during heating. Thick, gel-like substances were splattered along the panel of the juice fountain above the spouts where the juice is dispensed. (Photographic evidence obtained). A tour of the nourishment room conducted on 4/5/2021 at 1:35pm, revealed that a microwave and a juice fountain used for residents were not clean. Dried food particles were on the base and internal hood of the microwave, above the area where food is placed during heating. Thick, gel-like substances were splattered along the panel of the juice fountain above the spouts where the juice is dispensed. (Photographic evidence obtained). During an interview with the Activities Director on 4/6/2021 at 10:07 am, she said that there is only one nourishment room in the facility for resident use. The juice fountain is used to provide residents with beverages, and that the microwave located in the nourishment room is also for resident use. The Certified Nurse Assistants (CNAs) and dietary staff work together to keep the nourishment room and equipment clean. During a second tour of the kitchen and the nourishment room conducted on 4/6/2021 at 2:21 pm, the microwaves and juice fountains in each area remained unclean. During an interview on 4/6/2021 at 2:23pm with Employee D, Licensed Practical Nurse (LPN), she confirmed that the residents receive their beverages from the juice fountain in the nourishment room. It is the responsibility of a CNA, who gets the assignment at the beginning of the shift, to ensure that the nourishment room is cleaned each shift. During a third tour of the kitchen and nourishment room conducted on 4/7/2021 at 12:38pm, the microwaves and juice fountains remained unclean in each area. Review of the CNA daily assignment sheet provided by Employee A, LPN, revealed that on 4/7/2021, two CNAs were assigned to clean the nourishment room on their allotted shift. During an interview conducted on 4/7/2021 at 12:55 pm with the Certified Dietary Manager (CDM), he stated that the kitchen staff are solely responsible for the daily cleaning of the microwave and juice fountain located in the kitchen, and that kitchen staff and dietary work together to ensure the nourishment room equipment is cleaned daily. He was directed to the microwaves and drink fountains in the kitchen and nourishment room. Upon observation, he confirmed that they were not clean and that they should have been. .